What is the management approach for a young adult patient diagnosed with ureteric stones and presenting with hypertension?

Management of Ureteric Stones in a Young Adult with Hypertension

For this young adult with ureteric stones and severe hypertension (150/110 mmHg), immediate blood pressure control with ACE inhibitors or ARBs combined with calcium channel blockers is essential, while stone management depends on size: stones <10 mm warrant initial observation with alpha-blocker medical expulsive therapy, but stones >10 mm require ureteroscopy as first-line surgical intervention. 1, 2

Diagnosis and Initial Investigations

Imaging Studies

• Non-contrast CT scan is the gold standard for diagnosing ureteric stones, providing accurate stone size, location, and degree of obstruction 1
• Low-dose CT protocols should be used following ALARA principles to minimize radiation exposure, particularly important in young adults 3
• Ultrasound can assess for hydronephrosis but is inferior for determining exact stone size and location 2

Laboratory Workup

• Urinalysis is mandatory before any intervention to detect infection, which if present requires antibiotic therapy before stone manipulation to prevent urosepsis 3, 1
• Urine culture should be obtained if infection is suspected 3
• Serum creatinine and eGFR to assess renal function, especially critical given the hypertension 3
• In young adults diagnosed with hypertension before age 40, comprehensive screening for secondary hypertension causes is recommended 3
• Consider 24-hour urine collection for stone risk factors (calcium, oxalate, uric acid, citrate, pH) after acute episode resolves 3

Critical Assessment Points

• Verify well-controlled pain status 3, 1
• Rule out clinical signs of sepsis (fever, tachycardia, hypotension) 3, 1
• Confirm adequate renal functional reserve 3, 1
• Check for hydronephrosis severity on imaging 2

Management Based on Stone Size

Stones ≤10 mm

Initial conservative management with observation and medical expulsive therapy is appropriate 1, 2

• Alpha-blockers (tamsulosin) increase stone passage rates by 29% compared to placebo, with distal ureteral stones <10 mm achieving 77.3% stone-free rates versus 54.4% with placebo 1
• Maximum observation period is 6 weeks from initial presentation to prevent irreversible kidney injury 2
• NSAIDs are first-line analgesics for renal colic; opioids only if NSAIDs contraindicated or insufficient 1
• Periodic imaging (ultrasound or low-dose CT) to monitor stone position and hydronephrosis 3, 2

Indications for surgical intervention despite size <10 mm:

• Failure to pass stone after 6 weeks 2
• Uncontrolled pain despite adequate analgesia 1
• Progressive hydronephrosis 2
• Development of infection/sepsis 1
• Patient preference or inability to tolerate conservative management 3

Stones >10 mm

Surgical intervention is required as spontaneous passage is unlikely 1, 2

Ureteroscopy (URS) is first-line therapy:

• Stone-free rates: 95% for stones <10 mm, 78% for stones >10 mm 3
• Single-procedure success rate significantly higher than shock wave lithotripsy (SWL) 1
• Complication rates: stricture 1-4%, sepsis 2-4%, ureteral injury 3-6% 3, 1

Shock wave lithotripsy (SWL) is an alternative:

• Stone-free rates: 87% for stones <10 mm, 73% for stones >10 mm 3
• Lower complication rates (8-10%) compared to URS 3
• May require multiple sessions 3
• Less effective for mid-ureteral stones due to poor visualization 3

Hypertension Management Considerations

Blood Pressure Control Strategy

This patient's BP of 150/110 mmHg requires immediate pharmacological intervention 3

• Target systolic BP: 120-129 mmHg if well tolerated 3
• Initial therapy: ACE inhibitor (lisinopril 10 mg daily) or ARB as first-line for young adults 3, 4
• If BP not controlled with single agent, add dihydropyridine calcium channel blocker (amlodipine) 3
• Three-drug combination if needed: ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic, preferably as single-pill combination 3

Critical Drug Considerations with Ureteric Stones

ACE inhibitors/ARBs are generally safe but require monitoring:

• Monitor renal function closely as these drugs can worsen acute kidney injury in obstructed kidneys 4
• If significant obstruction present, consider delaying ACE inhibitor initiation until stone is managed 4
• Hyperkalemia risk increases, particularly if renal function compromised 4
• Avoid NSAIDs for prolonged periods in patients on ACE inhibitors as combination increases acute kidney injury risk 4

Thiazide diuretics have dual benefit:

• Effective for BP control 3
• Reduce urinary calcium excretion, preventing recurrent calcium stone formation 3
• Particularly valuable for long-term stone prevention in hypertensive patients 3

Hypertension-Stone Disease Connection

• Hypertensive patients have 5.5-fold increased risk of stone formation compared to normotensives 5
• Hypertensives demonstrate higher urinary calcium (263 vs 199 mg/day in males), oxalate (34.8 vs 26.5 mg/day), and uric acid excretion 5
• 14.3% of hypertensive patients develop stones during 5-year follow-up versus 2.9% of normotensives 5

Surgical Timing and Technique Selection

When to Proceed Urgently to Surgery

• Infected obstructed kidney (pyonephrosis) requires emergency decompression within hours 3
• Bilateral obstruction or obstruction in solitary kidney 3
• Acute kidney injury with rising creatinine 4
• Intractable pain or vomiting despite medical management 1

Technique Selection Algorithm

For this young adult, ureteroscopy is preferred over SWL because:

• Higher single-procedure stone-free rates 1
• Better for mid-ureteral stones 3
• Allows direct visualization and stone analysis 3
• Young adults tolerate anesthesia well and benefit from definitive single-procedure treatment 3

SWL may be considered if:

• Stone <10 mm in proximal ureter 3
• Patient preference for less invasive approach 3
• Anatomical factors favor SWL 3

Special Consideration: Anticoagulation

If this patient requires future anticoagulation for any reason, URS remains first-line as it can be safely performed without interrupting anticoagulation, unlike SWL or percutaneous procedures 3

Post-Treatment Management

Immediate Post-Procedure

• Stent placement after URS is not routine but may be needed if significant ureteral trauma, residual fragments, or edema present 3
• Monitor for complications: fever (sepsis), hematuria, flank pain 3, 1
• Ensure adequate hydration 3

Long-Term Stone Prevention

Given the hypertension-stone connection, aggressive metabolic evaluation and prevention is warranted 5

• Obtain 24-hour urine collection 6 months after stone episode to assess calcium, oxalate, uric acid, citrate, volume, and pH 3

• Dietary modifications:

  • Increase fluid intake to achieve urine output >2.5 L/day 3
  • Limit sodium to <2300 mg/day (reduces both BP and urinary calcium) 3, 5
  • Moderate animal protein intake (reduces uric acid and calcium excretion) 3, 5
  • Maintain normal calcium intake (1000-1200 mg/day); restriction paradoxically increases stone risk 3

• Pharmacological prevention based on stone composition:

  • Calcium oxalate stones with hypercalciuria: thiazide diuretics (dual benefit for BP and stones) 3
  • Calcium oxalate stones with hypocitraturia: potassium citrate 3
  • Uric acid stones: potassium citrate to alkalinize urine to pH 6.0 3

Hypertension Long-Term Management

• Maintain BP-lowering therapy lifelong 3
• Annual monitoring of renal function given stone history 3, 4
• Annual 24-hour urine collection to assess adherence and metabolic response 3
• Consider weight management if BMI elevated, as obesity increases both hypertension and stone risk 5

Common Pitfalls to Avoid

• Never perform blind basket extraction without endoscopic visualization - high risk of ureteral injury 3
• Do not use NSAIDs as sole long-term analgesic in patients on ACE inhibitors - increases acute kidney injury risk 4
• Avoid prolonged conservative management beyond 6 weeks - risks irreversible kidney damage 2
• Do not start ACE inhibitor if severe obstruction present - may precipitate acute kidney injury; relieve obstruction first 4
• Never ignore fever in stone patient - infected obstructed kidney is urological emergency requiring immediate decompression 3, 1
• Do not restrict dietary calcium - counterintuitively increases stone risk by increasing intestinal oxalate absorption 3
• Avoid combining two RAS blockers (ACE inhibitor + ARB) - not recommended for hypertension management 3