What medications are recommended for pain control in patients with ureteral stones?

Pain Control Medications for Ureteral Stones

NSAIDs are the first-line treatment for pain control in patients with ureteral stones, with opioids recommended as second-choice analgesics only when NSAIDs are contraindicated or insufficient. 1

First-Line Pain Management

• NSAIDs (diclofenac, ibuprofen, metamizole) should be used as the primary analgesics for renal colic due to ureteral stones 1
• NSAIDs reduce the need for additional analgesia compared to opioids and are more effective than antispasmodics in controlling pain 1, 2
• The lowest effective dose of NSAIDs should be used to minimize cardiovascular and gastrointestinal risks 1, 3
• NSAIDs may impact renal function in patients with low glomerular filtration rate, requiring caution in these patients 1
• NSAIDs significantly reduce the likelihood of requiring rescue medication compared to placebo (RR 0.35,95% CI 0.20 to 0.60) 2

Second-Line Pain Management

• Opioids should be used as second-choice analgesics when NSAIDs are contraindicated or insufficient for pain control 1
• If an opioid is required, agents other than pethidine are recommended, such as hydromorphone, pentazocine, or tramadol 1
• Opioids, particularly pethidine, are associated with a higher rate of vomiting compared to NSAIDs and a greater likelihood of requiring additional analgesia 1
• Tramadol has demonstrated efficacy in post-surgical pain at doses of 50-100 mg, with 100 mg providing analgesia superior to codeine sulfate 60 mg 4

Adjunctive Therapies

• Alpha-blockers (tamsulosin, terazosin, doxazosin) can be used as medical expulsive therapy (MET) for patients with ureteral stones, particularly those with stones >5 mm in the distal ureter 1
• Alpha-blockers facilitate stone passage and may reduce stone-passage time and limit pain 1
• Alpha-blockers have shown a statistically significant 29% increase in stone passage rates compared to control patients 1
• Alpha-blockers should be considered for patients with ureteral stent-related pain, along with or in combination with anticholinergics and NSAIDs 5

Special Considerations

• In cases of sepsis and/or anuria in an obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is strongly recommended before definitive treatment 1
• Patients should be counseled on the attendant risks of MET including associated drug side effects and should be informed that it is administered for an "off-label" use 1
• Patients who elect for an attempt at spontaneous passage or MET should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve 1
• For patients requiring stone removal, both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments, though URS yields significantly greater stone-free rates for most stone stratifications 1

Monitoring and Follow-up

• Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis 1
• Regular assessment of pain intensity using visual analogue scales (VAS), verbal rating scale (VRS), or numerical rating scale (NRS) is recommended to evaluate treatment efficacy 1
• Analgesics for chronic pain should be prescribed on a regular basis and not on an 'as required' schedule 1
• Rescue doses of medications (as required) other than the regular basal therapy must be prescribed for breakthrough pain episodes 1