What is the best way to manage pain after ureteroscopy with basket extraction?

Managing Pain After Ureteroscopy with Basket Extraction

A multimodal, non-opioid pain management approach should be the first-line treatment for pain after ureteroscopy with basket extraction, as this provides adequate pain control while minimizing opioid-related risks.

Pain Characteristics After Ureteroscopy

• Approximately 14.6% of patients experience significant acute postoperative pain (pain score >4 on visual analog scale) after ureteroscopic procedures 1
• Pain is typically most severe in the first 3-4 days after the procedure, with median time to pain resolution being postoperative day 3-4 2
• Pain is the leading cause of unplanned emergency department visits and readmissions after ureteroscopy 3

Risk Factors for Increased Post-Ureteroscopy Pain

• Young age and psychiatric illness are associated with higher pain levels 1
• History of urinary tract infection increases risk of postoperative pain 1
• Use of a stone basket during the procedure correlates with increased pain 1
• Large stone size and prolonged operation time (>60 minutes) are significant predictors of higher pain scores 1, 4
• Postoperative ureteral stenting is associated with higher pain scores on day 3 and higher complication rates 4

First-Line Pain Management

• NSAIDs should be the foundation of post-ureteroscopy pain management:

  • Oral naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours with food for the first 24-48 hours 5, 3
  • Ketorolac (10 mg oral) has demonstrated non-inferiority to opioids for post-ureteroscopy pain control 3

• Scheduled acetaminophen should be added to the regimen:

  • 1000 mg every 6 hours (not exceeding 4000 mg daily) 2
  • Pre-anesthesia acetaminophen administration may reduce postoperative pain 2

Non-Pharmacological Interventions

• Application of heat to the abdomen or back may help reduce cramping pain 5
• Cold, wet towels on the forehead can provide comfort 5
• Acupressure on points LI4 (on hand) or SP6 (on leg) may help reduce pain 5
• Adequate hydration should be maintained to help pass any small residual fragments 6

When to Consider Opioids

• Reserve opioids for breakthrough pain not controlled with NSAIDs and acetaminophen 2, 3
• If needed, prescribe minimal quantities (≤15 pills) of low-dose opioids 2
• Studies show only 15.5% of patients ultimately require any narcotic medication after ureteroscopy when given appropriate non-opioid alternatives 2

Follow-Up and Monitoring

• Patients should be counseled about expected pain duration (typically 3-4 days) 2
• Pain that persists beyond 5 days or worsens after initial improvement warrants evaluation 7
• The combination of preoperative obstruction and postoperative pain is associated with a higher likelihood of residual fragments or persistent obstruction 7
• Patients without preoperative obstruction who report no pain at follow-up rarely have persistent obstruction or residual fragments (96% negative predictive value) 7

When to Seek Immediate Medical Attention

• Development of fever or chills (signs of potential infection) 6, 8
• Severe, uncontrolled pain despite appropriate medication use 6
• Inability to urinate or significantly decreased urine output 6
• Visible blood clots in urine or heavy bleeding 8

Special Considerations

• Avoid "blind basketing" (stone extraction without endoscopic visualization) as this increases risk of ureteral injury 5, 8
• Consider selective rather than routine stenting after uncomplicated ureteroscopy to reduce postoperative pain 5
• Patient education about expected pain patterns and management strategies improves outcomes 5