Ureteral stones: choosing a management strategy

General principles

Management depends on:

• stone size and location;
• the likelihood of spontaneous passage;
• symptoms;
• kidney function;
• the presence of infection;
• patient preferences.

Observation

• Observation is acceptable in a clinically stable patient without infection, anuria, deteriorating kidney function, or uncontrolled pain, provided reassessment and access to urgent care are assured.
• An alpha-blocker may be discussed for a 5–10 mm distal stone. Make the decision jointly with the patient after assessing contraindications and the approved prescribing information.

Active treatment

Main methods:

• ureteroscopic removal/laser lithotripsy;
• extracorporeal shock wave lithotripsy (SWL).

The choice depends on: size, density, location, anatomy, equipment availability, and the desired speed of stone clearance.

Infection

• Fever, pyuria, a systemic inflammatory response, or sepsis in the presence of obstruction changes management.
• First: a stent or nephrostomy, cultures, and antibiotics.
• Definitive stone removal follows infection control.

Monitoring

• After active treatment, confirm that there is no significant residual stone.
• Assess upper urinary tract function.
• Explain recurrence prevention and the need for stone composition analysis to the patient.

Algorithm