What should a patient with a 5mm ureteral stone, unable to pass for 5 days, and ongoing pain do?

Should This Patient Return to the Emergency Department?

Yes, this patient should return to the ER or seek urgent urologic evaluation now—after 5 days with ongoing pain and a 5mm stone that hasn't passed, they need reassessment for potential complications and consideration of active intervention. 1

Why Urgent Evaluation is Needed

Timeline Concerns

• Most stones that pass spontaneously do so within approximately 17 days (range 6-29 days), but ongoing pain after 5 days warrants reassessment to exclude complications 2
• The patient should have well-controlled pain with oral analgesics to continue conservative management—if pain persists despite adequate analgesia, this is a red flag requiring immediate medical attention 1, 2

Critical Warning Signs to Assess

The patient needs urgent evaluation to rule out:

• Fever, chills, or signs of infection (which would mandate urgent decompression via stenting or nephrostomy) 1, 2
• Uncontrolled pain despite adequate analgesia (indication for intervention) 1, 2
• Progressive hydronephrosis or worsening obstruction (requires imaging to assess) 1, 2
• Anuria or significantly decreased urine output (medical emergency) 2

What Should Happen at This Visit

Immediate Assessment Required

• Urine microscopy and culture to exclude or treat urinary tract infection 1
• Imaging (preferably low-dose CT or ultrasound) to monitor stone position and assess for hydronephrosis 1, 2
• Evaluation for signs of sepsis or infection, which would require urgent decompression 1

Treatment Decision Points

If complications are present (fever, sepsis, anuria, uncontrolled infection):

• Urgent decompression via percutaneous nephrostomy or ureteral stenting is mandatory 1

If no complications but pain is uncontrolled:

• This constitutes an indication for elective intervention rather than continued conservative management 1
• Options include ureteroscopy (94% stone-free rate for distal stones, 86% for mid-ureter) or shock wave lithotripsy 3, 2

If pain is manageable and no complications:

• Can continue conservative management with medical expulsive therapy (alpha-blockers like tamsulosin) combined with NSAIDs 1, 2
• Alpha-blockers show greatest benefit for stones >5mm in the distal ureter 1
• However, intervention should not be delayed beyond 6 weeks total, as this risks irreversible kidney damage 1

Key Clinical Pitfall

A 5mm stone has a reasonable chance of spontaneous passage, but the persistence of pain after 5 days suggests either inadequate pain control, developing complications, or that the stone may not pass spontaneously. The European Urology guidelines emphasize that patients must have well-controlled pain with oral analgesics to continue conservative management 1. Since this patient is "still having pain," they do not meet criteria for safe outpatient observation without reassessment.

Bottom Line

Return to the ER now for reassessment. The goal is to exclude complications requiring urgent intervention and to determine whether continued conservative management is appropriate or whether active stone removal (ureteroscopy or lithotripsy) should be pursued 1, 2.