From the Guidelines
The recommended management of a patient with severe flank pain from a CT urogram-confirmed ureteric stone involves a combination of pain control, medical expulsive therapy, and appropriate follow-up, with a strong consideration for surgical treatment for stones >10 mm.
Initial Management
Initial management should focus on adequate analgesia with NSAIDs such as ketorolac (30mg IV or 10mg oral every 6 hours) as first-line treatment, which provides effective pain relief while reducing ureteral smooth muscle tone and inflammation 1. Opioids like morphine (2-5mg IV) or hydrocodone/acetaminophen (5-10mg/325mg oral every 4-6 hours) may be added for breakthrough pain.
Medical Expulsive Therapy
Medical expulsive therapy with tamsulosin 0.4mg daily should be considered for stones <10mm to facilitate passage by relaxing ureteral smooth muscle 1.
Surgical Treatment
For ureteral stones >10 mm, surgical treatment is often required, with both shock wave lithotripsy (SWL) and ureteroscopic removal (URS) being acceptable first-line treatments, although URS is associated with higher complication rates but better stone-free rates 1.
Follow-up
Patients should strain their urine to capture passed stones for analysis, and follow-up imaging with low-dose CT or ultrasound is recommended after 2-4 weeks to confirm stone passage.
Key Considerations
- Urgent urological intervention is indicated for patients with signs of infection (fever, pyuria), intractable pain, renal impairment, or stones unlikely to pass due to size (>10mm) or location.
- Preventive measures including increased fluid intake and dietary modifications should be discussed based on stone composition once analyzed.
- Patients should be informed about the existing active treatment modalities, including the relative benefits and risks associated with each modality, such as stone-free rates, anesthesia requirements, need for additional procedures, and associated complications 1.
From the Research
Management of Ureteric Stones
The management of ureteric stones involves various treatment options, including:
- Conservative treatment
- Medical expulsion therapy
- Interventional stone treatment such as ureteral stenting, ureteroscopy, and extracorporeal shock wave lithotripsy (ESWL) 2
- Oral chemolysis in selected cases 2
Medical Expulsive Therapy
Alpha-blockers are commonly used as medical expulsive therapy (MET) to improve stone passage, with studies showing that they may increase stone clearance and reduce the risk of major adverse events 3
- A meta-analysis of 67 studies with 10,509 participants found that treatment with an alpha-blocker may result in a large increase in stone clearance, with a risk ratio of 1.45 (95% CI 1.36 to 1.55) 3
- However, the quality of evidence was low, and a subset of higher-quality, placebo-controlled trials suggested that the likely effect is probably smaller, with a risk ratio of 1.16 (95% CI 1.07 to 1.25) 3
Imaging Modalities
The use of imaging modalities such as ultrasonography (US) and unenhanced helical CT (UHCT) can help diagnose and manage acute flank pain caused by ureteric stones 4
- UHCT has been shown to be superior in detecting ureteral stones, with a sensitivity and specificity of 98-100% regardless of size, location, and chemical composition 4
Treatment Options for Proximal Ureteric Stones
For proximal ureteric stones, both ESWL and ureterorenoscopic lithotripsy (URSL) are effective treatment options, with no significant difference in stone-free ratio or complications 5
- A prospective hospital-based study of 90 patients with upper ureteric calculus found that the total stone-free ratio was 88.9% for ESWL and 82.2% for URSL 5
Use of Alpha-Blockers after ESWL
The use of alpha-blockers after ESWL may enhance stone clearance, with a meta-analysis of seven trials showing a pooled absolute risk difference of 16% (95% CI 5-27%) in favor of the alpha-blocker group 6
- The pooled mean difference in expulsion time was 8 (-3-20) days in favor of the alpha-blocker group, and pain and analgesic usage were reported to be lower with alpha-blocker treatment 6