What are the treatment options for urolithiasis?

Treatment Options for Urolithiasis

Treatment of urolithiasis should follow a systematic approach based on stone type, location, and patient factors, with both medical and surgical options available depending on clinical presentation.

Initial Management of Renal Colic

• NSAIDs (diclofenac, ibuprofen, metamizole) are the first-line treatment for renal colic due to their superior efficacy in controlling pain and reducing the need for additional analgesia compared to opioids 1
• Use the lowest effective dose of NSAIDs to minimize cardiovascular and gastrointestinal risks, particularly in patients with low glomerular filtration rate 2, 1
• Opioids are recommended as second-choice analgesics when NSAIDs are contraindicated or insufficient, with agents other than pethidine preferred (hydromorphone, pentazocine, or tramadol) 2, 1
• 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 2, 1

Medical Expulsive Therapy (MET)

• Alpha-blockers (tamsulosin) can be used as medical expulsive therapy for patients with ureteral stones, particularly those with stones >5mm in the distal ureter 2, 1
• MET facilitates stone passage, reduces passage time, and limits pain with a 29% increase in stone passage rates compared to control patients 1
• Patients should have well-controlled pain, no clinical evidence of sepsis, and adequate renal function when attempting spontaneous passage or MET 1

Surgical Management

• For ureteral stones requiring removal, both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments, though URS yields significantly greater stone-free rates 2, 1
• For renal stones, treatment options include SWL, URS, and percutaneous nephrolithotomy (PCNL) depending on stone size, location, and composition 2
• Non-contrast CT is recommended prior to performing PCNL to determine optimal surgical intervention 2
• Preoperative imaging with non-contrast CT helps determine the optimal surgical approach with high diagnostic accuracy (93.1% sensitivity, 96.6% specificity) 2

Prevention of Recurrence Based on Stone Type

For All Stone Formers

• Increase fluid intake to achieve urine volume of at least 2.5 liters daily 3, 4, 5
• Follow-up with 24-hour urine collections to assess response to therapy (within 6 months per AUA/CUA or 8-12 weeks per EAU/UAA) 2, 3
• Periodic imaging studies to monitor for stone growth or new stone formation 2

For Calcium Stone Formers

• Maintain normal dietary calcium intake of 1,000-1,200 mg per day 2, 3
• For hypercalciuric patients: thiazide diuretics are strongly recommended 2, 3, 4
• For hypocitraturic patients: alkali citrate or sodium bicarbonate 2, 3
• For hyperuricosuric calcium stone formers: allopurinol is recommended 2, 4
• The EAU recommends febuxostat as a second-line agent for hyperuricosuric patients, though the FDA has issued a safety alert regarding increased cardiac death risk compared to allopurinol 2

For Uric Acid Stone Formers

• Urinary alkalization with alkaline citrates to achieve urine pH 6.2-6.8 2, 3
• The EAU supports allopurinol as first-line treatment in the presence of hyperuricosuria, while the AUA recommends against routine use of allopurinol as first-line therapy 2

For Cystine Stone Formers

• Increase fluid intake to achieve urine output of at least 3L 2, 3
• Urinary alkalization to achieve a urine pH 7-7.5 2
• If refractory to alkalization, thiol binding agents may be initiated 2

Monitoring and Follow-up

• Follow-up 24-hour urine collections to assess response to therapy (8-12 weeks after initiating therapy per EAU) 2, 3
• Periodic blood tests to monitor for adverse effects of pharmacological therapy 2
• Regular imaging studies to assess for stone growth or new stone formation 2

Pitfalls and Caveats

• Stone analysis should be performed for all first-time stone formers to guide targeted treatment 2, 3
• Patients with recurrent stone formation require more comprehensive metabolic evaluation 3
• NSAIDs may impact renal function in patients with low glomerular filtration rate, requiring careful monitoring 2, 1
• Treatment algorithms should be individualized based on stone characteristics (size, location, composition) and patient factors 2
• Approximately 50% of recurrent stone-formers experience only one recurrence, while 10% have highly recurrent disease requiring more aggressive prevention 3