What is the initial management for a patient presenting with a ureteric stone?

Initial Management of Ureteric Stones

For patients presenting with ureteric stones ≤10 mm, initiate conservative management with alpha-blockers (medical expulsive therapy) combined with NSAIDs for pain control, while monitoring with periodic imaging over 4-6 weeks. 1

Immediate Assessment Requirements

Before initiating conservative management, confirm the patient meets these criteria:

• Well-controlled pain with oral analgesics 1
• No clinical evidence of sepsis 1
• Adequate renal functional reserve 1
• Obtain urine microscopy and culture to exclude or treat UTI before any treatment 1
• Confirm stone size and location with appropriate imaging (preferably low-dose non-contrast CT) 1

First-Line Pain Management

NSAIDs are the primary analgesics for renal colic and should be used at the lowest effective dose to minimize cardiovascular and gastrointestinal risks. 1, 2 Options include diclofenac, ibuprofen, or metamizole. 2

• NSAIDs are superior to opioids, reducing the need for additional analgesia and providing more effective pain control than antispasmodics 2
• Reserve opioids as second-line therapy only when NSAIDs are contraindicated or insufficient 1, 2
• Avoid NSAIDs in patients with significantly reduced GFR or active gastrointestinal disease 1, 2

Medical Expulsive Therapy (MET)

Alpha-blockers are the cornerstone of medical expulsive therapy, showing greatest benefit for stones >5 mm in the distal ureter. 1, 2 Options include tamsulosin, terazosin, or doxazosin. 2

• Alpha-blockers increase stone passage rates by 29% compared to control patients 2
• Counsel patients that alpha-blockers are used off-label for this indication and discuss potential side effects 1, 2
• Most stones that pass spontaneously do so within approximately 17 days (range 6-29 days) 3

Mandatory Monitoring Protocol

Follow patients with periodic imaging (low-dose CT or ultrasound) to monitor stone position and assess for hydronephrosis. 1, 3

• Maximum duration of conservative management is 4-6 weeks from initial presentation 1, 3
• Do not delay intervention beyond 6 weeks, as this risks irreversible kidney damage 1
• Schedule follow-up with urology within 2-4 weeks if the stone has not passed 3

Urgent Intervention Requirements

Immediate decompression via percutaneous nephrostomy or ureteral stenting is mandatory for: 1, 2

• Sepsis or uncontrolled infection
• Anuria (complete cessation of urine output)
• Uncontrolled pain despite adequate analgesia

Do not use alpha-blockers in patients with sepsis or significant obstruction requiring urgent decompression. 1

Elective Intervention Indications

Proceed to definitive treatment if: 1

• Failed conservative management after 4-6 weeks
• Uncontrolled pain despite optimal medical therapy
• Development of fever or signs of infection
• Progressive hydronephrosis on follow-up imaging

For stones <10mm requiring intervention, ureteroscopy (URS) is the first surgical option, though shockwave lithotripsy (SWL) is an equivalent alternative. 1, 3 URS yields significantly greater stone-free rates but has slightly higher complication rates. 3

Special Considerations for Specific Stone Types

For uric acid stones, oral chemolysis with alkalinization is strongly recommended, with a success rate of 80.5%. 1 Potassium citrate should be used to raise urinary pH to 6.0. 4