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the vast majority of renal and ureteral stones. Furthermore, CT imaging can also assist with detection of
non-urological abnormalities that can mimic renal colic, such as acute appendicitis, ovarian disease or
other intra-abdominal diseases.
Additionally, other radiographic studies may be useful in diagnosis of renal lithiasis, either alone or as an
adjunct to the above studies. Ultrasonography is a commonly used tool in patients that should not receive
contrast or be exposed to radiation (e.g., because of pregnancy). Diuretic renography has less utility, but
ICAO Preliminary Unedited Version — November 2009 III-6-4
other studies such as Doppler ultrasonography2 with renal resistive indices, magnetic resonance imaging
(MRI), and retrograde pyelography are excellent diagnostic tools and may be performed following
appropriate consultation.
Causes of renal lithiasis
The majority of renal stones are composed of calcium oxalate. Inciting aetiologies may include
hypercalcaemia from hyperparathyroidism or other medical causes, idiopathic hypocalcuria, low urinary
citrate, hyperoxaluria, and hyperuricosuria. Additional types of stones result from infectious sources
(struvite stones), elevated uric acid (urate stones), renal tubular acidosis (calcium phosphate), cystinuria
(cysteine stones), and even from medication for treatment of HIV (indinavir stones).
Management
Parenteral narcotic analgesic medication is the initial standard treatment for renal colic. This treatment
inherently disqualifies the patient from aviation duties but allows for the rapid resolution of pain and
avoids the use of oral medications, which are often difficult to administer in nauseated patients. Some
reports state that non-steroidal anti-inflammatory drugs (NSAIDs) may be as effective as narcotic
analgesics. However, their use may diminish renal blood flow and intra-renal haemodynamics, which may
be detrimental to renal function. Therefore, caution is necessory with the use of NSAIDs in patients with
renal colic.
In the case of significant obstruction, the pressure transmitted onto the ureteral wall and renal capsule
may need to be relieved through the use of indwelling ureteral stents or percutaneous procedures.
Furthermore, relieving obstruction is necessary when there is evidence of progressive renal deterioration,
pyelonephritis, or unrelenting pain. Temporizing manoeuvres may have to be undertaken until more
definitive procedures can be carried out, such as extracorporeal shock wave lithotripsy, percutaneous
nephrolithotomy, or ureteroscopic stone extraction.
Aeromedical considerations
The pain of renal colic can be severe and is likely to be incapacitating in flight. All treatment including
conservative management aimed at encouraging the natural passage of the stone, surgery, and
extracorporeal shock wave lithotripsy will necessitate grounding until recovery.
Of these procedures, extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy have lower
morbidity and permit a quicker return to flying status than open procedures. The most common morbidity
associated with both procedures is bleeding, which is usually self-limiting. Infection may occur with
percutaneous nephrotomy. Interestingly, and ironically, some studies have shown reduction in ureteral
peristalsis following fluid administration, which may inhibit further passage of stone in spite of increased
diuresis. Luckily, the majority of calculi smaller than 4 to 5 mm spontaneously pass. Recovery of all
stone fragments is necessary for further analysis.
Cases of recurrent renal colic should be regarded with considerably more suspicion and may entail long
term unfitness for aviation duties. Prior to issuance of a license or permitting a license holder to return to
aviation duties, a comprehensive urological examination should be performed. The assessment should be
2 Doppler ultrasonography: application of the Doppler Effect in ultrasound to detect movement of scatterers (usually
red blood cells) by the analysis of the change in frequency of the returning echoes. It makes possible real-time
viewing of tissues, blood flow and organs that cannot be observed by any other method. After Johann Christian
Doppler, Austrian physicist (1803-1853).
ICAO Preliminary Unedited Version — November 2009 III-6-5
based on the presumptive risk of in-flight incapacitation. In some cases, a license may be issued with
certain operational limitations such as a commercial pilot being allowed to operate “as or with co-pilot
only.” Follow-up with renal function tests and radiology procedures should be performed at regular
intervals as required by the licensing authority.
The risk of recurrence in these patients is an important aeromedical consideration. For first-time stone
　
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