What is the initial management for patients with ureteric (ureteral) calculi or renal calculi?

Initial Management of Ureteric and Renal Calculi

For patients with ureteric or renal calculi, initial management depends on stone size, location, and symptom severity: stones <10mm with controlled symptoms should receive NSAIDs for pain control plus alpha-blocker medical expulsive therapy, while stones >10mm typically require surgical intervention with ureteroscopy or shock-wave lithotripsy. 1, 2

Pain Management (First Priority)

• NSAIDs (diclofenac, ibuprofen, metamizole) are first-line analgesics for renal colic due to superior efficacy and fewer side effects compared to opioids 1
• Use the lowest effective dose to minimize cardiovascular and gastrointestinal risks 1
• Opioids should only be used as second-line therapy when NSAIDs are contraindicated or insufficient 1
• Pain medications should be taken on a regular schedule rather than "as needed" for optimal control 1

Conservative Management (Stones <10mm)

Patient selection criteria for observation or medical expulsive therapy:

• Well-controlled pain 2
• No clinical evidence of sepsis 2
• Adequate renal functional reserve 2

Medical Expulsive Therapy (MET):

• Alpha-blockers (tamsulosin, terazosin, doxazosin) should be prescribed for stones <10mm to facilitate spontaneous passage 1, 3
• MET increases stone passage rates by 29% (77.3% vs 54.4% with placebo for distal stones) and reduces stone passage time 1, 2
• Most stones that pass spontaneously do so within approximately 17 days (range 6-29 days) 1
• Patients must be informed that alpha-blockers are used "off-label" for this purpose and counseled about potential side effects 1

Surgical Intervention (Stones >10mm or Failed Conservative Management)

Both shock-wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line surgical treatments: 1, 2

Ureteroscopy (URS):

• Yields significantly greater stone-free rates with a single procedure but has slightly higher complication rates 1, 2
• Stone-free rates: 81-94% depending on location 4
• Flexible URS for proximal stones: 87% success rate 4
• Rigid/semirigid URS for distal stones: 94% success rate 4
• Complication rates: stricture formation 1-4%, sepsis 2-4%, ureteral perforation <5% 4

Shock-Wave Lithotripsy (SWL):

• Less invasive but may require additional procedures 1
• Stone-free rates: 82% proximal ureter, 73% mid ureter, 74% distal ureter 3
• Additional procedures needed: 0.62 per patient (proximal), 0.52 (mid), 0.37 (distal) 3
• Can be performed with minimal anesthesia, making it attractive for patients who desire treatment without general anesthesia 3
• Serious complications are infrequent 3

Critical caveat: Blind basketing (stone extraction without endoscopic visualization) should never be performed due to high risk of ureteral injury 1, 4

Preoperative Evaluation

Before any surgical intervention:

• Obtain non-contrast CT scan to define exact stone location and degree of hydronephrosis 2, 4
• Perform urinalysis and urine culture to rule out infection 2, 4
• Assess for clinical sepsis 4
• Evaluate renal functional reserve 4

Follow-Up and Monitoring

• Schedule periodic imaging (preferably low-dose CT or ultrasound) to monitor stone position and assess for hydronephrosis 1
• Follow up with urologist within 2-4 weeks if stone has not passed 1
• Complete metabolic testing if indicated (first-time stone formers should have stone analysis performed) 1

Immediate Return to Care Indications

Patients must return immediately if:

• Uncontrolled pain despite adequate analgesia 1
• Fever, chills, or other signs of infection develop 1
• Development of obstruction or worsening hydronephrosis 1
• Anuria (complete cessation of urine output) 1

Special Populations

Pregnancy:

• Renal colic is the most common nonobstetric cause of abdominal pain requiring hospitalization in pregnant patients 3
• Evaluation begins with ultrasonography to limit ionizing radiation 3
• URS has been successfully performed in pregnant patients with very low morbidity 3
• Holmium laser has the advantage of minimal tissue penetration, theoretically limiting risk of fetal injury 3

Pediatric patients:

• SWL outcomes are similar to adults, making it a useful option particularly when patient size may make URS less attractive 3