What is the initial management for a patient presenting with ureteric calculi?

Initial Management of Ureteric Calculi

For patients presenting with ureteric calculi, initial management should include observation with pain control for stones <10 mm if symptoms are controlled, with medical expulsive therapy as an adjunct treatment option. 1

Assessment and Diagnosis

• Imaging: Non-contrast CT is the gold standard for diagnosis with approximately 97% sensitivity 2
• Stone characteristics to evaluate:
  • Size: Critical determinant of spontaneous passage probability
  • Location: Proximal, mid, or distal ureter
  • Presence of hydronephrosis or obstruction

Management Algorithm

For Stones <10 mm with Controlled Symptoms:

1. Observation with pain control

   • NSAIDs as first-line analgesics (if no contraindications)
   • Adequate hydration (>2L/day)
   • Medical Expulsive Therapy (MET) with alpha-blockers (e.g., tamsulosin)
     • Facilitates stone passage by relaxing ureteral smooth muscle
     • Most beneficial for distal ureteral stones >5mm
     • Expected absolute increase of 29% in stone passage rates 2

2. Patient monitoring

   • Periodic imaging studies to monitor stone position and assess for hydronephrosis 1
   • Follow-up within 1-2 weeks with ultrasound or KUB X-ray 2

For Stones >10 mm or Uncontrolled Symptoms:

Surgical intervention is typically required, as spontaneous passage is unlikely 1

1. First-line surgical options:

   • Shock Wave Lithotripsy (SWL)

     • Stone-free rates: 82% proximal ureter, 73% mid ureter, 74% distal ureter 1
     • Lower complication rates (ureteral injury 1-2%)
     • Can be performed with minimal anesthesia

   • Ureteroscopy (URS)

     • Higher single-procedure stone-free rates
     • Higher complication rates (ureteral injury 3-6%)
     • Better for lower pole stones and larger stones

Special Populations

Pregnant Patients:

• Coordinate management with obstetrician 1
• First-line: Observation if symptoms are controlled 1
• If observation fails: URS is preferred over temporary drainage with stent/nephrostomy tube 1
• NSAIDs are contraindicated; avoid CT imaging 1

Pediatric Patients:

• For ureteral stones, stenting prior to URS is not routinely recommended 1
• For renal stones ≤20 mm, either SWL or URS are appropriate first-line options 1

Complications to Monitor

• Infection/sepsis (2-5% with either SWL or URS)
• Ureteral injury (higher with URS: 3-6% vs. SWL: 1-2%)
• Steinstrasse (stone street) formation with SWL (4-8%)
• Stricture formation (1-4%)

Key Considerations

• Stenting is not routinely recommended as part of SWL 1
• Stenting following uncomplicated URS is optional 1
• Patients should be counseled about MET's "off-label" use and potential side effects 1
• Patients should be informed that URS offers better stone-free rates in a single procedure but has higher complication rates 1

Warning Signs Requiring Immediate Attention

• Fever (suggesting infection)
• Uncontrolled pain
• Persistent nausea/vomiting
• Signs of urinary obstruction