What is the likely cause and appropriate management of new flank pain and dysuria after endoscopic kidney stone removal with ureteral stent placement?

Flank Pain with Urination After Ureteral Stent Placement

The flank pain and dysuria you describe are most likely stent-related symptoms, which occur in approximately 80% of patients after ureteral stent placement and represent expected postoperative morbidity rather than a complication requiring urgent intervention. 1

Understanding the Cause

The symptoms arise from two primary mechanisms:

• Bladder irritation from the distal curl of the stent causing trigonal irritation, leading to dysuria and urinary frequency 1, 2
• Ureteral reflux with retrograde flow of urine through the stent up to the renal pelvis during voiding, transmitting high pressures that cause flank pain 1, 2

This pain pattern—flank discomfort specifically with urination—is pathognomonic for stent-related reflux and does not indicate stent malposition, obstruction, or infection in the absence of fever or other concerning features. 2

Critical Red Flags to Exclude

Before attributing symptoms to benign stent-related discomfort, you must actively exclude:

• Fever, rigors, or signs of sepsis - these mandate urgent evaluation for obstructive pyelonephritis, which requires emergent decompression and IV antibiotics 3, 4
• Severe unilateral flank pain at rest (not just with voiding) - consider stent migration or obstruction 5
• Complete anuria or significantly decreased urine output - suggests bilateral obstruction or stent malfunction 3
• Persistent gross hematuria beyond 48-72 hours - while mild hematuria is expected, persistent bleeding warrants evaluation 6

If any of these features are present, obtain urgent imaging (CT scan without contrast or renal ultrasound) and urine culture. 3

Management Approach

First-Line Pharmacologic Management

Initiate alpha-blocker therapy (tamsulosin 0.4 mg daily) as first-line treatment, as this has the strongest evidence for reducing stent-related symptoms. 7, 2

Additional options to consider in combination:

• Anticholinergic medications (e.g., oxybutynin, solifenacin) for bladder irritative symptoms and urgency 1, 2
• NSAIDs (ibuprofen, diclofenac) for pain control, using the lowest effective dose 3, 2
• Avoid routine opioids unless NSAIDs are contraindicated or insufficient 3

The evidence supports a multimodal approach combining alpha-blockers with anticholinergics and NSAIDs as most effective for symptom control. 2

Reassurance and Expectation Setting

• Stent-related symptoms are temporary and will resolve completely upon stent removal 1
• Symptoms typically persist throughout the stenting period but do not indicate treatment failure 2
• Plan for stent removal within 14 days when possible to minimize symptom duration and reduce infection risk 7

When to Escalate Care

Arrange urgent follow-up or imaging if:

• Symptoms worsen despite medical management
• New fever develops (temperature >38°C/100.4°F)
• Severe pain unresponsive to oral analgesics
• Signs of urinary retention or significantly decreased output

Common Pitfalls to Avoid

• Do not reflexively remove the stent prematurely if it was placed for a valid indication (ureteral injury, stricture, large residual stone burden, solitary kidney, or renal insufficiency), as these conditions mandate temporary stenting 6, 7
• Do not prescribe antibiotics empirically for stent symptoms alone without evidence of infection (fever, positive urinalysis, elevated WBC) 4
• Do not obtain routine imaging for typical stent symptoms in an afebrile patient with normal voiding—this adds unnecessary cost and radiation exposure 3

Follow-Up Planning

• Schedule stent removal at the appropriate interval based on the indication (typically 1-2 weeks for uncomplicated ureteroscopy) 7
• Provide clear return precautions regarding fever, severe pain, or urinary retention
• Consider a pull-string stent at initial placement when feasible to avoid secondary cystoscopy for removal 6