Can a clinically stable adult with a 2 mm distal ureteral stone, moderate hydronephrosis, no infection or renal impairment, and no major comorbidities (uncontrolled diabetes, coagulopathy, severe cardiac disease) be safely discharged?

Can You Discharge Someone with a 2mm Distal Ureteral Stone and Moderate Hydronephrosis?

Yes, a clinically stable adult with a 2mm distal ureteral stone and moderate hydronephrosis can be safely discharged with medical expulsive therapy, appropriate pain control, and close outpatient follow-up, provided there is no evidence of infection, uncontrolled pain, or renal impairment. 1, 2

Key Discharge Criteria That Must Be Met

Your patient must satisfy ALL of the following before discharge is appropriate:

• Well-controlled pain with oral analgesics (NSAIDs as first-line) 1, 3
• No clinical evidence of sepsis (no fever, normal or stable leukocytosis, negative signs of systemic infection) 1, 2
• Adequate renal functional reserve (stable creatinine, no acute kidney injury) 1
• Ability to tolerate oral intake and maintain hydration 2
• Reliable follow-up available within 2-4 weeks 2

Why This Stone Has Excellent Prognosis

A 2mm distal ureteral stone has a very high spontaneous passage rate (stones ≤5mm have approximately 62-65% passage rate, with smaller stones having even higher rates). 2, 4 Most stones that pass spontaneously do so within approximately 17 days (range 6-29 days). 2, 4

The moderate hydronephrosis, while notable, does not contraindicate discharge in a stable patient. Research shows that moderate hydronephrosis is associated with only slightly higher passage failure rates (28%) compared to mild hydronephrosis (20%), and is not strongly predictive of need for intervention in small stones. 5 Severe hydronephrosis would be more concerning and warrant closer monitoring or earlier urologic referral. 5

Discharge Management Plan

Pain Control

• NSAIDs (diclofenac, ibuprofen) are first-line for renal colic 2, 3
• Use at the lowest effective dose, particularly with eGFR considerations 2
• Opioids should be reserved as second-line only when NSAIDs are contraindicated or insufficient 2, 3

Medical Expulsive Therapy

• Alpha-blockers (tamsulosin 0.4mg daily) should be prescribed to facilitate stone passage 2, 3
• Counsel the patient that this is off-label use and discuss potential side effects (orthostatic hypotension, dizziness) 1, 3
• Alpha-blockers show greatest benefit for stones >5mm in the distal ureter, but can still be beneficial for smaller stones 2, 3

Mandatory Follow-Up Imaging

• Periodic imaging is required to monitor stone position and assess for worsening hydronephrosis 1, 2
• Preferred modalities: low-dose CT or ultrasound 2, 3
• Timing: within 2-4 weeks for routine follow-up, or sooner if symptoms change 2

Maximum Duration of Conservative Management

• Do not exceed 4-6 weeks of observation from initial presentation 2, 4, 3
• Prolonged obstruction beyond this timeframe risks irreversible kidney damage 4, 3

Red Flags Requiring Urgent Return or Intervention

Instruct the patient to return immediately or seek urgent urologic consultation if any of the following develop:

• Fever or signs of infection (this becomes a urologic emergency with obstruction) 1, 2, 3
• Uncontrolled pain despite adequate analgesia 2, 3
• Inability to tolerate oral intake or maintain hydration 2
• Anuria or significant decrease in urine output 3
• Worsening symptoms suggesting progression of obstruction 2

When Intervention Becomes Necessary

If conservative management fails, intervention options include:

• Ureteroscopy (URS): 90-95% stone-free rate in single procedure for stones <10mm, but more invasive 2, 4
• Extracorporeal shock wave lithotripsy (ESWL): 80-85% success rate with lower morbidity, may require repeat procedures 2, 4

For a 2mm stone, intervention would rarely be needed unless complications develop. 2

Critical Pitfalls to Avoid

• Do not discharge if there is any suspicion of infection in the setting of obstruction—this requires urgent decompression via ureteral stent or percutaneous nephrostomy 1, 3
• Do not confuse "small size" with "low risk"—even a small stone can cause complete obstruction and severe complications if infection develops 2
• Do not allow observation to extend beyond 6 weeks without reassessment, as this risks permanent renal damage 2, 4, 3
• Do not use NSAIDs indiscriminately—use caution with reduced eGFR or active GI disease 2, 3

Outpatient Urology Referral

• Non-urgent referral to urology is appropriate for stable patients with controlled symptoms 2
• Referral should occur within 2-4 weeks for follow-up imaging and assessment 2
• Urgent referral is necessary if red flags develop or if stone has not passed by 4-6 weeks 2, 3