Medication Summary
Please see Cystinuria, Hypercalciuria, Hyperoxaluria, Hyperuricosuria and Gouty Diathesis, Hypocitraturia, and struvite topics for information regarding medical therapy on the basis of stone composition. The medications listed below include those used in the emergency department (ED) and in outpatient management of renal (ureteral) colic, as well as selected antibiotics.
Analgesics, Narcotic
Class Summary
Narcotic analgesics act at the central nervous system (CNS) mu receptors and are commonly used in the 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
Butorphanol is a mixed agonist-antagonist narcotic with central analgesic effects for moderately severe to severe pain. It causes less smooth muscle spasm and respiratory depression than morphine or meperidine. Weigh these advantages against the increased cost of butorphanol.
Morphine sulfate (Kadian, MS Contin, Infumorph 200, Infumorph 500)
Morphine is the principal opium alkaloid product. It is the drug of choice for parenteral use in the immediate management of pain due to renal (ureteral) colic.
Oxycodone and acetaminophen (Percocet, Endocet, Roxicet, Xartemis XR, Primlev)
Oxycodone-acetaminophen is a drug combination indicated for oral relief of moderate to severe pain. It is employed in medical expulsive therapy (MET).
Hydrocodone and acetaminophen (Vicodin, Vicodin ES, Lortab, Norco, Zamicet)
Hydrocodone is also combined with acetaminophen. This drug combination is indicated for oral relief of moderate to severe pain.
Meperidine (Demerol)
Meperidine is a narcotic analgesic with multiple actions similar to those of morphine. It may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.
Nalbuphine
Nalbuphine is a synthetic opioid agonist-antagonist potent analgesic. It stimulates kappa opioid receptor in the CNS, which causes inhibition of ascending pain pathways. It is indicated for the relief of moderate to severe pain.
Analgesics, Miscellaneous
Class Summary
Analgesics such as acetaminophen can be used to provide relief of mild to moderate pain.
Acetaminophen
Acetaminophen is a nonopioid analgesic that is effective in relieving mild to moderate pain; however, it has no peripheral anti-inflammatory effects but can be used in pregnancy.
Analgesics, Nonsteroidal anti-inflammatory drugs (NSAIDs)
Class Summary
Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit pain and inflammatory reactions by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. Both properties are beneficial in the management of renal (ureteral) colic.
These agents are at least if not more effective than narcotic analgesics in numerous randomized controlled trials. They have now become the recommended standard of care analgesia in acute renal colic, though must be used with caution in patients with renal insuffiency. NSAIDs cause less nausea and less sedation than narcotic analgesics, do not cause respiratory depression, and have no abuse potential. Potential adverse effects on renal function, gastrointestinal (GI) mucosa, and platelet aggregation do not appear clinically important when they are used for short-term pain relief.
Ketorolac
Ketorolac inhibits prostaglandin synthesis by decreasing the activity of COX, which results in decreased formation of prostaglandin precursors. Its onset of action is evident within 10 min.
Ketorolac intranasal (Sprix)
Intranasal ketorolac inhibits cyclooxygenase, an early component of the arachidonic acid cascade, resulting in reduced synthesis of prostaglandins, thromboxanes, and prostacyclin. It elicits anti-inflammatory, analgesic, and antipyretic effects. It is indicated for short-term (up to 5 d) management of moderate to moderately severe pain. Bioavailability of a 31.5-mg intranasal dose (2 sprays) is approximately 60% of a 30-mg intramuscular (IM) dose. The intranasal spray delivers 15.75 mg per 100-µL spray; each 1.7-g bottle contains 8 sprays.
Ibuprofen (Motrin, Advil, Addaprin, Caldolor, Dyspel, Genpril)
Ibuprofen is an oral NSAID. It has antipyretic, analgesic, and anti-inflammatory properties and is used for outpatient management.
Meloxicam (Mobic, Vivlodex)
Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.
Corticosteroids
Class Summary
These are strong anti-inflammatory agents that reduce ureteral inflammation. They also have profound metabolic and immunosuppressive effects. Corticosteroids are not endorsed in current urologic guideline recommendations and are included for educational purposes only.
Prednisone (Deltasone, Rayos)
Prednisone has been used in MET. Only a short course of prednisone therapy (5-10 d) should be administered.
Prednisolone (Pediapred, Millipred, Veripred 20, Orapred ODT)
In combination with nifedipine or tamsulosin, prednisolone is 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.
Calcium Channel Blockers
Class Summary
Calcium channel blockers are smooth-muscle relaxants. In combination with prednisolone, they have facilitated ureteral stone passage in several small prospective studies, though are not in current guideline recommendations. They are included here for educational purposes only.
Nifedipine (Nifedical XL, Afeditab CR, Procardia, Procardia XL, Adalat CC)
Nifedipine facilitates the passage of ureteral stones. The extended-release formulation simplifies treatment and encourages compliance. Only short-term therapy (10 d) should be considered for this indication.
Alpha Blockers, Antihypertensives
Class Summary
Alpha-blockers are smooth-muscle relaxants. They have been shown to facilitate ureteral stone passage.
Tamsulosin (Flomax)
Tamsulosin, an alpha-1 selective blocker, is indicated for the treatment of lower urinary tract symptoms due to prostatic enlargement. An off-label use, as discussed above, is to facilitate passage of ureteral stones. Only short-term therapy (10 d) should be considered for this indication.
Terazosin
Terazosin is indicated for the treatment of hypertension, as well as lower urinary tract symptoms due to prostatic enlargement. An off-label use is to facilitate passage of ureteral stones. Only short-term therapy (10 d) should be considered for this indication.
Xanthine Oxidase Inhibitors
Class Summary
Uricosuric agents help prevent nephropathy. They also help prevent recurrent calcium oxalate calculi.
Allopurinol (Zyloprim, Aloprim)
Allopurinol inhibits xanthine oxidase, the enzyme that synthesizes uric acid from hypoxanthine. It reduces the synthesis of uric acid without disrupting the biosynthesis of vital purines.
Alkalinizing Agents, Oral
Class Summary
Oral alkalinizing agents are used for the treatment of metabolic acidosis. They are also employed when long-term maintenance of alkaline urine is desirable.
Potassium citrate (Urocit K)
Potassium citrate is absorbed and metabolized to potassium bicarbonate, thus acting as a systemic alkalizer. Its effects are essentially those of chlorides before absorption and those of bicarbonates subsequently. Oxidation is virtually complete so that < 5% of the potassium citrate is excreted in the urine unchanged. It is highly concentrated and, when administered after meals and before bedtime, allows maintenance of an alkaline urinary pH at all times, usually without necessity of 2 AM dose. In the recommended dosage, it alkalinizes urine without producing systemic alkalosis.
Antiemetics
Class Summary
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)
Metoclopramide is the only antiemetic that has been studied specifically in treatment of renal colic. In 2 small double-blinded studies, it provided relief of nausea and pain relief equal to that of narcotic analgesics. Metoclopramide's antiemetic effect is due to blockade of dopaminergic receptors in chemoreceptor trigger zone in CNS. Metoclopramide does not possess antipsychotic or tranquilizing activity and is less sedating than other central dopamine antagonists. Onset of action is 1-3 min after intravenous (IV) injection and 10-15 min after IM injection.
Ondansetron (Zofran)
A selective blocking agent of the serotonin 5-HT3 receptor type initially used for chemo-related nausea & vomiting. Comes in an intravenous (IV), oral pill, dissolving tablet and oral solution. Can prolong QT interval therefore should be avoided in patients with known QT prolongation. Use also has small risk of inducing serotonin syndrome though most reports have been associated with concomitant use of serotonergic drugs.
Prochlorperazine (Compazine, Compro)
Prochlorperazine may relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through its anticholinergic effects and depressing the reticular activating system.
Promethazine (Phenadoz, Phenergan)
Promethazine is a phenothiazine derivative that possesses antihistaminic, sedative, antimotion sickness, antiemetic, and anticholinergic effects.
Antibiotics
Class Summary
Infected hydronephrosis mandates IV antibiotic therapy in addition to urgent drainage via percutaneous nephrostomy or urethral stent placement. Aerobic gram-negative enteric organisms, including Escherichia 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
Ampicillin is a 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. Ampicillin is usually combined with gentamicin.
Gentamicin
Gentamicin is an 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.
Ciprofloxacin (Cipro)
Ciprofloxacin is a reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones are 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. Ciprofloxacin is not effective against anaerobes. It is variably effective against E faecalis, though ampicillin and gentamicin are likely to be more effective.
Levofloxacin (Levaquin)
Levofloxacin is a reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. Fluoroquinolones are 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. Levofloxacin is not effective against anaerobes. It is variably effective against E faecalis, though ampicillin and gentamicin are likely to be more effective.
Ofloxacin
Ofloxacin is a reasonable alternative for treating infected hydronephrosis in penicillin-allergic patients. It is 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. It is not effective against anaerobes. It is variably effective against E faecalis, though ampicillin and gentamicin are likely to be more effective.
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Small renal calculus that would likely respond to extracorporeal shockwave lithotripsy.
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Complete staghorn calculus that fills the collecting system of the kidney (no intravenous contrast material in this patient). Although many staghorn calculi are struvite (related to infection with urease-splitting bacteria), the density of this stone suggests that it may be metabolic in origin and is likely composed of calcium oxalate. Percutaneous nephrostolithotomy or perhaps even open surgical nephrolithotomy is required to remove this stone.
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Distal ureteral stone observed through a small, rigid ureteroscope prior to ballistic lithotripsy and extraction. The small caliber and excellent optics of today's endoscopes greatly facilitate minimally invasive treatment of urinary stones.
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Two calculi in a dependent calyx of the kidney (lower pole) visualized through a flexible fiberoptic ureteroscope. In another location, these calculi might have been treated with extracorporeal shockwave lithotripsy (ESWL), but, after being counseled regarding the lower success rate of ESWL for stones in a dependent location, the patient elected ureteroscopy. Note that the image provided by fiberoptics, although still acceptable, is inferior to that provided by the rod-lens optics of the rigid ureteroscope in the previous picture.
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Nephrolithiasis: acute renal colic. Anatomy of the ureter.
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Nephrolithiasis: acute renal colic. Distribution of nerves in the flank.
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Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
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Nephrolithiasis: acute renal colic. Renal colic and flank pain.
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Nephrolithiasis: acute renal colic. Nerve supply of the kidney.
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Nephrolithiasis: acute renal colic. Distribution of renal and ureteral pain.
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Noncontrast helical CT scan of the abdomen demonstrating a stone at the right ureterovesical junction.
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Intravenous pyelogram (IVP) demonstrating dilation of the right renal collecting system and right ureter consistent with right ureterovesical stone.
Tables
Imaging Study (Pro/Con) |
Details |
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CT scan |
Pro |
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Con |
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IVP |
Pro |
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Con |
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*Many urologists find CT scans inadequate to help plan surgery, predict stone passage, or monitor patients; however, recently developed software programs may improve the capacity of CT in this respect. †This causes a delay, which may be significant in some institutions, and adds additional patient radiograph exposure and cost. ‡These include significant allergic responses and acute kidney injury. |
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