What is the management plan for a patient with a 4.8 mm renal calculus, prostatic hypertrophy, and right flank pain?

Management of a 4.8 mm Renal Calculus with Prostatic Hypertrophy and Right Flank Pain

For a patient with a 4.8 mm renal calculus in the mid-lower left renal pole, prostatic hypertrophy, and right flank pain, observation with medical expulsive therapy is the recommended initial management approach, with follow-up imaging to monitor stone position and assess for hydronephrosis. 1

Initial Assessment and Management

• The 4.8 mm renal calculus is located in the left kidney, while the patient's pain is on the right side, suggesting the calculus may not be the direct cause of the current symptoms 1
• Urine microscopy and culture should be obtained to exclude or treat urinary tract infection, as infection can complicate stone management 2
• Pain management should be optimized with appropriate analgesics to ensure the patient has well-controlled pain during observation 1
• Medical expulsive therapy (MET) can be offered for stones <10 mm to facilitate spontaneous passage, though patients must be informed this is an "off-label" use with potential side effects 1

Imaging Follow-up

• Periodic imaging studies should be performed to monitor stone position and assess for development of hydronephrosis 1
• Follow-up imaging can include renal ultrasound or low-dose CT depending on clinical circumstances 1
• The presence of hydronephrosis on follow-up imaging would increase the likelihood of urinary obstruction requiring intervention 1

Indications for Intervention

• Intervention should be considered if:
  • The patient develops signs of infection/sepsis 1
  • Pain becomes uncontrollable with medical management 1
  • Observation with or without MET is not successful after 4-6 weeks 1
  • Follow-up imaging shows development of hydronephrosis or stone migration causing obstruction 1

Intervention Options

• For stones requiring removal, both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments 1
• URS has a higher stone-free rate in a single procedure (90% vs 72% for SWL) but carries a slightly higher risk of complications 1
• SWL is the procedure with the least morbidity and lowest complication rate 1
• The patient should be informed about the relative benefits and risks of each procedure 1

Management of Prostatic Hypertrophy

• The prostatic hypertrophy (49.9 cm³) should be addressed as a separate issue from the renal calculus 3
• Alpha-adrenergic antagonists can be considered to decrease smooth muscle tone in the prostate, improving urinary flow 4
• If the patient has significant lower urinary tract symptoms from the prostatic hypertrophy, urological evaluation for potential BPH treatment should be arranged 4

Special Considerations

• If the stone is confirmed to be composed of uric acid, oral chemolysis with alkalinization using citrate or sodium bicarbonate may be considered 2
• Stone analysis should be performed if the stone is passed or retrieved to guide future prevention strategies 2
• If intervention becomes necessary, the choice between SWL and URS should consider the patient's comorbidities, bleeding risk, and stone characteristics 2

Follow-up Plan

• Re-evaluate symptoms and repeat imaging in 4-6 weeks if conservative management is chosen 1
• If symptoms worsen or new symptoms develop (fever, worsening pain, hematuria), earlier reassessment is indicated 1
• Consider urological evaluation for the prostatic hypertrophy if the patient has bothersome lower urinary tract symptoms 4