What is the recommended treatment for an adult with a ureteral stone larger than 5 mm, including analgesia, medical expulsive therapy, dietary recommendations, and criteria for urologic intervention?

Treatment of Ureteral Stones >5 mm in Adults

For adults with ureteral stones larger than 5 mm, initiate medical expulsive therapy with alpha-blockers (tamsulosin 0.4 mg daily) combined with NSAIDs for pain control, while monitoring with periodic imaging over 4-6 weeks maximum; if the stone has not passed by 6 weeks or complications develop, proceed immediately to urologic intervention with ureteroscopy as first-line treatment. 1, 2

Analgesia

First-Line Pain Management

• NSAIDs (diclofenac, ibuprofen, or metamizole) are the primary analgesics for renal colic and should be used at the lowest effective dose to minimize cardiovascular and gastrointestinal risks 1, 3
• NSAIDs reduce the need for additional analgesia compared to opioids and are more effective than antispasmodics 3
• Exercise caution with NSAIDs in patients with reduced glomerular filtration rate, as they may impact renal function 1, 3

Second-Line Pain Management

• Opioids serve as second-choice analgesics only when NSAIDs are contraindicated or provide insufficient pain control 1, 3
• If opioids are required, use hydromorphone, pentazocine, or tramadol rather than pethidine, which causes higher rates of vomiting and need for additional analgesia 1, 3

Medical Expulsive Therapy (MET)

Alpha-Blocker Therapy

• Alpha-blockers demonstrate greatest benefit for stones >5 mm in the distal ureter, with a 29% absolute increase in stone passage rates compared to controls 1, 2
• Tamsulosin 0.4 mg daily is the preferred agent, increasing stone expulsion rates to 81-87% compared to 61-79% with placebo for stones 5-10 mm 4
• The number needed to treat is 4-5 patients for stones 5-10 mm 4
• Tamsulosin reduces time to stone expulsion by approximately 3 days and decreases pain episodes and analgesic requirements 4
• Counsel patients that alpha-blockers are used off-label for this indication and discuss potential side effects including orthostatic hypotension, dizziness, and retrograde ejaculation 2, 4

Duration and Monitoring

• Continue MET for a maximum of 4-6 weeks from initial presentation; do not exceed this timeframe as complete ureteral obstruction beyond 6 weeks risks irreversible kidney injury 1, 2, 4
• Follow patients with periodic low-dose CT or renal ultrasound to monitor stone position and assess for progressive hydronephrosis 2
• Obtain repeat imaging at weeks 2-4 if no stone passage occurs to reassess stone position 4

Patient Selection Criteria

• Patients must have well-controlled pain with oral analgesics, no clinical evidence of sepsis, and adequate renal functional reserve before initiating conservative management 2, 3
• Discontinue tamsulosin immediately if infection/sepsis, declining renal function, or signs of obstruction requiring urgent intervention develop 4

Dietary Recommendations

For Acute Stone Episode

• No specific dietary modifications are recommended during the acute stone episode; focus remains on hydration and medical management 1

For Long-Term Stone Prevention

• Increase fluid intake to achieve urine output >2.5 L/day to prevent recurrent stone formation 1
• Current evidence is insufficient to conclude that assessing baseline stone composition before initiating dietary interventions reduces stone recurrence 1
• Specific dietary recommendations should be tailored after stone analysis is performed on the passed or retrieved stone 1

Criteria for Urologic Intervention

Urgent Intervention (Immediate)

• Sepsis and/or anuria in an obstructed kidney requires urgent decompression via percutaneous nephrostomy or ureteral stenting 1, 2
• Collect urine for antibiogram testing before and after decompression 1
• Administer antibiotics immediately and re-evaluate the regimen following antibiogram findings 1
• Delay definitive stone treatment until sepsis is resolved 1

Elective Intervention Indications

• Failed conservative management after 4-6 weeks (mandatory intervention to prevent irreversible renal damage) 2, 4
• Uncontrolled pain despite adequate analgesia 2
• Development of fever or signs of infection during observation period 2
• Progressive hydronephrosis on follow-up imaging 2

Surgical Options for Stones 5-10 mm

• Ureteroscopy (URS) is the first surgical option for ureteral stones that fail conservative management, achieving stone-free rates of 90-95% in a single session 1, 2
• Extracorporeal shock wave lithotripsy (ESWL) is an equivalent first-line option with stone-free rates of 80-85%, though it often requires repeat sessions 2
• URS has no specific contraindications aside from general anesthesia risks and untreated UTIs 1
• Routine pre-stenting before URS is not required, as successful access is achievable on the initial attempt in most cases 1, 2
• Routine post-URS stenting is unnecessary after uncomplicated procedures but should be considered with trauma, residual fragments, bleeding, perforation, UTI, or pregnancy 1

Surgical Options for Stones >10 mm

• For stones >10 mm, proceed directly to urologic intervention rather than attempting MET, as spontaneous passage rates are low and complication risk is high 2, 4
• URS remains the preferred option, with flexible ureteroscopy increasingly favored due to technical advances 1
• Percutaneous antegrade URS is an option for large (>15 mm), impacted proximal ureteral stones in dilated systems or when retrograde access is not feasible 1

Special Considerations

Uric Acid Stones

• Oral chemolysis with alkalinization using citrate or sodium bicarbonate (target pH 7.0-7.2) is strongly recommended for uric acid stones, with an 80.5% success rate 1, 2
• Patients should monitor their urine pH during treatment 1
• Combining alkalinization with tamsulosin improves passage rates for uric acid stones in the distal ureter 4

Pretreatment Requirements

• Obtain urine microscopy and culture before any stone treatment to exclude or treat UTI 2
• Perform biochemical urine work-up (dipstick) and blood tests (creatinine, uric acid, ionized calcium, sodium, potassium, blood cell count, CRP) 1
• Use low-dose non-contrast CT to confirm stone size, location, density, and anatomy after initial ultrasound evaluation 1, 2

Common Pitfalls to Avoid

• Never delay intervention beyond 6 weeks in patients attempting conservative management, as this risks irreversible kidney damage 2, 4
• Do not use alpha-blockers in patients with sepsis or significant obstruction requiring urgent decompression 2
• Avoid NSAIDs in patients with significantly reduced GFR or active gastrointestinal disease 1, 3
• Do not continue tamsulosin beyond 30 days if the stone has not passed; reassess for intervention 4
• Do not withhold tamsulosin from women based solely on FDA labeling for BPH, as the mechanism of action for stone passage is sex-independent 4