Signs and Management of Ureteral Stones
Ureteral stones present with characteristic signs and symptoms that require prompt evaluation, with management decisions primarily based on stone size, location, and presence of complications such as infection or obstruction. 1
Clinical Presentation
Common Signs and Symptoms
- Renal colic (severe, colicky flank pain that may radiate to groin)
- Hematuria
- Nausea and vomiting
- Lower urinary tract symptoms (frequency, urgency)
- Fever and chills (if infection present)
Warning Signs Requiring Immediate Attention
- Fever or signs of sepsis
- Intractable pain or vomiting
- Evidence of urinary obstruction with infection
- Acute kidney injury
- Solitary kidney with obstruction
Diagnostic Evaluation
Imaging
- Low-dose CT scan: Gold standard with approximately 97% sensitivity 1
- Ultrasound: Limited sensitivity (75% overall, but only 38% for ureteral stones) 1
- KUB (Kidney, Ureter, Bladder) X-ray: May be used for follow-up of radiopaque stones
Laboratory Tests
- Urinalysis: To detect hematuria, pyuria, and signs of infection
- Urine culture: Recommended prior to intervention 2
- Serum chemistries: Assessment of renal function with electrolytes, creatinine, and BUN 2
Management Algorithm
1. Stones <10 mm with Controlled Symptoms
- Observation with periodic evaluation is appropriate initial treatment 2, 1
- Medical expulsive therapy (MET) with alpha blockers (e.g., tamsulosin)
- Facilitates stone passage, especially for distal ureteral stones
- Patients must be informed this is an "off-label" use 2
- Pain management with oral NSAIDs as first-line treatment 1
- Follow-up imaging to monitor stone position and assess for hydronephrosis 2
2. Stones >10 mm or Complicated Cases
3. Special Considerations
- Infection/Sepsis: Urgent decompression of collecting system plus antibiotics 3
- Pregnancy: Requires special consideration and immediate care if symptomatic 1
- Bleeding disorders/anticoagulation: URS with laser lithotripsy is preferred 1
Comparison of Treatment Options
| Treatment | Stone-Free Rate | Complications | Best For |
|---|---|---|---|
| URS | Higher (single procedure) | Slightly higher rates of ureteral injury (3-6%) [2] | Most stone locations, especially >10 mm |
| SWL | Lower (may need multiple sessions) | Lower rates of ureteral injury (1-2%) [2] | Proximal stones <10 mm |
Important Cautions
- Never perform blind basketing (stone extraction without endoscopic visualization) due to high risk of ureteral injury 2
- Untreated bacteriuria can lead to infectious complications and urosepsis if combined with obstruction 2
- Female gender and elevated urine WBCs are predictive of developing sepsis in patients with ureteral stones 3
- Patients with suspected infection stones should have complete stone removal to prevent recurrent UTI and renal damage 2
Follow-up Care
- Urological follow-up within 1-2 weeks with imaging 1
- Stone material should be sent for analysis to guide prevention strategies 2
- Metabolic evaluation and dietary modifications may be necessary to prevent recurrence 1
- Increased fluid intake (>2L/day) helps prevent recurrent stones 1
By following this evidence-based approach to the diagnosis and management of ureteral stones, clinicians can optimize outcomes while minimizing complications and recurrence rates.