From the Guidelines
For pain management in a patient with a 3 mm ureteral stone, urinary tract infection, and hydrocodone allergy, I recommend tramadol 50-100 mg orally every 6 hours as needed for pain. This recommendation is based on the need to manage pain effectively while avoiding hydrocodone due to the patient's allergy. Alternative options include ketorolac 10 mg orally every 6 hours (limited to 5 days use) or acetaminophen 1000 mg every 6 hours 1.
The patient's presentation with a urinary tract infection (UTI), as indicated by the urinalysis showing WBC urine 21-50, RBC urine 21-30, bacteria many, and protein urine 100, along with the CT abdomen and pelvis findings of mild left hydroureteronephrosis and urinary bladder wall thickening, suggests the need for prompt antibiotic therapy. According to the European Association of Urology guidelines on urological infections, fluoroquinolones and cephalosporins are recommended for oral empiric treatment of uncomplicated pyelonephritis 1. Therefore, the patient should also receive antibiotic therapy, typically a fluoroquinolone like ciprofloxacin 500 mg twice daily for 7 days or trimethoprim-sulfamethoxazole DS twice daily for 7 days, based on local resistance patterns.
Key considerations in the management of this patient include:
- Increased fluid intake of 2-3 liters daily to help pass the stone and flush bacteria
- The potential use of alpha-blockers such as tamsulosin 0.4 mg daily to facilitate stone passage by relaxing ureteral smooth muscle
- The importance of prompt treatment of the UTI to prevent complications such as sepsis, especially in the context of obstruction
- Advising the patient to strain urine to catch the passed stone for analysis and to seek immediate medical attention if fever, severe pain, or vomiting develops.
From the Research
Treatment Plan
The patient's urinalysis results show WBC urine 21-50, RBC urine 21-30, bacteria many, blood trace, protein urine 100, and leukocytes est small. The CT abdomen and pelvis results indicate mild left hydroureteronephrosis to the level of the UVJ, a 3 mm stone either at or immediately adjacent to the UVJ, and urinary bladder wall thickening, which correlates with cystitis.
Pain Management
For pain management, considering the patient is allergic to hydrocodone, the following options can be considered:
- Acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) as the first-line pharmacologic agent for the symptomatic treatment of mild to moderate pain 2
- Tramadol, which has been shown to be effective in relieving pain in patients with acute musculoskeletal pain, although it may provide inferior analgesia compared to hydrocodone-acetaminophen in some cases 3
- Combination tablets of tramadol and acetaminophen, which have been shown to provide effective and rapid analgesia for the treatment of postoperative dental pain, with better tolerability compared to hydrocodone/acetaminophen combination tablets 4
Key Considerations
When prescribing pain management medications, it is essential to:
- Identify the underlying cause of pain and provide disease-specific treatment 2
- Consider patient risk factors for NSAID-related adverse effects and choose medications accordingly 2
- Monitor patients for adverse treatment effects and adjust medications as needed 5
- Provide patients with instructions on proper disposal of unused medications to prevent misuse and diversion of controlled substances 2