What is the treatment for urolithiasis?

Treatment of Urolithiasis

NSAIDs (diclofenac, ibuprofen, or metamizole) are the first-line treatment for acute renal colic, while definitive management depends on stone size, location, and clinical presentation—with ureteroscopy offering the highest stone-free rates for most ureteral stones requiring intervention. 1

Acute Pain Management

Initial Analgesia:

• NSAIDs are superior to opioids for controlling renal colic pain and reduce the need for additional analgesia 1, 2
• Use the lowest effective NSAID dose to minimize cardiovascular and gastrointestinal risks, particularly in patients with reduced glomerular filtration rate 1, 2
• Opioids (hydromorphone, pentazocine, or tramadol—NOT pethidine) serve as second-line agents when NSAIDs are contraindicated or insufficient 1, 2

Critical Caveat: NSAIDs may impair renal function in patients with low GFR, requiring careful monitoring or alternative analgesics 2

Emergency Management

Immediate decompression via percutaneous nephrostomy or ureteral stenting is mandatory before any definitive treatment in patients with:

• Sepsis with obstructed kidney 1, 3
• Anuria with obstruction 1, 3
• Purulent urine discovered during endoscopic procedures (stop procedure immediately) 3

For infected nephrolithiasis with obstruction:

• Perform urgent drainage first 3
• Start broad-spectrum antibiotics immediately (third-generation cephalosporins or fluoroquinolones covering gram-negative enterobacteria) 3
• Delay definitive stone treatment until complete infection resolution 3

Medical Expulsive Therapy (MET)

Alpha-blockers (tamsulosin) are recommended for:

• Ureteral stones, particularly >5mm in the distal ureter 1, 2
• Patients with well-controlled pain, no sepsis, and adequate renal function 1, 2
• MET increases stone passage rates by 29% compared to controls and reduces passage time 1, 2

Patient counseling required: Inform patients this is off-label use with associated drug side effects 2

Definitive Surgical Management

Treatment Algorithm by Stone Characteristics:

Ureteral Stones Requiring Removal:

• Both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line options 1
• URS yields significantly greater stone-free rates for most stone stratifications 1, 2

Renal Stones:

• Stones >20mm: Percutaneous nephrolithotomy (PCNL) is the accepted indication 1, 4
• Staghorn and partial staghorn calculi: PCNL 4
• Stones 10-20mm (excluding lower pole): ESWL or flexible ureteroscopy 4
• Lower pole stones 1.5-2cm: Flexible ureteroscopy preferred if difficult anatomy or ESWL-resistant stones 4

Pre-operative imaging: Non-contrast CT is recommended before PCNL to determine optimal surgical approach (93.1% sensitivity, 96.6% specificity) 1

Prevention of Recurrence

Universal Recommendations for All Stone Formers:

• Increase fluid intake to achieve urine volume ≥2.5 L/day 1, 5, 6
• Perform stone analysis for all first-time stone formers to guide targeted treatment 1
• Follow-up with 24-hour urine collections within 8-12 weeks after initiating therapy 1

Stone-Specific Prevention:

Calcium Stone Formers:

• Maintain normal dietary calcium intake of 1,000-1,200 mg/day 1
• Hypercalciuric patients: Thiazide diuretics 1, 5
• Hypocitraturic patients: Alkali citrate or sodium bicarbonate 1, 5
• Hyperuricosuric calcium stone formers: Allopurinol 1, 5

Uric Acid Stone Formers:

• Urinary alkalization with alkaline citrates to achieve urine pH 6.2-6.8 1, 5
• Allopurinol for hyperuricosuric patients 5

Cystine Stone Formers:

• Increase fluid intake to achieve urine output ≥3L/day 1, 5
• Urinary alkalization to achieve urine pH 7.0-7.5 1, 5
• Restrict sodium and animal protein ingestion 5
• Cystine-binding thiol drugs (tiopronin, D-penicillamine) reserved for conservative treatment failures 5

Struvite Stone Formers:

• Complete stone removal is optimal management 5
• Acetohydroxamic acid only after surgical options exhausted, but has many side effects 5

Monitoring and Follow-Up

• Follow-up 24-hour urine collections at 8-12 weeks after initiating therapy 1
• Periodic blood tests to monitor for adverse effects of pharmacological therapy 1
• Regular imaging studies to assess for stone growth or new stone formation 1, 2
• Do not treat asymptomatic bacteriuria after treatment 3

Critical Pitfalls to Avoid

• Never attempt stone removal before draining an infected obstructed system—this is a urological emergency that can progress to sepsis and death 3
• Approximately 50% of recurrent stone-formers experience only one recurrence, while 10% have highly recurrent disease requiring aggressive prevention 1
• Febuxostat carries FDA safety alert for increased cardiac death risk compared to allopurinol 1
• Post-intervention residual fragments <4mm in asymptomatic patients without infection can be monitored actively 4