Dosing for Ureteric Stones with Chronic Ureteric Colic
For chronic ureteric colic from ureteral stones, use tamsulosin 0.4 mg once daily for stones 5-10 mm in the distal ureter; Buscopan (hyoscine butylbromide) is not recommended as it lacks evidence for stone passage and NSAIDs are superior for acute pain control.
Tamsulosin Dosing and Indications
The standard dose is tamsulosin 0.4 mg once daily, taken for up to 28-30 days or until stone passage occurs. 1, 2
Stone Size Criteria
- For stones 5-10 mm in the distal ureter: Tamsulosin provides a 22-29% absolute increase in stone passage rates (81-87% vs 61-79% with placebo), with a number needed to treat of 4-5 patients 1
- For stones ≤5 mm: Do not use tamsulosin—spontaneous passage rates are already 68-89% regardless of treatment, providing no clinically meaningful benefit 1
- For stones >10 mm: Consider urologic intervention rather than medical expulsive therapy due to low spontaneous passage rates and high complication risk 1, 2
Duration and Monitoring
- Continue tamsulosin for a maximum of 30 days 1
- If the stone has not passed by 30 days, reassess for urologic intervention 1
- Discontinue immediately if: infection/sepsis develops, renal function declines, or signs of obstruction requiring urgent intervention appear 1
Additional Benefits
- Reduces time to stone expulsion by approximately 3 days 1
- Decreases pain episodes and analgesic requirements 1
- Works through alpha-1 receptor blockade causing ureteral smooth muscle relaxation 1, 2, 3
Buscopan (Hyoscine Butylbromide) - Not Recommended
Buscopan has no established role in medical expulsive therapy for ureteral stones. The available guidelines do not support its use for facilitating stone passage 4. While it is an antispasmodic, there is no evidence demonstrating efficacy for stone expulsion rates or long-term pain control in chronic ureteric colic.
Pain Management for Acute Exacerbations
For acute pain episodes during the stone passage period:
- First-line: NSAIDs (diclofenac, ibuprofen, or metamizole) at the lowest effective dose 4
- Second-line: Opioids other than pethidine (such as hydromorphine, pentazocine, or tramadol) if NSAIDs are contraindicated or insufficient 4
- NSAIDs reduce the need for additional analgesia compared to opioids but may impact renal function in patients with low GFR 4
Important Caveats
Conflicting Evidence on Efficacy
Two large, high-quality randomized controlled trials from 2015 and 2018 found no benefit of tamsulosin over placebo for stone passage 5, 6. However, current guidelines from the American Urological Association and European Association of Urology continue to recommend tamsulosin based on earlier meta-analyses showing benefit, particularly for stones 5-10 mm 1, 2. The discrepancy may relate to patient selection, stone location confirmation, and study design differences.
Stone Location Matters
The greatest benefit is seen with distal ureteral stones confirmed on CT imaging 1. Proximal and mid-ureteral stones have less robust evidence for tamsulosin efficacy 4.
Comparative Alpha-Blockers
Tamsulosin, terazosin, and doxazosin appear equally effective for medical expulsive therapy, though tamsulosin has been most extensively studied 4, 2