What are the treatment options for kidney stone symptoms?

Treatment Options for Kidney Stone Symptoms

NSAIDs, specifically intramuscular diclofenac 75 mg, are the definitive first-line treatment for acute kidney stone pain, providing superior relief within 30 minutes by directly decreasing ureteral smooth muscle tone and spasm rather than just masking symptoms. 1, 2

Acute Pain Management

• Administer diclofenac 75 mg IM, ibuprofen, or metamizole as first-line analgesics for renal colic, as NSAIDs reduce the need for additional analgesia compared to opioids and address the underlying pain mechanism. 1, 2

• Use the lowest effective NSAID dose to minimize cardiovascular and gastrointestinal risks, particularly in patients with low glomerular filtration rate. 1

• Reserve opioids (hydromorphine, pentazocine, or tramadol) only as second-line agents when NSAIDs are contraindicated due to cardiovascular disease, gastrointestinal comorbidities, hypertension, renal insufficiency, heart failure, or peptic ulcer risk. 1, 2

• Avoid pethidine specifically, as it is associated with higher rates of vomiting and need for additional analgesia compared to other opioids. 1

Emergency Situations Requiring Urgent Intervention

Sepsis with obstructed kidney demands immediate decompression via percutaneous nephrostomy or ureteral stenting—this is a urologic emergency that cannot be delayed. 1, 2

• Collect urine for antibiogram testing before and after decompression, administer antibiotics immediately, and re-evaluate the regimen following antibiogram findings. 1

• Delay definitive stone treatment until sepsis resolves. 1

• Admit immediately for fever with obstruction, shock, failure to respond to analgesia within one hour, abrupt recurrence of severe pain after initial relief, patients over 60 years, or women with delayed menses. 2

Conservative Management with Medical Expulsive Therapy

For stones ≤10 mm, offer observation with alpha-blockers (tamsulosin) as medical expulsive therapy (MET), which provides greatest benefit for stones >5 mm in the distal ureter. 1, 2

• Spontaneous passage rates vary by location: 68–83% for distal ureteral stones, 58–70% for mid-ureteral stones, and 49–52% for upper ureteral stones. 1

• Stones <5 mm pass in 75% of cases, typically within 17 days, while stones ≥5 mm pass in 62% of cases. 1

• For distal stones <5 mm, passage rate is 89%; for upper ureteral stones <5 mm, it is 75%. 1

• Stop MET if complications arise, including infection, refractory pain, or decline in renal function. 1

• The maximum duration of conservative treatment is 4–6 weeks from initial presentation. 2

Surgical Intervention Options

For stones >10 mm, most will require surgical treatment, with ureteroscopy (URS) being first-line for distal ureteral stones, offering better stone-free rates with a single procedure but higher complication rates than shock wave lithotripsy (SWL). 2

Extracorporeal Shock Wave Lithotripsy (ESWL)

• ESWL has fewer complications than PCNL or URS, with 18.43% Clavien grade I–II and 2.48% Clavien grade III–IV complications. 1

• Complications include steinstrasse (4%), macroscopic hematuria (17.2%), pain (12.1%), need for auxiliary procedures (6–9%), and sepsis (0.15%). 1

Ureteroscopy (URS)

• URS has no specific contraindications aside from general anesthesia risks and untreated UTIs. 1

• Routine post-URS stenting is unnecessary after uncomplicated procedures and may increase morbidity, but stenting is advised with trauma, residual fragments, bleeding, perforation, UTI, or pregnancy. 1

• Alpha-blockers improve stent tolerability. 1

Percutaneous Nephrolithotomy (PCNL)

• PCNL remains the standard treatment for large renal stones. 1

• Mini-PCNL (12–22 F) and standard PCNL (>22 F) provide similar stone-free rates, but mini-PCNL reduces blood loss, transfusion rates, and length of hospital stay. 1

• Complications include fever (10.8%), transfusion (7%), thoracic complications (1.5%), sepsis (0.5%), organ injury (0.4%), and mortality (0.05%). 1

• Tubeless PCNL reduces pain and length of hospital stay; totally tubeless PCNL is effective in uncomplicated cases. 1

Stone Type-Specific Medical Management

Uric Acid Stones

• Potassium citrate is first-line therapy to alkalinize urine to pH 6.0–7.2, as most patients have low urinary pH rather than hyperuricosuria. 3, 2

• Oral chemolysis with citrate or sodium bicarbonate shows 80.5% success rate, with 15.7% needing further intervention. 1

• Do not prescribe allopurinol as first-line therapy without addressing urinary pH. 3, 2

Calcium Stones

• Offer thiazide diuretics (hydrochlorothiazide) to patients with hypercalciuria and recurrent calcium stones, with dietary sodium restriction to maximize hypocalciuric effect. 3, 2

• For patients with low urinary citrate, potassium citrate therapy increases urinary pH and inhibits stone formation. 3

Cystine Stones

• First-line treatment includes increased fluid intake (at least 4 liters per day), sodium/protein restriction, and urinary alkalinization to pH 7.0 with potassium citrate. 3, 2

• Add cystine-binding thiol drugs (tiopronin preferred over d-penicillamine) if unresponsive to dietary modifications. 3

Struvite Stones

• Urease inhibitors (acetohydroxamic acid) may be beneficial, though side effects may limit use. 3

• Monitor for reinfection. 4

Supportive Care and Prevention

• Instruct patients to drink fluids targeting urine output of at least 2.5 liters daily to promote stone passage and prevent recurrence. 3, 2

• Coffee, tea, wine, and orange juice are associated with lower stone risk, while sugar-sweetened beverages should be avoided. 2

Diagnostic Workup

• Obtain stone analysis at least once when available, as composition directs specific preventive measures. 4, 2

• Perform urinalysis with both dipstick and microscopic evaluation to assess urine pH, infection indicators, and identify pathognomonic crystals. 4

• Order serum chemistries including electrolytes, calcium, creatinine, and uric acid to identify underlying metabolic conditions. 4

• Renal ultrasonography is the recommended first-line imaging modality to quantify stone burden. 4, 2

Antibiotic Prophylaxis for Procedures

• Obtain urine microscopy and culture results before stone treatment to exclude or treat UTI. 1

• Administer perioperative antibiotic prophylaxis to all patients undergoing endourological treatment, with a single dose before ureteroscopy being sufficient. 1

• For PCNL in high-risk patients, an extended course of preoperative antibiotics significantly reduces postoperative sepsis and fever compared to a single dose. 1

• Tailor antibiotic choice to institutional or regional antimicrobial susceptibility patterns. 1

Follow-Up and Monitoring

• Obtain a 24-hour urine specimen within six months of initiating treatment to assess response to therapy. 3

• Perform annual 24-hour urine collections for ongoing monitoring, with more frequent testing depending on stone activity. 3

• Obtain periodic blood testing to monitor for adverse effects in patients on pharmacological therapy, such as hypokalemia with thiazides or hyperkalemia with potassium citrate. 3

• Obtain repeat stone analysis when available, especially in patients not responding to treatment. 3, 2

Critical Pitfalls to Avoid

• Do not use opioids as first-line therapy for acute kidney stone pain, as NSAIDs are superior and avoid dependence risks. 2

• Do not delay admission for fever with obstruction, as this represents sepsis requiring urgent drainage. 2

• Do not use sodium citrate instead of potassium citrate, as it may increase urine calcium excretion. 3

• Failure to monitor for medication side effects can be detrimental to patient care. 3