Urology Annals

LETTER TO EDITOR
Year
: 2015  |  Volume : 7  |  Issue : 1  |  Page : 130--132

Can intracutaneous sterile water injection be used as a possible treatment for acute renal colic pain in the emergency department? A short literature review


Seyed Mohammad Hosseininejad1, Amir Emami Zeydi2,  
1 Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
2 Department of Nursing, Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari; PhD Student in Nursing, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

Correspondence Address:
Amir Emami Zeydi
Department of Nursing, Nasibeh Nursing and Midwifery Faculty, Vesal Street, Amir Mazandarani Boulevard, Sari
Iran




How to cite this article:
Hosseininejad SM, Emami Zeydi A. Can intracutaneous sterile water injection be used as a possible treatment for acute renal colic pain in the emergency department? A short literature review .Urol Ann 2015;7:130-132


How to cite this URL:
Hosseininejad SM, Emami Zeydi A. Can intracutaneous sterile water injection be used as a possible treatment for acute renal colic pain in the emergency department? A short literature review . Urol Ann [serial online] 2015 [cited 2020 Jul 12 ];7:130-132
Available from: http://www.urologyannals.com/text.asp?2015/7/1/130/148669


Full Text

Sir,

Renal colic is an important and severely painful condition which is frequently encountered in the emergency department (ED). [1] More than 12% of people worldwide will suffer from this condition in their lifetime; with the recurrence rate of 50%. [2] Each year, renal colic affects about 1.2 million people and accounts for 1% of all ED visits and hospitalizations. [3] Urinary tract obstruction caused by calculi is the most common cause of renal colic occurrence. Sudden onset of colicky pain begins in the flank that radiating to the groin is the classic clinical features of a ureteric colic. This pain is usually described as the worst pain experienced by humans. [1],[4]

Due to the intense nature of the pain associated with renal colic, prompt and effective pain control is one of the first responsibilities of emergency physicians, and the main issue in the management of these patients until the time stone passes spontaneously or is removed surgically. [5],[6] Considering that most kidney stones will pass spontaneously, conservative management including observation with analgesia remains the preferred approach for these patients. [1] Many pharmacologic agents such as nonsteroid antiinflammatory drugs (NSAID), opioid analgesics, antispasmodics and antidiuretic hormones, can be administered for pain management in renal colic. [6],[7] Nonetheless, the most effective analgesic regimen has not been determined. [8] Intravenous (IV) administrations of analgesics, either NSAIDs or opioids are still routine clinical practice for pain management in patients with renal colic. [9] Although IV administration of these drugs has been reported to be effective, they are generally problematic in terms of side effects, availability especially in private clinics or opioids abuse. [1],[9] In addition, considering that the NSAIDs may potentially interfere with the kidney's autoregulatory response to obstruction by reducing renal blood flow, renal failure may be induced with preexisting renal disease. [1] Furthermore, the majority of physicians are not comfortable with using these drugs due to their side-effects including; respiratory depression, lightheadedness, nausea, vomiting, narcotic dependence, sedation, dizziness, disorientation, and hypotension. Therefore, administration of alternative therapies for the control of renal colic pain would appear to be inevitable. [10]

In recent times, an intracutaneous sterile water injection (ISWI) has been proposed as a new modality for acute renal colic pain management with none of the aforementioned negative outcomes and problems. In a study that conducted by Ahmadnia et al. with aim to evaluate the efficacy of Intracutaneous injection of sterile water or normal saline (0.5 mL) in the treatment of renal colic pain, have shown that although in all patients, pain had been relieved; but in patients who received intracutaneous injection of normal saline, only 34% reported a decrease in pain, whereas in all treated patients with sterile water injection (100% of cases), pain was relieved. [11] Similar results were observed in a study by Bengtsson et al. in treatment of pain due to urolithiasis by ISWI. [12] In another study with the aim to evaluate the analgesic efficacy of ISWI (0.5 mL) compared with oral paracetamol in pregnant women with acute renal colic pain showed that pain severity was significantly less in patients who received ISWI compared than patients treated with paracetamol. Also rescue analgesics requirement were significantly lower in patients receiving sterile water injection compared with another group. [7] It has been previously shown that this technique is effective in the pain management following whiplash injuries [13] and low back pain in labor; so that, in a systematic review have been demonstrated that administration of sterile water injections, possess powerful analgesic benefits to women experiencing lower back pain during labor. [14] The underlying mechanisms of action of sterile water injection in pain control are not fully understood but the majorities of the authors refer to pain inhibition in accordance with the gate control theory and/or diffuse noxious inhibitory control as a pain inhibitory system. [15] Furthermore, it has been stated that the ISWI produces chemical irritation in the skin and triggers the A cutaneous afferents. This may lead to endorphin release, similar to that seen with acupuncture. Another explanation is that it may exert its effect through physiological distraction. [15],[16] In this technique, onset of pain relief is almost immediate and if requested, the injections can be repeated several times. [16] In some of studies which conducted in this regard, isotonic saline has been considered to be placebo treatment. [11] This is based on the fact that the percentage of salt is similar to that in the human body, which probably means that saline does not cause osmotic irritation or mechanical stimulation as salt-free water most likely does. [16]

In conclusion, considering the importance of acute renal colic pain management and some problems and side-effects in the use of common pharmacologic agents for renal colic pain, it seems that ISWI can be used as an effective, inexpensive, safe and low technology analgesic option that is suitable for all emergency care settings. Although further clinical trials are warranted to determine its potential effect on acute renal colic pain, as well as the optimal amount of sterile water in each injection.

References

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2Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med 2004;350:684-93.
3Claros OR, Silva CH, Consolmagno H, Sakai AT, Freddy R, Fugita OE. Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital. Clinics (Sao Paulo) 2012;67:415-8.
4Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. BMJ 2004;328:1401.
5Graham CA. Pain relief in the emergency department. Eur J Emerg Med 2010;17:1.
6O′Connor A, Schug SA, Cardwell H. A comparison of the efficacy and safety of morphine and pethidine as analgesia for suspected renal colic in the emergency setting. J Accid Emerg Med 2000;17:261-4.
7Xue P, Tu C, Wang K, Wang X, Fang Y. Intracutaneous sterile water injection versus oral paracetamol for renal colic during pregnancy: a randomized controlled trial. Int Urol Nephrol 2013;45:321-5.
8Safdar B, Degutis LC, Landry K, Vedere SR, Moscovitz HC, D′Onofrio G. Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med 2006;48:173-81, 181.e1.
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10Golzari SE, Soleimanpour H, Rahmani F, Zamani Mehr N, Safari S, Heshmat Y, et al. Therapeutic approaches for renal colic in the emergency department: a review article. Anesth Pain Med 2014;4:e16222.
11Ahmadnia H, Younesi Rostami M. Treatment of renal colic using intracutaneous injection of sterile water. Urol J 2004;1:200-3.
12Bengtsson J, Worning AM, Gertz J, Struckmann J, Bonnesen T, Palludan H, et al. Pain due to urolithiasis treated by intracutaneous injection of sterile water. A clinically controlled double-blind study. Ugeskr Laeger 1981;143:3463-5.
13Byrn C, Olsson I, Falkheden L, Lindh M, Hösterey U, Fogelberg M, et al. Subcutaneous sterile water injections for chronic neck and shoulder pain following whiplash injuries. Lancet 1993;341:449-52.
14Fogarty V. Intradermal sterile water injections for the relief of low back pain in labour-a systematic review of the literature. Women Birth 2008;21:157-63.
15Derry S, Straube S, Moore RA, Hancock H, Collins SL. Intracutaneous or subcutaneous sterile water injection for relieving pain in labour. Cochrane Database Syst Rev 2012;1:CD009107.
16Mårtensson L, Wallin G. Sterile water injections as treatment for low-back pain during labour: A review. Aust N Z J Obstet Gynaecol 2008;48:369-74.