Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Primary options
indomethacin: 25-50 mg orally (immediate-release) three times daily when required
or
diclofenac sodium: 50 mg orally (immediate-release) three times daily when required; 37.5 mg intravenously every 6 hours when required
or
ketorolac: consult specialist for guidance on dose
-- AND / OR --
morphine sulfate: 2.5 to 10 mg intravenously/intramuscularly/subcutaneously every 2-6 hours when required
-- AND --
ondansetron: 4 mg intravenously every 8-12 hours when required
Acute medical treatment for suspected renal or ureteric colic includes conservative therapies such as hydration, analgesia (a nonsteroidal anti-inflammatory drug [NSAID] such as diclofenac, indomethacin, or ketorolac, and/or an opioid such as morphine), and an anti-emetic (e.g., ondansetron).[55]
[ 
]
NSAIDs should be offered first-line unless contraindicated (e.g., patients at risk of renal impairment, cardiac failure, gastric ulceration).[38][56][57][Evidence C] Parental NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[53][58] However, NSAIDs can be offered by any route.[56][Evidence C] Examples are listed above.
Primary options
indomethacin: 25-50 mg orally (immediate-release) three times daily when required
or
diclofenac sodium: 50 mg orally (immediate-release) three times daily when required; 37.5 mg intravenously every 6 hours when required
or
ketorolac: consult specialist for guidance on dose
-- AND / OR --
morphine sulfate: 2.5 to 10 mg intravenously/intramuscularly/subcutaneously every 2-6 hours when required
-- AND --
ondansetron: 4 mg intravenously every 8-12 hours when required
Patients with newly diagnosed ureteric stones <10 mm without complicating factors (urosepsis, intractable pain and/or vomiting, impending acute renal failure, obstruction of a solitary or transplanted kidney, or bilateral obstruction) can be managed expectantly.[48]
Conservative treatment for confirmed stones with renal or ureteric colic includes hydration, analgesia (nonsteroidal anti-inflammatory drugs [NSAIDs] such as diclofenac, indomethacin, or ketorolac, and/or an opioid such as morphine), and an anti-emetic (e.g., ondansetron).[55]
[ ]
NSAIDs should be offered first-line unless contraindicated (e.g., patients at risk of renal impairment, cardiac failure, gastric ulceration).[38][56][57][Evidence C] Parental NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[53][58] However, NSAIDs can be offered by any route.[56][Evidence C] Examples are listed above.
demonstrated bacteriuria
Treatment recommended for SOME patients in selected patient group
If infection is present, but no obstruction or signs of sepsis, the patient can be treated with conservative therapy and antibiotics.
Empiric antibiotic therapy should be started pending sensitivity results based on urinalysis cultures. The empiric regimen depends on various factors, including the type of infection, patient factors, and local antibiotic resistance patterns; consult local guidelines for more information on choice of antibiotics.
Treatment recommended for SOME patients in selected patient group
Patients with urinary calculi along with fever and other signs or symptoms of infection need emergency urologic consultation for drainage and intravenous antibiotics.
Drainage can be accomplished in two ways. In the acute setting, a urologist can place a ureteric stent past the obstructing stone and achieve renal drainage. Alternatively, percutaneous nephrostomy by an interventional radiologist may be performed. Failure to perform rapid renal decompression can lead to urosepsis and death.
stones <10 mm
Treatment recommended for SOME patients in selected patient group
Primary options
tamsulosin: 0.4 mg orally once daily
OR
alfuzosin: 10 mg orally once daily
OR
silodosin: 8 mg orally once daily
There is evidence to support that MET can increase ureteral stone passage rate and decrease the time to stone passage in stones <10 mm in size.[54]
Using an alpha-blocker, such as tamsulosin, alfuzosin, or silodosin may be of benefit in promoting larger (but still <10 mm) distal ureteral stone passage; however, efficacy rates have been questioned.[64][61][62][60][63][103][104][105]
[ ]
These agents should be given for 4-6 weeks or until the stone is passed. If the stone has still not passed by that time, surgical intervention is recommended.
Patients should be made aware that prescribing alpha-blockers for this indication is considered an off-label use of these drugs. Additionally, tamsulosin has been associated with intraoperative floppy iris syndrome, therefore it should not be prescribed if a patient has planned cataract surgery.
stones ≥10 mm or failed medical therapy
Treatment recommended for SOME patients in selected patient group
For smaller stones that fail conservative therapies (e.g., uncontrolled symptoms, failure of stone to progress, or persistent obstruction), additional surgical treatment is necessary.
Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy are considered first-line treatments. However, ureteroscopy in general is associated with better stone-free rates than ESWL.
Percutaneous antegrade ureteroscopy involves percutaneous antegrade removal of ureteric stones, and can be considered in select cases with very large (>15 mm) stones impacted in the upper ureter or when retrograde access is not possible.
Percutaneous nephrostolithotomy (PCNL) is minimally invasive and usually reserved for renal and proximal ureteric stones (i.e., in the lower pole) and those that are large (>20 mm), have failed therapy with ESWL and ureteroscopy, or are associated with complex renal anatomy.[48]
Laparoscopic or open surgical stone removal may be considered in rare cases where ESWL, ureteroscopy, and percutaneous ureteroscopy fail, or are unlikely to be successful.
Primary options
indomethacin: 25-50 mg orally (immediate-release) three times daily when required
or
diclofenac sodium: 50 mg orally (immediate-release) three times daily when required; 37.5 mg intravenously every 6 hours when required
or
ketorolac: consult specialist for guidance on dose
-- AND / OR --
morphine sulfate: 2.5 to 10 mg intravenously/intramuscularly/subcutaneously every 2-6 hours when required
-- AND --
ondansetron: 4 mg intravenously every 8-12 hours when required
Patients with obstructed urinary calculi with infection require emergency urologic consultation and surgical drainage, with intravenous antibiotics and supportive measures (hydration, analgesia with a non steroidal anti-inflammatory drug such as diclofenac, indomethacin, or ketorolac, and/or an opioid such as morphine, and an anti-emetic such as ondansetron) as necessary.
If obstruction is present without infection, the patient can be managed conservatively; if the pain cannot be managed with a nonsteroidal anti-inflammatory drug (if renal function normal) and/or an opioid, then decompression should be considered.[1] If obstruction is present with infection decompression and antibiotics are essential to minimize risk for life-threatening sepsis.
NSAIDs should be offered first-line unless contraindicated (e.g., patients at risk of renal impairment, cardiac failure, gastric ulceration).[38][56][57][Evidence C] Parental NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[53][58] However, NSAIDs can be offered by any route.[56][Evidence C] Examples are listed above.
Treatment recommended for ALL patients in selected patient group
Patients with urinary calculi along with fever and other signs or symptoms of infection need emergency urologic consultation for drainage and intravenous antibiotics.
Drainage can be accomplished in two ways. In the acute setting, a urologist can place a ureteric stent past the obstructing stone and achieve renal drainage. Alternatively, percutaneous nephrostomy by an interventional radiologist may be performed.
Treatment recommended for ALL patients in selected patient group
For smaller stones that fail conservative therapies (e.g., uncontrolled symptoms, failure of stone to progress, or persistent obstruction), additional surgical treatment is necessary.
Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy are considered first-line treatments. However, ureteroscopy in general is associated with better stone-free rates than ESWL.
Percutaneous antegrade ureteroscopy involves percutaneous antegrade removal of ureteric stones, and can be considered in select cases with very large (>15 mm) stones impacted in the upper ureter or when retrograde access is not possible.
Percutaneous nephrostolithotomy (PCNL) is minimally invasive and usually reserved for renal and proximal ureteric stones (i.e., in the lower pole) and those that are large (>20 mm), have failed therapy with ESWL and ureteroscopy, or are associated with complex renal anatomy.[48]
Laparoscopic or open surgical stone removal may be considered in rare cases where ESWL, ureteroscopy, and percutaneous ureteroscopy fail, or are unlikely to be successful.
with infection
Treatment recommended for ALL patients in selected patient group
Primary options
gentamicin: 1.5 mg/kg intravenously every 8 hours
OR
ampicillin: 2 g intravenously every 6 hours
and
gentamicin: 1.5 mg/kg intravenously every 8 hours
OR
cefuroxime sodium: 750-1500 mg intravenously every 8 hours
or
cefotetan: 1-2 g intravenously every 12-24 hours
or
ceftriaxone: 1-2 g intravenously every 24 hours
-- AND --
gentamicin: 1.5 mg/kg intravenously every 8 hours
OR
ceftriaxone: 1-2 g intravenously every 24 hours
Secondary options
piperacillin/tazobactam: 3.375 g intravenously every 6 hours
MoreOR
piperacillin/tazobactam: 3.375 g intravenously every 6 hours
Moreand
gentamicin: 1.5 mg/kg intravenously every 8 hours
Patients with urinary calculi along with fever and other signs or symptoms of infection need emergency urologic consultation for drainage and intravenous antibiotics.
Empiric broad-spectrum antibiotic therapy should be started pending sensitivity results based on urinalysis cultures.[38] Empiric regimens differ across locations, and local guidance with the aid of a local antibiogram should be sought.
Patients should be treated with 14 days of culture-specific antibiotics.
The principles of treatment for the acute stone episode are similar in pregnant and nonpregnant patients. However, analgesics, antibiotics, anti-emetics, and intravenous fluids are given relative to their safety and risk for that particular trimester. For example, nonsteroidal anti-inflammatory drugs should be avoided, particularly during the first and third trimesters. Alpha-blockers (e.g., tamsulosin) are are not recommended as there are no adequate and well-controlled studies in pregnant women.
Similarly antibiotics are given according to their risk benefit ratio.
Temporary measures for symptomatic obstruction or intractable symptoms include a ureteric stent or percutaneous nephrostomy tube. However, they need frequent changes because of increased encrustation risk. If the patient has no evidence of infection, definitive therapy with ureteroscopy may be performed and has been demonstrated to be safe.[93] Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrostolithotomy (PCNL) are contraindicated in pregnancy.
Long-term dietary modification is essential for preventing future calculi. This modification is centered on increasing fluid intake. At least 2 liters of urine output daily should be recommended to help prevent future episodes of stone formation.[94]
Decreased dietary sodium, protein, and oxalate should be recommended for stone prevention. Increased citrus fruit intake is recommended to prevent stone recurrence.[95]
Normal calcium intake is recommended.[95] Dietary calcium restriction can lead to less binding of calcium to oxalate in the GI tract, promoting hyperoxaluria and increased stone formation.[106]
hyperuricosuria and/or uric acid stones
Treatment recommended for SOME patients in selected patient group
Primary options
potassium citrate: 30-60 mEq/day orally given in 3-4 divided doses
OR
allopurinol: 100-300 mg orally once daily
OR
potassium citrate: 30-60 mEq/day orally given in 3-4 divided doses
and
allopurinol: 100-300 mg orally once daily
Secondary options
sodium bicarbonate: 4 g orally initially, followed by 1-2 g every 4-6 hours, maximum 16 g/day
OR
sodium bicarbonate: 4 g orally initially, followed by 1-2 g every 4-6 hours, maximum 16 g/day
and
allopurinol: 100-300 mg orally once daily
Tertiary options
febuxostat: 40-80 mg orally once daily
MoreHyperuricosuria is treated with allopurinol. Elevated urinary uric acid levels (>800 mg/day) promote calcium oxalate and uric acid stones. Allopurinol is effective; it may work especially well in patients with gout. Febuxostat is an alternative agent which, at high dose, lowers urinary uric acid to a greater extent than allopurinol.[107] Febuxostat should only be prescribed for patients who can not tolerate allopurinol or when treatment with allopurinol has failed, and who have been counselled regarding cardiovascular risk.[97] Febuxostat should be avoided in patients with pre-existing major cardiovascular disease (e.g., myocardial infarction, unstable angina, stroke), unless no other therapy options are appropriate.[99] The double-blind Cardiovascular Safety of Febuxostat or Allopurinol in Patients with Gout (CARES) safety trial found that cardiovascular death and all cause mortality were significantly more common among patients taking febuxostat than allopurinol (4.3% vs. 3.2%, HR 1.34 [95% CI 1.03 to 1.73]; 7.8% vs. 6.4%, HR 1.22 [95% CI 1.01 to 1.47], respectively).[98] Treatment group did not differ with respect to a primary composite outcome of cardiovascular events.
Uric acid stones are treated with alkalinization therapy, with or without allopurinol. Oral alkalinization therapy with medications such as potassium citrate and sodium bicarbonate may be beneficial for dissolving uric acid stones and preventing uric acid supersaturation. It may be used for treating uric acid stones that do not require urgent surgical treatment, as well as asymptomatic stones. The ideal goal for alkalinization therapy is to maintain urine pH between 6.5 and 7.0. In patients with CHF or renal failure, extra care should be taken when prescribing alkalinization therapy. Potassium citrate is first-line therapy.
hypercalciuria
Treatment recommended for SOME patients in selected patient group
Primary options
chlorthalidone: 25-50 mg orally once daily
OR
hydrochlorothiazide: 25-50 mg orally twice daily
OR
indapamide: 1.25 to 2.5 mg orally once daily
Secondary options
potassium citrate: 10-20 mEq orally three to four times daily
Given until urinary calcium normalizes.
Thiazide diuretics are generally combined with potassium citrate to prevent the development of hypokalemia and hypocitraturia associated with this therapy.
hypocitraturia
Treatment recommended for SOME patients in selected patient group
Primary options
potassium citrate: 30-60 mEq/day orally given in 4 divided doses
Hypocitraturia is treated with oral alkalinization therapy.
hyperoxaluria
Treatment recommended for SOME patients in selected patient group
Primary options
calcium carbonate: 1-2 g/day orally given in 3-4 divided doses
MoreOR
calcium citrate: 1-2 g/day orally given in 3-4 divided doses
MoreOR
potassium citrate: 30-60 mEq/day orally given in 4 divided doses
OR
magnesium oxide: 400-800 mg orally two to three times daily
OR
cholestyramine: 2-4 g orally four times daily
OR
pyridoxine (vitamin B6): 250-500 mg orally once daily
For patients with elevated urinary oxalate level secondary to small bowel or ileal disease, oral administration of calcium with meals is recommended.[108]
Cholestyramine is also effective for hyperoxaluria due to intestinal disease, but is poorly tolerated.
Treatment with potassium citrate can fix the metabolic acidosis and hypokalemia that may be present and can increase the urinary citrate.
Pyridoxine is indicated in primary hyperoxaluria.
cystinuria
Treatment recommended for SOME patients in selected patient group
Primary options
potassium citrate: 30-60 mEq/day orally given in 4 divided doses
Secondary options
tiopronin: 800 mg/day orally in 3 divided doses, adjust dose according to response, usual dose is 1000 mg/day
OR
penicillamine: 250 mg orally four times daily
The goal for treatment of cystinuria is to decrease urine levels to <250 mg/L.
Conservative therapy involves increased hydration to keep urine output at ≥3 L/day in order to reduce the saturation of cystine and decreased sodium intake.
Alkalinization of urine with potassium citrate leads to an increase in the solubility of cystine, although a substantial increment in solubility does not occur unless the pH is >7.5.
If conservative therapy and alkalinization fail, chelating agents such as tiopronin or penicillamine should be used. Tiopronin has a better adverse-effect profile than penicillamine and is therefore the preferred therapy.[109]
struvite stones
Treatment recommended for SOME patients in selected patient group
Primary options
acetohydroxamic acid: 250 mg orally three to four times daily
Acetohydroxamic acid, a urease inhibitor, may reduce the urine saturation of struvite and therefore prevent stone formation. It is best reserved for complex and recurrent struvite stones under secondary care supervision.
This medication has a high rate of adverse effects including deep vein thrombosis, tremors, and headaches.[14]
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