How to use Clinical Evidence to get the most up-to-date information, quickly, to aid your decision makingA case presentation using the CE review on kidney stones

A typical history of ureteric stonesCase history37-year-old manSelf-employed builderAfter a few twinges over past 2 months, presents with 2 hours of excruciating pain in left groinKUB appears normal in A+E, but blood ++ on urine dipReferred to urologyIVU showed two small calculi, 4 mm and 5 mm, sited in left mid-ureter, with no signs of dilatation or hydronephrosis

Questions that might ariseWhat is the best conservative management?Analgesia and fluids are the obvious answers, butHow much fluid?Some people use hyoscine as an adjunct to other analgesics is this a good idea?Is there anything else that could be done?How strong is the evidence supporting our usual practice?

Removing symptomatic ureteric stonesManagement of acute renal colic

alpha-blockers categorised as Likely to be beneficial

fluids categorised as Unknown effectivenessantispasmodics categorised as Unlikely to be beneficial

moderate-quality evidence for using alpha-blockersfull details about the RCTs (tamsulosin was the most commonly tested)

no good RCT evidence to support high-volume iv fluids

Changing managementConsider adding an alpha-blocker (possibly tamsulosin) to speed up stone explusionAvoid anti-spasmodicsStick with regular iv fluid replacement

SummaryClinical Evidence can be used to make sure your practice is up to dateAnswers clinical questionsKeeps you informed of new treatmentsDemonstrates when existing treatments are not supported by good evidence

BMJ Publishing Group Limited (BMJ Group) 2009. All rights reserved.

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