Can dicyclomine or buscopan (hyoscine butylbromide) be used to treat spasm associated with ureteral stents?

Management of Ureteral Stent-Associated Spasm

NSAIDs are the first-line treatment for ureteral spasm associated with ureteral stents, while anticholinergics like dicyclomine may be used as second-line therapy; however, buscopan (hyoscine butylbromide) should be avoided due to potential cardiovascular risks. 1

Pathophysiology of Ureteral Stent-Associated Spasm

Ureteral stent-associated spasm is multifactorial and likely results from:

• Mucosal irritation from the stent causing local inflammation 2
• Ureteral smooth muscle spasm partially mediated by prostaglandins 3, 2
• Retrograde reflux of urine causing irritation and spasm 2
• Trigonal irritation from the distal end of the stent 4

First-Line Treatment Options

NSAIDs

• NSAIDs are recommended as first-line treatment for ureteral spasm due to their ability to decrease ureteral smooth muscle tone and ureteral spasm 1
• NSAIDs inhibit cyclooxygenase, reducing prostaglandin production that mediates pain and spasm 3
• Diclofenac, ibuprofen, and other NSAIDs are specifically recommended by European Urology guidelines for renal colic and can be applied to stent-related pain 5
• NSAIDs should be used at the lowest effective dose to minimize cardiovascular and gastrointestinal risks 5

Second-Line Treatment Options

Alpha-Blockers

• Alpha-blockers (tamsulosin, alfuzosin) significantly reduce stent-related pain and urinary symptoms 4
• Meta-analysis shows alpha-blockers reduce the relative risk of stent pain by 41% (RR 0.59,95% CI 0.47-0.71) 4
• Alpha-blockers reduce smooth muscle activity in the ureter and bladder neck, decreasing spasm 2

Anticholinergics (Including Dicyclomine)

• Anticholinergics like dicyclomine may be considered for ureteral spasm due to their antispasmodic effects on smooth muscle 2
• Dicyclomine works by blocking muscarinic receptors in the GI tract and urinary system, reducing smooth muscle contractions 6
• Anticholinergics can be used in combination with alpha-blockers for better symptom control 2

Caution Regarding Buscopan (Hyoscine Butylbromide)

• Buscopan (hyoscine butylbromide) should be used with extreme caution due to reported cases of hypotension and myocardial ischemia 7
• While buscopan has anticholinergic properties that could theoretically help with ureteral spasm, its cardiovascular risks outweigh potential benefits 7, 6
• Case reports document hyoscine-induced hypotension and acute myocardial infarction, making it unsuitable for routine use 7

Treatment Algorithm for Ureteral Stent-Associated Spasm

1. First-line therapy: NSAIDs (diclofenac, ibuprofen) if not contraindicated 1, 5
2. Second-line therapy: Add alpha-blockers (tamsulosin, alfuzosin) 4, 2
3. Third-line therapy: Consider adding anticholinergics like dicyclomine if symptoms persist 2
4. Avoid: Buscopan (hyoscine butylbromide) due to cardiovascular risk profile 7

Special Considerations

• For patients with contraindications to NSAIDs (renal insufficiency, GI bleeding risk, cardiovascular disease), start with alpha-blockers 5, 4
• In cases of severe, refractory pain not responding to medical therapy, consider early stent removal if clinically appropriate 8
• For patients with infection along with stent-related symptoms, appropriate antibiotic therapy should be initiated 5

Monitoring and Follow-up

• Regular assessment of symptom control and medication side effects is essential 5
• If symptoms worsen despite medical therapy, evaluate for complications such as stent migration, encrustation, or infection 8
• CT scan may be indicated if obstruction or perinephric stranding is suspected 5

Remember that ureteral stent-associated symptoms significantly impact quality of life, and prompt, effective management is essential for patient comfort and compliance with treatment.