Nephrolithiasis

Treat an obstructive stone with infected urine as a urologic emergency. Obtain urinalysis and urine culture, begin empiric antibiotics and intravenous fluid resuscitation, and arrange urgent drainage with either a ureteral stent or percutaneous nephrostomy tube; intensive care may be required. Defer definitive stone treatment until the infection has been addressed. PubMedPubMedNephrolithiasis - Endotext - NCBI Bookshelf

Do not continue observation when pain is uncontrolled, renal function is impaired from baseline, obstruction is clinically consequential, or urinary anatomy makes spontaneous passage unlikely. These features exclude the uncomplicated pathway used for medical expulsive therapy and instead warrant urologic intervention planning. PubMedPubMedNephrolithiasis - Endotext - NCBI Bookshelf

Use noncontrast abdominopelvic CT to establish stone size, number, and location when ureterolithiasis is suspected and the result will direct observation versus intervention. CT is described as the diagnostic gold standard, with reported sensitivity of 98%, specificity of 100%, and negative predictive value of 97%. PubMedPubMedUreterolithiasis - StatPearls - NCBI Bookshelf - NIH

Use ultrasonography selectively when radiation avoidance or rapid assessment of obstruction is prioritized, but do not treat a negative study as excluding a ureteral stone. In one comparative study, ultrasound identified only 10 of 22 CT-detected ureteral stones (46% sensitivity); another study found lower detection of mid- and distal-ureteral stones and an overall ultrasound sensitivity of 75.4%. PubMed+1PubMedDiagnostic accuracy of ultrasonography compared to unenhanced CT for stone and obstruction in patients with renal failurePubMedThe role of ultrasonography in detecting urinary tract calculi compared to CT scan

If surveillance imaging is needed after a radiopaque stone has been documented, a KUB radiograph may support tracking of passage. A CT scout can occasionally suffice but may lack the necessary detail. PubMedPubMedUreterolithiasis - StatPearls - NCBI Bookshelf - NIH

Offer a trial of passage for a ureteral stone up to 10 mm only when there are no signs or symptoms of urinary tract infection, renal function is at baseline, and pain is controlled. Smaller stones and distal ureteral location predict a higher likelihood of spontaneous passage and a shorter passage interval. PubMedPubMedNephrolithiasis - Endotext - NCBI Bookshelf

Use stone size to frame expectations: stones 5 mm or smaller tend to pass spontaneously, whereas stones larger than 7 mm commonly require surgical intervention; stones that have not moved within 4 to 6 weeks should prompt intervention assessment. Stone size does not fully predict symptoms or passage because ureteral anatomy modifies both. PubMedPubMedUreterolithiasis - StatPearls - NCBI Bookshelf - NIH

For an uncomplicated trial of passage, provide analgesia and consider an alpha-blocker for 4 to 6 weeks. Evidence summarized in guideline-linked reviews supports increased expulsion and shorter time to passage with alpha-blockers or calcium-channel blockers, while more recent large trials have questioned the magnitude of benefit from tamsulosin; use medication as an adjunct, not as a substitute for reassessment of infection, renal function, pain, or obstruction. ScienceDirect+2ScienceDirectMedical Expulsive Therapy of Ureteral Calculi and Supportive Therapy After Extracorporeal Shock Wave Lithotripsy - ScienceDirectScienceDirectMedical Treatment for Renal Colic and Stone Expulsion - ScienceDirectPubMedNephrolithiasis - Endotext - NCBI Bookshelf

Ureteroscopy, commonly with laser lithotripsy and basket extraction, and extracorporeal shock-wave lithotripsy are the two commonly used procedures for ureteral stone removal. URS can be used for proximal ureteral stones of any size and produced an 81% overall proximal-ureter stone-free rate in the cited guideline analysis, including rates of 93% for stones smaller than 10 mm and 87% for stones larger than 10 mm. auajournals+1auajournals2007 Guideline for the Management of Ureteral CalculiPubMedUreterolithiasis - StatPearls - NCBI Bookshelf - NIH

Use SWL when a noninvasive fragmentation strategy is suitable after preprocedure assessment of indications, contraindications, stone localization, and follow-up clearance. SWL guideline recommendations address medication management, prestenting, analgesia or anesthesia, position, energy settings, postprocedure auxiliary therapy, complication management, and clearance evaluation; procedure planning should therefore include a mechanism to confirm fragment clearance rather than assuming treatment success. ScienceDirectScienceDirectInternational Alliance of Urolithiasis Guideline on Shockwave Lithotripsy - ScienceDirect

For selected very large impacted proximal ureteral stones, percutaneous antegrade removal is an option; the cited guideline specifically identifies stones larger than 15 mm between the ureteropelvic junction and lower border of the sacroiliac joint as a potential indication. ScienceDirectScienceDirect2007 Guideline for the Management of Ureteral Calculi - ScienceDirect

For recurrent calcium stone formers, use metabolic evaluation to identify and address modifiable urinary risk factors, then add pharmacologic prevention when stone formation persists. The AUA guideline recommends offering thiazide diuretics and/or potassium citrate to patients with recurrent calcium stones when other metabolic abnormalities are absent or have been appropriately addressed and stones continue to form. auajournalsauajournalsMedical Management of Kidney Stones: AUA Guideline

Potassium citrate can be selected when recurrent calcium stone formation persists despite normal-range urinary citrate or when no specific risk factor is identified; the guideline notes its relatively favorable adverse-effect profile as a reason it may be preferred first-line in patients without identified risk factors. auajournalsauajournalsMedical Management of Kidney Stones: AUA Guideline

Use stone composition and clinical pattern to avoid assuming all stones share the same natural history. Calcium oxalate, calcium phosphate, uric acid, and cystine stones may pass spontaneously, whereas struvite stones and staghorn stones rarely pass spontaneously and should not be managed with an expectation of uncomplicated passage. PubMedPubMedNephrolithiasis - Endotext - NCBI Bookshelf