What is the symptomatic treatment for kidney stones?

Symptomatic Treatment for Kidney Stones

The most effective symptomatic treatment for kidney stones includes NSAIDs as first-line pain management, increased fluid intake to achieve urine output of at least 2.5 liters daily, and medical expulsive therapy for stones ≤10mm in the distal ureter. 1, 2

Pain Management

• NSAIDs are the first-line medication for pain control in patients with renal colic, as they effectively reduce pain and inflammation while avoiding the risks of opioid dependence 1
• Opioids should be reserved as second-line therapy when pain is not adequately controlled with NSAIDs or when NSAIDs are contraindicated 1
• Recent trends show decreased opioid prescribing for kidney stone pain in emergency departments, reflecting improved opioid stewardship 1

Hydration Therapy

• Increased fluid intake to achieve urine output of at least 2.5 liters daily is critical for symptom management and stone prevention 3, 4
• Adequate hydration helps dilute stone-forming substances and facilitates stone passage 4
• Target fluid intake should be 2.5-3.0 liters per day to achieve diuresis of >2.0-2.5 liters daily 4

Medical Expulsive Therapy (MET)

• MET is recommended as first-line therapy for uncomplicated distal ureteral stones ≤10 mm in diameter 2
• Alpha-blockers are the primary agents used for MET, facilitating stone passage by relaxing ureteral smooth muscle 2
• MET should be considered before more invasive interventions for appropriately sized stones 2

Stone-Specific Treatments

For Calcium Stones:

• Potassium citrate therapy is indicated for patients with calcium stones and low urinary citrate to increase urinary pH and inhibit stone formation 3
• Thiazide diuretics are recommended for patients with high urinary calcium and recurrent calcium stones 3
• Dietary sodium restriction should be advised to maximize the hypocalciuric effect of thiazides 3

For Uric Acid Stones:

• Potassium citrate is the first-line therapy to increase urinary pH to approximately 6.0, enhancing uric acid solubility 3
• Allopurinol should not be routinely offered as first-line therapy for uric acid stones unless hyperuricosuria is present 3

For Cystine Stones:

• Increased fluid intake is particularly important, with a target of at least 4 liters per day to decrease urinary cystine concentration below 250 mg/L 3
• Potassium citrate should be offered to raise urinary pH to approximately 7.0 3
• Sodium and protein restriction should be advised to reduce cystine excretion 3
• For patients unresponsive to these measures, cystine-binding thiol drugs like tiopronin should be considered 3

For Struvite Stones:

• Complete surgical removal of stone material is the primary treatment 3
• Aggressive medical management is required to mitigate risk of recurrence 3
• Monitoring for recurrent urinary tract infections is essential 5

Follow-up Care

• A 24-hour urine specimen should be obtained within six months of initiating treatment to assess response to therapy 3
• Periodic blood testing is necessary to monitor for adverse effects in patients on pharmacological therapy 3
• Annual 24-hour urine specimens should be collected to assess patient adherence and metabolic response 3
• Repeat stone analysis should be performed when available, especially in patients not responding to treatment 3

Common Pitfalls to Avoid

• Relying solely on opioids for pain management without trying NSAIDs first 1
• Inadequate fluid intake, which increases risk of stone recurrence 3, 4
• Using sodium citrate instead of potassium citrate, as the sodium load may increase urine calcium excretion 3
• Prescribing allopurinol as first-line therapy for uric acid stones without addressing urinary pH 3
• Failing to monitor for medication side effects, such as hypokalemia with thiazides or hyperkalemia with potassium citrate 3