From the Guidelines
Yes, you should consult urology for a 2.3 mm right proximal ureteral calculus in the emergency room setting. According to the most recent guidelines, specifically the 2018 evaluation of guidelines for surgical management of urolithiasis 1, ureteroscopy (URS) is recommended as the first-line treatment for proximal ureteral stones regardless of stone size. Although the stone is small (2.3 mm), its proximal location may complicate spontaneous passage and increase the risk of complications.
Initial management should include:
- Pain control with NSAIDs like ketorolac 30 mg IV or ibuprofen 600 mg orally every 6 hours
- An alpha-blocker such as tamsulosin 0.4 mg daily to facilitate stone passage
- Ensuring adequate hydration
- Considering antiemetics if the patient has nausea
The urologist can determine if immediate intervention is needed or if medical expulsive therapy is appropriate. They may recommend follow-up imaging in 1-2 weeks if pursuing conservative management. Urological consultation is particularly important if the patient has signs of infection (fever, elevated WBC), renal impairment, intractable pain, or a solitary kidney. The American Urological Association (AUA) and European Association of Urology (EAU) guidelines suggest that conservative management can be considered for uncomplicated ureteral stones less than 10 mm 1. However, given the proximal location of the stone, urological consultation is crucial to determine the best course of treatment.
From the Research
Ureteral Calculus Management
The management of ureteral calculi depends on various factors, including the size and location of the stone.
- For a 2.3 mm right proximal ureteral calculus, the decision to consult urology should be based on the patient's symptoms and overall condition.
- The American Family Physician recommends that patients with kidney stones should be screened for risk of stone recurrence with medical history, basic laboratory evaluation, and imaging 2.
- The American Journal of Emergency Medicine suggests that tamsulosin, an alpha-1-adrenocepter blocking agent, may be used to induce spontaneous stone passage by relaxing ureteral smooth muscle tone, but its efficacy is still a topic of debate 3.
Medical Expulsive Therapy
Medical expulsive therapy (MET) with an alpha blocker, such as tamsulosin, may be considered for patients with ureteral stones.
- A systematic review and meta-analysis of randomized controlled trials found that tamsulosin was associated with a higher stone expulsion rate, shorter stone expulsion time, and lesser incidence of ureteral colic 4.
- However, the study also found that the benefit of tamsulosin was significant only for patients with stones greater than 5 mm.
- Another study found that tamsulosin increased and hastened stone expulsion rates, decreased acute attacks, and reduced mean days to stone expulsion and analgesic dose usage 5.
Emergency Department Management
In the emergency department, the primary goal is to alleviate pain and rule out conditions requiring immediate referral.
- The American Journal of Emergency Medicine recommends that patients with urolithiasis be treated with pain control and medical expulsive therapy, and that tamsulosin may be considered for off-label use 3.
- However, the Journal of Urology suggests that ketorolac may be used to reduce post-stent removal renal colic, but its effectiveness in reducing overall subjective pain is still uncertain 6.