Nephrolithiasis/Urolithiasis: The Daily PANCE Blueprint

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Nephrolithiasis/Urolithiasis: The Daily PANCE Blueprint

A 39-year-old man presents with the sudden onset of severe, colicky left flank pain that radiates to the groin, accompanied by nausea and vomiting. He is afebrile, writhing on the exam table, and unable to find a comfortable position. Urinalysis shows microscopic hematuria. He is not on any medications and has normal renal function. Which of the following is the most appropriate initial imaging study?

A. Plain abdominal radiograph (KUB)
B. Intravenous pyelography
C. Renal ultrasound
D. Noncontrast helical CT of the abdomen and pelvis
E. Contrast-enhanced CT of the abdomen and pelvis

Answer and topic summary

The answer is D. Noncontrast helical CT of the abdomen and pelvis.

Noncontrast helical CT is the imaging study of choice for suspected nephrolithiasis — it is highly sensitive and specific, detects stones regardless of composition (including radiolucent uric acid stones), shows the size and location, and identifies hydronephrosis and alternative diagnoses. A KUB misses radiolucent and small stones; IV pyelography is largely obsolete and requires contrast. Renal ultrasound is the preferred first-line study in pregnant patients and children (to avoid radiation) but is less sensitive for small or ureteral stones. Contrast is unnecessary and can actually obscure stones.

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