Sixty seconds on . . . kidney stonesBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3190 (Published 20 July 2018) Cite this as: BMJ 2018;362:k3190
You can say that again. The discomfort caused by kidney stones passing through the ureter has been compared to birth contractions with pain radiating across the lower abdomen and groin. The stones—which can vary in size, shape, and make-up—can also cause pain in the testicles and scrotum as well as nausea, frequent urination, and pain on urination.
Is there anything I give my patient for that?
They can’t have pethidine or an epidural, but the National Institute for Health and Care Excellence recommends non-steroidal anti-inflammatory drugs or intravenous paracetamol—and opioids if neither of these help.1 Alpha blockers and oral nifedipine can also help some people pass certain small stones.
But they’ve hit rock bottom. How long will it last?
Not for much longer if latest draft guidelines from NICE are followed. If a doctor suspects their patient could have a kidney stone, they should order a computed tomography scan within 24 hours. If kidney stones are confirmed, the pain is persisting, and the patient is unlikely to pass the stone naturally, they should be offered treatment with shockwave lithotripsy (SWL) within 48 hours of diagnosis.
This is NICE at its finest. In the long run this is good for patients—they are treated promptly and don’t need more complicated surgery, their symptoms are resolved more quickly, and there’s less risk of postsurgical complications. If left untreated, ureteric stones can lead to loss of kidney function, which is far more expensive to treat and has clear downsides. The NHS also benefits—SWL can generally be delivered on a day case basis without expensive hospital stays.
That sounds like joined-up thinking to me
There’s more. Andrew Dickinson, consultant urologist at Plymouth Hospitals NHS Trust and chair of the NICE committee that produced the guidance, is also concerned about patients’ mental health. “There has been an increase in surgery for renal and ureteric stones. Waiting times for treatment are increasing and this means that patient satisfaction is likely to be lower,” he said. “This is why offering shockwave lithotripsy is important for both a patient’s health and mental wellbeing.”
Wow. There must be a downside
Unfortunately, not all hospitals are set up to deliver this service just yet. But while reconfiguring services will involve some investment, there are savings to be made from early intervention, says NICE.
Is this advice set in stone?
Not yet. The consultation on the guidance closes on 29 August 2018.