What is the first-line treatment for a kidney stone?

First-Line Treatment of Kidney Stones

For acute renal colic, NSAIDs (diclofenac, ibuprofen, or metamizole) are the first-line treatment, and for stone management, treatment depends on stone size and location: stones ≤5mm can be observed with medical expulsive therapy using alpha-blockers, while stones >10mm typically require surgical intervention with ureteroscopy or shock wave lithotripsy. 1

Acute Pain Management

• NSAIDs are superior to opioids for renal colic pain control, reducing the need for additional analgesia while minimizing side effects 1
• Use the lowest effective dose of NSAIDs to minimize cardiovascular and gastrointestinal risks 1
• Exercise caution with NSAIDs in patients with reduced glomerular filtration rate as they may impact renal function 1
• Reserve opioids (hydromorphine, pentazocine, or tramadol) as second-line agents; avoid pethidine due to high vomiting rates 1

Conservative Management and Medical Expulsive Therapy

• For ureteral stones ≤10mm without complications, observation with medical expulsive therapy is appropriate 1
• Alpha-blockers provide the greatest benefit for stones >5mm in the distal ureter (strong recommendation) 1
• Conservative management requires well-controlled pain, absence of sepsis, and adequate renal functional reserve 1
• Maximum duration of conservative treatment should be 4-6 weeks from initial presentation 1
• Mandatory periodic imaging is required to monitor stone position and assess for hydronephrosis 1

Surgical Treatment Based on Stone Characteristics

Ureteral Stones

• For distal ureteral stones >10mm, ureteroscopy is the first-line surgical treatment 1
• For distal stones <10mm, both ureteroscopy and shock wave lithotripsy are acceptable options 1
• Ureteroscopy yields significantly higher stone-free rates (90%) compared to SWL (72%) but has slightly higher complication rates 2

Renal Stones

• For renal stones ≤20mm, either shock wave lithotripsy or ureteroscopy may be offered as first-line treatment 2
• For renal stones >20mm, percutaneous nephrolithotomy is the first-line therapy due to significantly higher stone-free rates 2
• For lower pole stones 10-20mm, ureteroscopy (81% success) or PCNL (87% success) are preferred over SWL (58% success) 2

Special Considerations for Lower Pole Stones

• For symptomatic lower pole stones ≤10mm, both SWL and ureteroscopy are acceptable, with SWL offering better quality of life outcomes 2
• SWL should NOT be offered as first-line therapy for stones >10mm due to significantly lower success rates 2

Emergency Situations Requiring Urgent Intervention

• In cases of sepsis and/or anuria with obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is mandatory 1
• Delay definitive stone treatment until sepsis is resolved 1
• Collect urine for antibiogram testing before and after decompression 1
• Administer antibiotics immediately and adjust based on culture results 1

Oral Chemolysis for Specific Stone Types

• For uric acid stones, oral chemolysis with alkalinization using citrate or sodium bicarbonate (target pH 7.0-7.2) is strongly recommended 1
• Patients should monitor urine pH and adjust medication accordingly 1
• Success rate is approximately 80.5%, with 15.7% requiring further intervention 1

Common Pitfalls to Avoid

• Do not use routine stenting before shock wave lithotripsy as it provides no benefit and causes frequent stent-related symptoms 1
• Do not delay urgent decompression in patients with obstructing stones and infection, as conservative treatment carries 28% mortality over 10 years 3
• Do not offer prolonged conservative management beyond 6 weeks without reassessment 1
• Avoid using NSAIDs in patients with significantly reduced renal function without careful monitoring 1