Radiología.

2015;57(2):113---122

www.elsevier.es/rx

UPDATE IN RADIOLOGY

Diagnostic management of renal colic夽

C. Nicolau a,∗ , R. Salvador a , J.M. Artigas b

a
Servicio de Radiología, Hospital Clínic de Barcelona, Barcelona, Spain
b
Servicio de Radiología, Hospital Universitario Miguel Servet, Zaragoza, Spain

Received 2 August 2014; accepted 3 November 2014

KEYWORDS Abstract Renal colic is a common reason for presentation to emergency departments, and
Renal colic; imaging has become fundamental for the diagnosis and clinical management of this condi-
Ultrasonography; tion. Ultrasonography and particularly noncontrast computed tomography have good diagnostic
Noncontrast performance in diagnosing renal colic. Radiologic management will depend on the tools avail-
computed able at the center and on the characteristics of the patient. It is essential to use computed
tomography; tomography techniques that minimize radiation and to use alternatives like ultrasonography
Low dose computed in pregnant patients and children. In this article, we review the epidemiology, clinical and
tomography radiologic presentations, and clinical management of ureteral lithiasis.
© 2014 SERAM. Published by Elsevier España, S.L.U. All rights reserved.

PALABRAS CLAVE Manejo diagnóstico del cólico renal

Cólico renal;
Ecografía; Resumen El cólico renal es un motivo frecuente de consulta en los Servicios de Urgencias
Tomografía y la imagen diagnóstica se ha convertido en una herramienta fundamental del diagnóstico y
computarizada sin manejo clínico. La ecografía y, fundamentalmente, la tomografía computarizada sin contraste
contraste; permiten diagnosticarlo con un rendimiento elevado. El manejo radiológico va a depender de
Tomografía la disponibilidad del centro y de las características de la población. Es imprescindible usar
computarizada baja técnicas de baja dosis de radiación en la tomografía computarizada y técnicas alternativas como
dosis la ecografía en embarazadas y niños. En este artículo hacemos una revisión epidemiológica,
clínica, radiológica y del manejo clínico de la litiasis ureteral.
© 2014 SERAM. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.

Introduction

夽 Renal colics (RC) are the most frequent clinical manifes-

Please cite this article as: Nicolau C, Salvador R, Artigas JM.
Manejo diagnóstico del cólico renal. Radiología. 2015;57:113---122. tation of renal lithiasis and a common cause for seeking
∗ Corresponding author. Hospital Emergency Services (HES). Diagnosing and treat-
E-mail address: cnicolau@clinic.cat (C. Nicolau). ing them early reduce complication which is derived from

2173-5107/© 2014 SERAM. Published by Elsevier España, S.L.U. All rights reserved.
114
maintained urinary obstruction, such as renal function dete-
rioration and infection accompanied by septic shock risk.
Diagnostic imaging plays an important role in clinical man-
agement when trying to confirm lithiasis, stage the extent
of obstruction in the collector system, assess the probabil-
ity of spontaneous expulsion and identify complications or
alternative diagnoses.1---3 In addition, it makes it easier to
select the best therapeutic option, which can be a medical
treatment, extracorporeal lithotripsy or nephrolithotomy,
endoscopically or percutaneously. The number and size
of the calculi as well as their composition influence the
selection,2 in such a way that uric acid lithiases respond
to medical treatment and extracorporeal lithotripsy is not
effective in cases of cysteine, brushite or calcium oxalate
monohydrate lithiases. Radiological techniques are also use-
ful to follow the calculus until it is expelled and then to
decide whether to maintain medical treatment or com-
plement it with an endourological procedure. The options
include simple radiography, intravenous urography (IVU),
ultrasound, computed tomography (CT) and magnetic reso-
nance images (MRI). A swift and precise diagnosis has made
it possible to use CT without contrast as the first option
for patients with acute lumbar pain suggesting RC, a rec-
ommendation endorsed by scientific societies such as the
American College of Radiologists and the American Urolog-
ical Association.2,3 Such a recommendation, along with the
progressive availability of CT scanners in ER, has promoted
a rapid increase in the number of examinations, which in
patients with suspicion of RC got multiplied by a factor of
10 in 11 years.4 As a consequence, there has been a par-
allel rise in the collective radiation dose, which has not
entailed a parallel improvement of the ‘‘patient-based indi-
cators’’, such as the increase in the percentage of lithiasis
diagnoses, relevant alternative disease or the percentage
of hospitalized patients.4 In order to minimize the doses of
radiation it is recommended to use low-dose techniques2
that allow us to reduce such doses up to 70%, according to
personal preferences and the technological availability of
the scanner. Results with studies using ultra-low doses have
been recently published with a range below that of abdom-
inal radiography,5 yet availability of this technique is still
limited, as shown by a recent study where only 2% of the CT
were performed with doses lower than 3 milisieverts (mSv).6
Also patients with ureteral lithiasis undergo image examina-
tion before, during and after treatment, a situation that gets
itself more complicated due to a certain trend to have lithi-
asis relapses. Therefore, the examination is highly likely to
be repeated once or twice along the process, with the sub-
sequent cumulative effect of the dose in a population that
due to its average age of around 40 years is radiosensitive
suggestive of caution with the doses.7,8 Consequently, the
European Association of Urology recommends ultrasound as
the first imaging modality to be used in RC.9
The goal of this article is to review the utility of imaging
diagnostic techniques for the clinical diagnosis and manage-
ment of renal colics.
Epidemiology
The incidence of urolithiasis in Spain is 0.73%, which
amounts to some 325,000 new cases every year.10 RC is the
C. Nicolau et al.
most frequent complication of renal lithiasis, with an inci-
dence between 0.9 and 3 cases/1000 inhabitants/year11,12
and it usually affects patients between 20 and 60 years old,
with a maximum incidence between 40 and 60 years old men
predominantly.12---14 It is estimated that up to 12% of men
and 6% of women will experience one or more RC episodes
in their lives,12 with a recurrence rate of 50%.15 One in four
patients with RC has a family history of RC a situation that
multiplies the risk of lithiasis by three.16
Depending on the size and location of the calculus, expul-
sion can take a few hours or even several weeks, a period of
time in which successive episodes of colic pain may occur.
Some calculi will not be expelled spontaneously and will
require intervention; also relapse is common after the index
event.17
Clinical context
RC is triggered by partial or complete ureteral obstruction,
usually due to an impacted lithiasis that raises pressure
significantly. The classic clinical presentation of ureteral
lithiasis is intense, unilateral, sudden colic pain. It is ini-
tially located in the lumbar fossa usually irradiating toward
the inguinal and genital areas to later evolve when the cal-
culus descends in such a way that in the middle ureter it
can simulate appendicitis or diverticulitis, depending on its
location---right or left. As the calculus comes closer to the
bladder, the symptoms of vesical irritation predominate,
such as polakisuria and tenesmus. It is usually accompanied
by digestive symptoms such as nausea, vomiting or consti-
pation due to ileus reflux.12,16,18 In approximately 90% of
the patients hematuria occurs yet the lack of it does not
exclude RC12,15 ; even half of the patients with aneurisma
of the abdominal aorta can have it.19 With the typical pain
accompanied by hematuria, clinical diagnosis is possible and
the imaging tests do not strictly be necessary since they
will not change the therapeutic decisions.20---22 Nevertheless,
most of today’s guidelines and recommendations indicate an
immediate imaging test---ideally CT without contrast in all
patients who come into the ER with RC, even with typical
presentation.2,3 This recommendation that can have defen-
sive nuances, seems to be justified by the fact that it is
necessary to rule out other processes, in addition to the fact
that it confirms ureteral lithiasis and the need for immediate
treatment if the calculus is large. However interventions on
the urinary tract are not free from complications and medi-
cal treatment is considered to be an option, at least during
the first 2 weeks. The probability of spontaneous expulsion
with medical treatment of a calculus smaller than 5 mm is
65%, and 47% if it is between 5 and 10 mm, irrespective of its
location. Based on its location, distal lithiases are expelled
more often and before the proximal ones.23 When a calculus
has not been expelled in 4---6 weeks, it is not likely to be
expelled and hence indicative of intervention.12
Performing systematically irradiating radiological tests is
more under discussion in higher-risk populations. In chil-
dren 3% of the studies are performed with CT without
contrast when suspicion of RC8 yet today the need for using it
systematically because of its greater radiosensitivity is ques-
tionable. Another risk group is that of patients with known
nephrolithiasis and previous colic episodes, in whom an
Diagnostic management of renal colic 115

alternative diagnosis is improbable and CT without contrast

Table 1 Urgent indications for image modalities in patients
will change the therapy in 6.5%24 only yet it increases the
with acute renal coil.
accumulated effective dose.8 Finally, there is a lower preva-
lence of nephrolithiasis among women and their gynecologic 1. Suspicion of sepsis: fever (>38.5 ◦ C), signs of shock
symptoms are frequent, on occasions clinically overlapping, or systemic infection
that is why they are more often studied with CT than men8 2. Risk of irreversible damage of renal function
with less diagnostic yield. In some works, up to 58.2% of the suggestive of urgent drainage:
CT performed on women did not produce any findings, and a. Single or transplanted kidney
the rate of lithiasis rate found (26.8%) was significantly lower b. Prior renal failure
than that of men (61.6%).13 It seems reasonable to avoid any c. Suspicion of bilateral ureteral obstruction
systematic use of CT without contrast in these three groups 3. Unresponsive to analgesics and antiemetic therapy
and use alternative strategies. in 1 h (or before based on clinical assessment)
The calculi that cannot be seen in the ultrasound are 4. Sudden relapse of acute pain despite early analgesics
usually the smallest ones that are usually expelled spon- 5. Persistent digestive symptoms (nausea and vomits)
taneously and this is why their results, in practice, do not 6. Diagnosis of uncertain renal colic especially males
vary significantly from those of CT without contrast.25 That >60 years of age with left pain (to discard acute
is why it has been decided to use ultrasound and simple aortic syndrome)
radiography as an initial option in the general population
too reserving CT without contrast for patients with a fever
and clinical suspicion of a complicated colic, or in cases recommend hospitalization12 (Table 1). It is also indicated in
when the ultrasound is negative.26 But even the ultrasound cases where clinical presentation is atypical and can simu-
and the X-ray might not be necessary at the beginning with late other processes making it necessary to include ureteral
patients without a fever who respond well to painkillers lithiasis among the possible causes of abdominal pain16,18
which occurred in 76% of the patients of a recent series.11 In (Table 2).
this group, complications were minimal and there were no
morbidity differences when the imaging examination was
delayed for 2---3 weeks. In another study in which the CT Imaging techniques
outcomes did not change the clinical decisions in patients
with clinically overt RC, the authors considered that benefit Simple radiography
is marginal and should be avoided.20 For that purpose it
has been suggested that it is helpful to develop a rule of It is the fastest modality to help identify calcic lithiasis.
clinical decision to minimize the use of CT in patients with Although 90% of urinary calculi have been classically consid-
RC without jeopardizing their own safety.7,20 A clinical pre- ered as radiopaque, the figures of sensitivity and specificity
dictive rule was recently developed and validated including of the abdomen X-ray to detect them are 45---59% and
five factors associated with ureteral lithiasis: male gender, 71---77% respectively. Vision in radiography is made difficult
recent pain, non-black race, nausea and vomiting, and due to intestinal and bone structure overlapping.29 Its sen-
microscopic hematuria.27 Three groups were classified as sitivity is especially low in calculi <4 mm, and those located
follows: patients with low, medium and high probability of
RC. In the latter group, the probability was close to 90%,
and the probability of an alternative diagnosis was very Table 2 Differential diagnosis of reno-ureteral colic.
low. In young people and women included in this group it
1. Renal
would be justified to avoid using CT without contrast in the
a. Acute pielonefritis
ER or to perform such CT with low-dose techniques.
Another argument to use CT in acute lumbar pain is to 2. Genital
exclude alternative diagnoses, especially the feared acute a. Testicular torsion
aortic syndrome.19 The probability of a non-urinary alter- b. Ovarian torsion
native diagnosis as a cause for colic lumbar pain is usually c. Ectopic pregnancy
10---13%,18,27 though when patients are evaluated with a tool d. Salpingitis
to help in the making of the clinical decision the percentage 3. Digestive
of patients highly likely to have ureteral lithiasis is ≤3%28 a. Appendicitis
only or <0.3---1.6%.27 b. Intestinal obstruction
In most patients, colic diagnosis is clinical. With typi- c. Diverticulitis
cal pain and hematuria, and a good response to treatment, d. Pancreatitis
clinical and radiological correlation is a close one and
the emergency imaging tests do not change the initial 4. Vascular
management,20 the probability of spontaneous expulsion is a. Renal infarction
70---90% and functional recovery complete when the obstruc- b. Aortic dissection
tion resolves in 2 weeks.11 On the contrary emergency tests, c. Retroperitoneal hemorrhage due to aortic
CT without contrast or ultrasound based on the clinical con- aneurysm tear or renal tumor
text, are clearly indicated in cases of acute lumbar pain 5. Neurologic
suspicious of colic, with a fever, single kidney or pain refrac- a. Lumbosciatic
tory to treatment, situations where the NICE guidelines
116
in the middle or distal ureter.29 The second difficulty is
distinguishing between lithiasis and other intraabdominal
calcifications such as phleboliths, vascular calcifications or
apendicoliths yet phleboliths usually has a typical radiolu-
cent center in simple radiographies which helps to diagnose
them. At present use is recommended for the follow up of
ureteral calculi diagnosed through CT or ultrasound, for con-
trol purposes of the position of Double J urethral catheters
or in combination with ultrasound, especially in cases of RC
where there is no hydronephrosis.1
Intravenous urography
For years the IVU was the diagnostic modality of choice in
RC allowing us to identify lithiasis in the excretory duct and
repercussions on such duct ---location, presence or not of
dilatation, extent of obstruction, contrast and nephrogram
delay in the excretory duct. However, it has been pro-
gressively replaced by CT without contrast, since the work
by Smith et al.30 in 1995. Prospective studies have shown
similar31---35 or greater36,37 CT without contrast sensitivity fig-
ures to that of urography for the detection of urinary lithiasis
with greater safety, more rapidly and cost-effectively.
Ultrasound
It is a quick, portable, relatively cheap method that does not
use ionizing radiations or require iodized contrast. It allows
us to detect lithiasis and, especially, the dilation and degree
of dilation of the excretory duct above the obstruction point.
It allows us to identify radiotransparent lithiases not visible
through simple radiology and even indinavir calculi also not
visible through CT (Fig. 1). It also helps find other diseases
of the excretory duct, kidney and extrarenal structure that
can all simulate a RC.
Calculi are identified as hyperechoic focuses with a pos-
terior acoustic shadow. Small lithiases (<5 mm) or those
located in the middle ureter are especially difficult to see.
That explains the wide variation (47.5---98%) in the sensitiv-
ity of the ultrasound.38---40 Another limitation of ultrasounds
is that several hours must pass until the dilation of the
excretory duct; so it can be negative in the initial stage
of RC if lithiasis is not identified. The correct hydration of
the patient before the proceeding provokes the distension
of excretory duct and the adequate filling of the urinary
bladder improving the view of the distal ureter.40,41 Com-
bining the ‘‘B-mode’’ with the color and pulsated Doppler
methods increases diagnostic yield thanks to other suspi-
cious signs such as twinkling or comet-tail artifact (Fig. 2)
of the Doppler color ultrasound allowing us to detect small
lithiases that do not get to generate a posterior shadow.42---44
A reduced or asymmetrical ureteral jet and especially the
lack of it are also suspicious signs of ureteral obstruction.45
The high intrarenal resistance index (RI) is used as a dif-
ferential criterion between obstructive and non-obstructive
dilation in such a way that >0.7 RI or a difference >10%
between the two kidneys is considered diagnostic of obstruc-
tive uropathy.46 However, the variability of RI normal values
with a trend to increase with age, systolic pressure and
decrease of renal function, should be considered.47
C. Nicolau et al.
Computed tomography
CT is available nowadays in most HES and it is a rapid check-
out confirming the calculus, its size and location, as well as
hydronephrosis or possible complications. It facilitates the
management of patients and shortens the hospital stay time
at the HES. Since no IV contrast is needed, it improves its
profile of safety since it avoids the risks of renal toxicity
and any other possible allergic reactions. The CT without
contrast is considered to be the modality that provides the
greatest diagnostic yield for the detection of ureteral cal-
culi, with sensitivity and specificity >95% in most recent
papers.3 Yield is even better especially in small ureteral
lithiases.48,49 In the absence of lithiasis it shows us the recent
passage of the calculus or allows us to determine alterna-
tive diagnoses, such as acute vascular disease, renal tumors
or appendicitis, for which it is usually necessary to adminis-
ter IV contrast. On the other hand, in cases in which one
endourological procedure is indicated, clinical guidelines
recommend using multidetector CT with IV contrast to be
able to have access to the excretory duct map. Lastly when
it comes to the follow-up, it is important that the analysis
not only shows the size and location of lithiases but also if
they are visible in the topogram, which will allow us to do
more follow-up through radiographies.50 To be able to use
lithotripsy it is necessary to report on the distance between
the lithiasis and the skin.
Dose of radiation
Both the IVU and the abdomen radiography, as well as the CT
without contrast lead to exposure to ionizing radiation. The
cumulative effect of the doses of radiation together with
epidemiological data that half the patients with lithiasis
will relapse within the next 10 years suggests a foresee-
able significant cumulative radiation dose if this technique
is used to diagnose and control these patients.6 The effec-
tive dose of a simple abdomen radiography ranges between
0.5 and 1 mSv, while that of the IVU ranges between 1.3
and 3.5 or more mSv based on the number of radiographies
obtained. The dose of CT without contrast is even higher,
around 4.5---5 mSv, but in older scanners, especially if a low
noise index is required, 10 mSv can be surpassed. Low-dose
CT without contrast protocols not beyond 3 mSv have been
proposed for the analysis of patients with RC. With these
protocols the diagnostic precision is close to that of conven-
tional CT without contrast, with a sensitivity of 97% and a
specificity of 95%.51 Routine use of these types of protocols
is recommended except for patients whose body mass index
>30 kg/m2 , in whom it is recommended to use a conventional
technique to guarantee the good quality of images.2,52 When
contrast is necessary in CT, the radiation dose increases pro-
portionally to the number of phases performed.
Diagnosis
Direct visualization of the calculus is the main CT sign in RC
and can usually be identified in most cases. On occasion,
it can be difficult to see because of respiratory or metal
devices adjacent to the lithiasis, because it is very small
or because its composition is ‘‘CT-lucid’’. The latter occurs
with certain infective lithiases made up of proteinaceous
material or in lithiases secondary to some antiretroviral
Diagnostic management of renal colic 117

Figure 1 Patient with left renal colic. (a)---(c) Ultrasound. Calyx lithiasis (a) and (c) and proximal obstructive ureteral lithiasis (b).
(d) Computed tomography (CT) without contrast to assess treatment not showing renal or ureteral lithiases but showing indirect
signs of renal colic. (e) and (f) After the resolution of the symptoms through ureterorenoscopy with ureteral calculus removal and
placement of a pig-tail catheter a CT with contrast examination is performed in the excretory phase showing the lower calyx defect
(arrows) corresponding to the image lithiasis (c).

Figure 2 Ultrasound of a patient with right RC. (a) Right kidney with minimal ectasia of some calyces---almost indiscernible
without other findings. (b) Around the right meatus there is a dubious ureteral lithiasis without evident dilation. (c) Color Doppler.
‘‘Twinkling’’ artifact that helps identify ureteral lithiasis. This artifact occurs in coarse and irregular interfaces reflecting ultrasound
waves intensely. It is a rapid alternation of several colors that appear right behind a hyperechogenic image giving the false appearance
of movement.
118
Figure 3 Computed axial tomography without contrast of a
patient with left RC. Two pelvic calcifications are identified. One
of them corresponds to an obstructive distal ureteral lithiasis
showing a discontinued circle (halo sign) formed by the ede-
matous ureteral wall around the lithiasis. Another larger and
posterior calcification is a phlebolith with the comet tail sign,
corresponding to a posterior trail made up of the vessel where
the phlebolith is (parallel to the arrow).
drugs in HIV patients.53 When the calculus is located in the
distal ureter, it can be difficult to differentiate from a phle-
bolith, especially if fine sections are not available. In this
case the ‘‘halo’’ and ‘‘comet tail’’ signs are useful (Fig. 3).
The former refers to the padding of soft parts around the
lithiasis, caused by the edematous ureteral wall,54 and the
latter, described as typical of phleboliths, consists of the
observation of a tail of soft tissue density corresponding to
the venous vessel.55 When it is not possible to differentiate
them IV contrast in the excretory phase is necessary to be
able to see the ureteral pathway.
Like in ultrasound there are indirect signs that increase
the CT diagnostic yield, whose relevance is greater when
lithiasis is not identified for the reasons aforementioned or
because it has already been expelled. These signs do not
usually appear until 6 h before the beginning of the obstruc-
tion, and they include excretory duct dilation, change in
ureteral caliber, perirenal and periureteral fat stringiness,
renal edema, the presence of other non-obstructive renal
Table 3 Lithiasic composition through DECT.
Lithiasis Opacity in simple radiography CT density (HU)
Apatite + 1200---1600
Oxalate + 1700---2800
Struvite + 600---900
Cystine ± 600---1100
Uric acid − 200---450
HU, Hounsfield units; DECT, double energy CT.
C. Nicolau et al.
lithiases and delays in uptake and excretion if IV contrast
has been administered.
Analysis of the lithiastic composition
In addition to identifying lithiasis, CT also provides infor-
mation about its composition, which is useful to determine
treatment. Uric acid and xanthine lithiases are radiotrans-
parent and cannot be identified through a simple abdomen
radiography and can only be detected indirectly through the
IVU as filling defects. Although they can be seen well with
CT without contrast, its density is lower than that of the rest
(Table 3). Nevertheless, there is great density overlapping
especially in uric acid lithiases compared to the rest that do
not allow us to identify them in vivo.56
The CT modality with double energy, whether with a
single source (alternating the energy or performing a dou-
ble study at different energies) or with a double source
(double tube) allows us to differentiate materials of sim-
ilar density through the absorption variation at different
energies.57,58 Most lithiases have a greater density when
kilo voltage kV) is lower (80---100 kV). On the contrary, uric
acid calculi are attenuated in a similar way both spectra,
or even more in those of greater kV (Fig. 4). This differ-
ence, quantifiable through the double energy index allows us
to distinguish uric acid lithiases from the rest,59 even using
low-dose protocols.60---62
Magnetic resonance images
The uro-MR, especially the sequences that are highly T2-
weighted allows us to detect excretory duct dilation63,64
and distinguish pregnancy physiological hydronephrosis from
that secondary to lithiasis. Although lithiases can go unno-
ticed, when the urinary tract is dilated they are usually
identified as filling defects with signal void (Fig. 5). MRIs
are a good alternative to CT for pregnant women with nega-
tive or non-conclusive ultrasound result yet its safety is not
proved in the first quarter, its use is arguable and it must
only be indicated after the assessment of the risk-benefits
ratio. On the other hand, the availability of MR machines for
emergency studies is very limited.
Clinical-radiological diagnostic management
The tendency in all HES is to indicate imaging examination
for all RC patients. CT is the modality with the best diag-
nostic yield and in many centers it has become the initial
test to assess the index RC. Using imaging modalities sys-
tematically in patients suspicious of RC and typical clinical
Frequency Atomic number Index DECT
20---40% 15.7---15.8 1.78---1.76
70---80% 12.9---13.8 1.76---1.63
5---15% 12.1 1.55
<1% 10.7 1.40
5---15% 6.8---7.01 0.96---1.17
Diagnostic management of renal colic 119

Figure 4 Computed tomography without contrast with double energy of a patient with symptoms of left RC. (a) Curve coronal
reconstruction following the ureteral tract. The white arrow shows a proximal obstructive ureteral lithiasis. The perirenal and peri-
ureteral fat shows stringiness (black arrow). (b) Coronal image of application for renal lithiasis once the double energy information
is processed showing a mixed composition of the obstructive lithiasis (red = uric acid, blue = not uric acid) and a pure uric acid
composition of the proximal non-obstructive ureteral lithiasis. (c) and (d) Quantification of the pure uric acid lithiasis composition
showing double energy relation <1 (0.91) and a location in the graph corresponding to uric acid lithiasis (KS2). The color in this
figure is visible only in the electronic version of this article.

presentation does not change management significantly.20---22
Its use should be limited to patients who do not show any
clinical improvement after treatment, in cases of fever or
leukocytosis, in patients with a single kidney or with renal
failure, or in high-risk populations.1,9,12 If CT without con-
trast is performed low-dose techniques should be used.
Although the ultrasound is inferior to the CT for the detec-
tion of lithiasis, it would be reasonable to use it as an initial
method especially in younger patients where the probabil-
ity of an alternative serious diagnosis is lower.26,65,66 Lower
cost, greater availability, absence of ionizing radiations and
the fact that in most cases therapeutic management will
not change, even in those cases where the ultrasound has
not identified lithiasis, are other arguments in favor of the
ultrasound.1,24 In older patients with persistence of clinical
signs, especially if the initial ultrasound examination is neg-
ative, the CT would be indicated. Although in all the cases
the first step can be to resort to ultrasound, its use is com-
pulsory in children and young people as well as in pregnant
and fertile women. When it is not conclusive, CT without
contrast allows us to identify ureteral lithiasis with great
precision and to investigate possible alternative diagnoses.
If CT without contrast is negative for lithiasis and there are
no signs of a recent passage of a calculus it is recommended
to administer an IV contrast, once any other medical con-
traindication have been excluded (history of anaphylaxis,

Figure 5 Magnetic resonance in a 20-week pregnant patient with right renal colic. (a) Coronal reconstruction showing ureter
dilation (arrow) up to the pelvis. (b) T2-weighted axial sequence showing dilated distal ureter with juxtavesical intraureteral signal
void image corresponding to lithiasis (arrow).
120
renal failure or dehydration due to vomiting). In women
in their 2nd and 3rd quarters of pregnancy if available MRI
should be the 2nd-choice image modality.
Ethical responsibilities
Protection of people and animals. Authors confirm that no
experiments have been performed on human beings or ani-
mals.
Data confidentiality. Authors confirm that the protocols of
their institution have been followed on the publication
of data from patients.
Right to privacy and informed consent. Authors confirm
that in this report there are no personal data from patients.
Author contribution
Manager of the integrity of the study: CN.
Original idea of the study: CN.
Study design: CN, JMA.
Data mining: not applicable.
Data analysis and interpretation: not applicable.
Statistical analysis: not applicable.
Reference search: CN, RS, JMA.
Writing: CN, RS, JMA.
Manuscript critical review with intellectually relevant
contributions: CN, RS, JMA.
Final version approval: CN, RS, JMA.
Conflict of interest
Authors reported no conflict of interest.
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