eMedicine Specialties > Emergency Medicine > Genitourinary
Renal Calculi: Treatment & Medication
Updated: Oct 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Emergency Department Care
- Intravenous access should be obtained to facilitate delivery of analgesic and antiemetic medications.
- Intravenous hydration is controversial.
- Some authorities believe that intravenous fluids hasten passage of the stone through the urogenital system. Others express concern that additional hydrostatic pressure exacerbates the pain of renal colic. One small study of 43 ED patients found no difference in pain score or rate of stone passage in patients who received 2 liters of saline over 2 hours versus those who received 20 mL of saline per hour.18
- Intravenous hydration should be given to patients with clinical signs of dehydration or to those with a borderline serum creatinine level who must undergo IVP.
- Analgesia should be provided promptly.
- The pain of renal colic is mediated by prostaglandin E2. Nonsteroidal anti-inflammatory drugs inhibit formation of this mediator, and ketorolac (the only parenteral NSAID approved by the US FDA) has been proven in multiple studies to be as effective as opioid analgesics, with fewer adverse effects.19,20
- Opioid analgesics can be added in cases of incomplete pain control.
- Antiemetics should be administered as needed.
- Medical expulsive therapy
- Multiple prospective randomized controlled studies21,22,23 in the urology literature have demonstrated that patients treated with oral alpha-blockers have an increased rate of spontaneous stone passage and a decreased time to stone passage. The best studied of these is tamsulosin, 0.4 mg administered daily.
- Calcium channel blockers in combination with oral steroids have also proven efficacious in multiple studies. The most common regimen is 30-mg slow-release nifedipine daily plus oral corticosteroid such as prednisolone.
- A systematic review by Singh et al in November 2007 found that medical expulsive therapy using either alpha antagonists or calcium channel blockers augmented the stone expulsion rate for moderately sized distal ureteral stones. Adverse effects were noted in 4% of those taking alpha antagonists and in 15.2% of those taking calcium channel blockers.24
- A systematic review by Beach et al in August 2006 found that medical expulsive therapy with alpha antagonists for 28 days increased the rate of stone passage, decreased the time to stone passage, and decreased the rates of hospitalization and ureteroscopy, with minimal adverse effects.25
- A 2009 randomized study of 77 emergency department patients with ureterolithiasis found no benefit to a 14-day course of tamsulosin, though the study group was small and the average stone size was 3.6 mm, making spontaneous passage without expulsive therapy highly likely.26
- Future studies may identify a subgroup of patients such as those with larger stones or history of inability to pass stones that would benefit from medical expulsive therapy.
- Strain urine for stone collection.
Consultations
- Consult a urologist immediately in cases of ureterolithiasis with proximal UTI. Infected hydronephrosis is a true urologic emergency and requires hospital admission, intravenous antibiotics, and immediate drainage of the infected hydronephrosis via percutaneous nephrostomy or ureteral stent placement.
- Urologic consultation is also appropriate in patients who are unable to tolerate oral fluids and medications and in those with unrelenting pain, renal failure, renal transplant, a solitary functioning kidney, and history of prior stones that required invasive intervention.
Medication
Pain of renal colic is mediated locally primarily by prostaglandin E2. Ureteral obstruction stimulates synthesis of prostaglandin E2 in the renal medulla, which increases ureteral contractility and renal blood flow, leading to increased ureteral pressures and painful renal colic.
Narcotic analgesics
These agents act at the CNS mu receptors and are the standard of care for treatment of renal colic. They are inexpensive and proven effective. Disadvantages include sedation, respiratory depression, smooth muscle spasm, and potential for abuse and addiction.
Butorphanol (Stadol)
Mixed agonist-antagonist narcotic with central analgesic effects for moderately severe to severe pain. Causes less smooth muscle spasm and respiratory depression than morphine or meperidine. Weigh these advantages against increased cost of butorphanol.
Adult
0.5-2.9 mg IV q3-4h prn
1-4 mg IM q3-4h prn
Pediatric
Not established
Guanabenz, MAOIs, CNS depressants, phenothiazines, barbiturates, and skeletal muscle relaxants increase toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in hepatic or renal insufficiency, respiratory limitations (bronchial asthma, obstructive respiratory conditions, cyanosis); may increase CSF pressure and cardiac overload; causes respiratory depression
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents inhibit synthesis of prostaglandin E2 and are at least as effective as narcotic analgesics in numerous randomized controlled trials. NSAIDs cause less nausea and less sedation than narcotic analgesics, do not cause respiratory depression, and have no abuse potential. Principal disadvantage is cost. Potential adverse effects on renal function, GI mucosa, and platelet aggregation do not appear clinically important when used for short-term pain relief.
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which, in turn, decreases formation of prostaglandin precursors. Only NSAID approved for IV or IM use in adults in United States. Single IM dose of 30 mg provides pain relief comparable to meperidine 100 mg IM with fewer adverse effects. Also can be administered IV. Onset of analgesic action is evident within 10 min of IM administration. Efficacy of PO formulation for outpatient treatment of renal colic has not yet been studied.
Adult
30-60 mg IM initial, followed by 15-30 mg q6h prn; not to exceed 5 d of treatment
Pediatric
Not established
Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Do not administer into CNS
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur
Antiemetics
Patients with acute renal colic frequently experience intense nausea and/or vomiting. Effective pain control often is accompanied by resolution of nausea and vomiting, but some patients may require antiemetics in addition to analgesics. Various antiemetic medications are used, including phenothiazines and butyrophenones.
Metoclopramide (Reglan)
Only antiemetic that has been studied specifically in treatment of renal colic. In 2 small double-blinded studies, provided relief of nausea and pain relief equal to that of narcotic analgesics.
Antiemetic effect due to blockade of dopaminergic receptors in chemoreceptor trigger zone in CNS. Does not possess antipsychotic or tranquilizing activity and is less sedating than other central dopamine antagonists. Onset of action is 1-3 min after IV injection and 10-15 min after IM injection.
Adult
10 mg IV/IM; repeat q4-6h prn
Pediatric
0.1-0.2 mg IV; repeat q6-8h prn
Accelerated gastric emptying may increase rate or extent of absorption of drugs such as acetaminophen, aspirin, diazepam, lithium, and tetracycline; as a central dopamine antagonist, may diminish effectiveness of dopamine agonists such as amantadine, bromocriptine, levodopa, or pergolide
Documented hypersensitivity; pheochromocytoma; GI hemorrhage, obstruction, or perforation; history of seizure disorders
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in history of mental illness or Parkinson disease; children and adolescents more likely to experience extrapyramidal side effects; elderly persons more likely to experience drowsiness
Antibiotics
Infected hydronephrosis mandates IV antibiotic therapy in addition to urgent drainage via percutaneous nephrostomy or urethral stent placement. Aerobic gram-negative enteric organisms, including E coli and Klebsiella, Proteus, Enterobacter, and Citrobacter species, are typical pathogens. Enterococcal infection occasionally is seen in patients recently on antibiotics. Candida albicans sometimes is responsible in diabetic or immunosuppressed patients. Initial empiric antibiotic therapy should cover common bacterial pathogens.
Ampicillin (Omnipen) plus gentamicin (Garamycin)
Ampicillin is beta-lactam aminopenicillin antibiotic. Non–penicillinase-producing staphylococci and most streptococci are susceptible. Ampicillin is effective against E coli and Proteus and Enterococcus species, but most Klebsiella, Serratia, Acinetobacter, indole-positive Proteus, and Pseudomonas species and Bacteroides fragilis are resistant.
Gentamicin is aminoglycoside antibiotic, which is active against Staphylococcus aureus and Enterobacteriaceae organisms including E coli and Proteus, Klebsiella, Serratia, Enterobacter, and Citrobacter species. Pseudomonas aeruginosa is usually sensitive, although its sensitivity varies somewhat. When used in combination with ampicillin, gentamicin also effective against Enterococcus faecalis.
Adult
Ampicillin: 150-200 mg/kg/d IV in equally divided doses q3-4h; dosages can be increased, but not to exceed 14 g/d
Gentamicin (patients with normal renal function): 3-6 mg/kg/d IV administered in 2-3 divided doses; monitor at least a trough level drawn on third or fourth dose (0.5 h before dosing); may draw peak level 0.5 h after 30-min infusion
Pediatric
Ampicillin: 100-200 mg/kg/d IV in equally divided doses q4-6h; not to exceed 12 g/d
Gentamicin: 2.5 mg/kg IV q8h
Ampicillin - Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Gentamicin - Other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; enhances effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur; loop diuretics may increase auditory toxicity of aminoglycosides—irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; evaluate rash and differentiate from hypersensitivity reaction; patients who develop diarrhea during or after therapy should be evaluated for pseudomembranous colitis; ampicillin excreted via kidneys, and dosing interval should be adjusted as follows:
CrCl <50 mL/min: Adjust dosing interval
CrCl 10-50 mL/min: Extend dosing interval to q6-12h
CrCl <10 mL/min: Extend dosing interval to q12-16h
Gentamicin also excreted via kidneys, and following reduction in dose and dosing frequency necessary in patients with renal insufficiency:
CrCl >70 mL/min: Multiply maintenance dose by 0.85 and administer IV q8-12h
CrCl 50-69 mL/min: Multiply maintenance dose by 0.85 and administer IV q12h
CrCl 25-49 mL/min: Multiply maintenance dose by 0.85 and administer IV q24h
CrCl <25 mL/min: Multiply maintenance dose by 0.85 and administer IV
Ticarcillin and clavulanic acid (Timentin)
Ticarcillin is extended-spectrum penicillin, beta-lactam antibiotic. Clavulanic acid is beta-lactamase inhibitor that, in combination with ticarcillin, extends spectrum of ticarcillin to include many beta-lactamase–producing bacteria.
Timentin active against most staphylococci and streptococci and gram-negative organisms including E coli, Morganella morganii, Proteus mirabilis, Proteus vulgaris, Neisseria gonorrhoeae, and Pseudomonas and Providencia species. Anaerobic spectrum includes Peptococcus and Peptostreptococcus species, Clostridium perfringens, Clostridium tetani, and Bacteroides species, including many strains of B fragilis. Timentin not effective against Enterococcus species or methicillin-resistant staphylococci.
Timentin excreted via urinary tract.
Adult
<60 kg: 200-300 mg/kg/d (based on ticarcillin content) IV divided q4-6h
>60 kg: 3.1g IV infused over 30 min q4-6h
Hemodialysis: 2 g IV q12h supplemented with 3.1 g after each dialysis session
Pediatric
200-300 mg/kg/d (based on ticarcillin content) IV in divided doses q6h; not to exceed 18-24 g/d
Tetracyclines may decrease effects; high concentrations may physically inactivate aminoglycosides if administered in same IV line; synergistic effects with aminoglycosides; probenecid may increase levels; can inhibit renal tubular excretion of methotrexate—do not coadminister
Documented hypersensitivity; severe pneumonia; bacteremia; pericarditis; emphysema; meningitis
Purulent or septic arthritis should not be treated with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT during therapy; caution in patients with hepatic insufficiencies; perform urinalysis and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions; may cause pseudomembranous colitis; after loading dose of 3.1 g, administer maintenance dose using renal function kinetics as follows:
CrCl >60 mL/min: No dosage adjustment needed
CrCl 30-60 mL/min: 2 g IV q4h
CrCl 10-30 mL/min: 2 g IV q8h
CrCl <10 mL/min: 2 g IV q12h
CrCl <10 mL/min with hepatic failure: 2 g IV q24h
Ciprofloxacin (Cipro)
Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and Streptococcus pneumoniae. Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more effective.
Adult
400 mg IV q8-12h
Pediatric
<18 years: Not recommended; if quinolone therapy clearly indicated, may be used in dose of 15-20 mg/kg/d IV divided q12h
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after; cimetidine may interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; associated with tendon rupture and should be discontinued in any patient who develops tendonitis; may lower seizure threshold and should be used cautiously in patients with seizures or cerebral atherosclerotic disease
Levofloxacin (Levaquin)
Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and S pneumoniae. Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more effective.
Adult
250 mg IV over 60 min qd for 10 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after; cimetidine may interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; associated with tendon rupture and should be discontinued in any patient who develops tendonitis; may lower seizure threshold and should be used cautiously in patients with seizures or cerebral atherosclerotic disease
Ofloxacin (Floxin)
Reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Active against aerobic gram-negative organisms and generally effective against aerobic gram-positive organisms, though some resistance has been noted in S aureus and S pneumoniae.
Not effective against anaerobes. Variably effective against E faecalis, though ampicillin and gentamicin likely to be more effective.
Adult
200 mg IV over 60 min q12h
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking; cimetidine may interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy; associated with tendon rupture and should be discontinued in any patient who develops tendonitis; may lower seizure threshold and should be used cautiously in patients with seizures or cerebral atherosclerotic disease
Corticosteroids
These agents are strong anti-inflammatory drugs that reduce ureteral inflammation. They also have profound metabolic and immunosuppressive effects.
Prednisolone (Econopred, Pediapred, Delta-Cortef, Articulose-50, AK-Pred)
In combination with nifedipine or tamsulosin, proven to facilitate spontaneous passage of a ureteral stone in several small prospective studies. Only a short course of therapy (5-10 d) should be administered.
Adult
25 mg PO qd
Pediatric
0.1-2 mg/kg/d PO qd
Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects of corticosteroids
Documented hypersensitivity; viral, fungal, tubercular skin, and connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes, and myasthenia gravis
Calcium channel blockers
These agents are smooth muscle relaxants that, in combination with prednisolone, facilitate ureteral stone passage in several small prospective studies.
Nifedipine (Procardia)
Sustained-release (SR) formulation simplifies treatment and encourages compliance. Only short-term therapy (5-10 d) should be considered for this indication.
Adult
30 mg SR PO qd
Pediatric
Not established
Caution with coadministration of any agent that can lower BP, including beta-blockers and opioids; H2 blockers (cimetidine) may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause lower extremity edema; allergic hepatitis has occurred (rare)
Alpha-adrenergic blockers
These agents promote smooth muscle relaxation and, in combination with prednisolone, facilitate spontaneous passage of a ureteral stone.
Tamsulosin (Flomax)
Alpha-adrenergic blocker specifically targeted to alpha1-receptors. Has advantage of relatively less orthostatic hypotension and requires no gradual up-titration from initial introductory dosage. Inhibits postsynaptic alpha-adrenergic receptors, resulting in vasodilation of veins and arterioles and decrease in total peripheral resistance and blood pressure. Improves irritative and obstructive voiding symptoms. Only short-term therapy (5-10 d) should be considered for this indication.
Adult
0.4 mg PO qd
Pediatric
Not established
Cimetidine may significantly increase plasma concentrations; may increase toxicity of warfarin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for use as antihypertensive drug; may cause orthostasis; avoid situations that may result in injuries if syncope occurs; exclude presence of carcinoma or cancer before initiating treatment; adverse effects include increased rate of retrograde ejaculation and rhinitis
More on Renal Calculi |
| Overview: Renal Calculi |
| Differential Diagnoses & Workup: Renal Calculi |
 Treatment & Medication: Renal Calculi |
| Follow-up: Renal Calculi |
| Multimedia: Renal Calculi |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
kidney stone symptoms, kidney stone causes, kidney stone treatment, renal calculi, kidney stone, renal stone, ureteral calculi, nephrolithiasis, ureterolithiasis, kidney calculi, acute nephrolithiasis
