What is the management for ureter spasm?

Management of Ureteral Spasm

NSAIDs are the first-line treatment for ureteral spasm, as they not only provide superior analgesia but also directly decrease ureteral smooth muscle tone and spasm, making them more effective than opioids for this specific indication. 1

Pharmacologic Management

First-Line: NSAIDs

• NSAIDs should be used preferentially for ureteral spasm because they are at least as effective as opioids for kidney stone pain and have the unique advantage of directly reducing ureteral smooth muscle tone and spasm. 1
• Diclofenac, ibuprofen, and other NSAIDs provide superior pain control with fewer side effects compared to opioids in renal colic. 2
• Use the lowest effective dose to minimize cardiovascular and gastrointestinal risks, particularly in patients with hypertension, renal insufficiency, heart failure, or peptic ulcer disease risk. 1
• NSAIDs work through dual mechanisms: reducing prostaglandin-mediated inflammation and directly relaxing ureteral smooth muscle. 1

Second-Line: Opioids

• Reserve opioids for cases where NSAIDs are contraindicated or provide insufficient pain control. 1, 2
• Opioids provide analgesia but do not address the underlying ureteral spasm mechanism. 1

Adjunctive Therapy: Alpha-Blockers

• Prescribe alpha-blockers (tamsulosin, terazosin, or doxazosin) for stones <10mm to facilitate stone passage and reduce ureteral spasm through alpha-1 receptor blockade. 2, 3
• Alpha-blockers relax ureteral smooth muscle and can increase stone passage rates by 29% while reducing passage time. 2
• These medications are used off-label for this indication; counsel patients accordingly. 2
• Alpha-blockers are particularly effective when combined with NSAIDs for managing both pain and spasm. 3

Pain Management Strategy

• Administer pain medications on a regular schedule rather than "as needed" for optimal control of ureteral spasm and associated pain. 2
• Most stones that will pass spontaneously do so within approximately 17 days (range 6-29 days). 2

Special Considerations

Contraindications to NSAIDs

• When NSAIDs are contraindicated due to cardiovascular or gastrointestinal comorbidities, use opioids as the primary analgesic. 1
• Consider epidural morphine for persistent ureteral colic when conventional systemic treatments fail or are contraindicated, as it abolishes pain and spasm for prolonged periods without interfering with spontaneous stone elimination. 4

Procedural Adjuncts

• During ureteroscopy, local administration of aminophylline (250 mg in 10 mL added to 150 mL irrigation solution) can reduce ureteral spasm, decrease procedure duration, and increase success rates. 5
• This approach reduces the need for ureteral stenting and decreases stone migration to the kidney. 5

Monitoring and Follow-Up

• Schedule periodic imaging (preferably low-dose CT or ultrasound) to monitor stone position and assess for hydronephrosis. 2
• Follow up within 2-4 weeks if the stone has not passed. 2

Urgent Reassessment Indications

• Return immediately for uncontrolled pain despite adequate analgesia, fever/chills suggesting infection, anuria, or signs of worsening obstruction. 2

Common Pitfalls

• Avoid using calcium channel blockers like nifedipine, as clinical trials have shown no significant difference from placebo in relieving acute renal colic despite theoretical benefits. 6
• Do not perform blind basketing (stone extraction without endoscopic visualization) during ureteroscopy. 2
• Ensure timely stent removal if placed, as prolonged stenting causes ongoing mechanical irritation and bladder spasms that no medication can completely eliminate. 3