Nephrolithiasis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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

INITIAL

acute renal colic, non-pregnant

1st line – hydration and analgesia

Back

1st line –

hydration and analgesia

In the absence of urgent considerations, the main goal of initial treatment for an acute stone event is symptomatic relief with hydration and analgesia as needed.[67][68] [ ]

For pain management, give:

A non-steroidal anti-inflammatory drug (NSAID) by any route first-line[47][69][Evidence C]
- NSAIDS have been shown to offer effective pain relief from acute kidney stone related pain with fewer side effects than opioids and paracetamol.[67]
- Parenteral NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[67][75]
Intravenous paracetamol if NSAIDs are contraindicated or are not giving the patient sufficient pain relief.[16]

Consider an opioid only if NSAIDs and intravenous paracetamol are contraindicated or not giving the patient enough pain relief.[16] If giving an opioid, co-prescribe an antiemetic for opioid-induced nausea.

Do not use antispasmodics in patients with suspected renal colic.[16][47]

Primary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

diclofenac sodium: children: consult specialist for guidance on dose; adults: 75 mg intramuscularly once or twice daily when required

diclofenac potassium: children: consult specialist for guidance on dose; adults: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

Secondary options

paracetamol: children <10 kg body weight: 10 mg/kg intravenously every 4-6 hours when required, maximum 30 mg/kg/day; children 10-50 kg and adults <50 kg body weight: 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; children and adults ≥51 kg body weight: 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

Tertiary options

morphine sulfate: children: consult specialist for guidance on dose; adults: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

ACUTE

confirmed renal or ureteric stone: with evidence of obstruction, non-pregnant

Back

1st line –

hydration and analgesia

In the absence of urgent considerations, the main goal of initial treatment for an acute stone event is symptomatic relief with hydration and analgesia as needed.[67][68] [ ]

For pain management, give:

A non-steroidal anti-inflammatory drug (NSAID) by any route first-line[47][69][Evidence C]
- NSAIDS have been shown to offer effective pain relief from acute kidney stone related pain with fewer side effects than opioids and paracetamol.[67]
- Parenteral NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[67][75]
Intravenous paracetamol if NSAIDs are contraindicated or are not giving the patient sufficient pain relief.[16]

Do not use antispasmodics in patients with suspected renal colic.[16][47]

Primary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

diclofenac sodium: children: consult specialist for guidance on dose; adults: 75 mg intramuscularly once or twice daily when required

diclofenac potassium: children: consult specialist for guidance on dose; adults: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

Secondary options

Tertiary options

Consider – antibiotic therapy

Consider – watchful waiting

Consider – surgical intervention

Back

Consider –

surgical intervention

Additional treatment recommended for SOME patients in selected patient group

For larger stones (≥10 mm), and smaller stones that remain despite conservative therapies, surgical intervention may be necessary, with the recommended approach based on stone size.

More info: Surgical treatment

Historically, open surgery was the only way to remove stones. However, with the development and success of endourology, a term used to describe less invasive surgical techniques that involve closed manipulation of the urinary tract with scopes, open surgery is now very rarely performed. Options include shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), ureteroscopy, and laparoscopic stone removal. Each of the surgical options has its own specific indications and considerations, but in general they are all relatively comparable in terms of safety and efficacy.[85]

Shock wave lithotripsy (SWL) is the least invasive method of definitive stone treatment and is suitable for most patients with uncomplicated stone disease. In SWL, shock waves are generated by a source external to the patient's body and are then propagated into the body and focused on a stone. The shock waves break stones by both compressive and tensile forces. The stone fragments then pass out in the urine. Limitations to SWL include stone size and location. However, SWL is often done without any need for general anaesthesia so can usually be performed as an outpatient procedure. Adjunctive treatment with tamsulosin or a diuretic appears to be effective in assisting stone clearance in patients with renal and ureteric calculi.[86][87] While SWL has been shown to have limited success with lower pole stones, there is evidence to suggest that ancillary manoeuvres such as percussion, diuresis, and inversion increase stone-free rates.[88][89] Contraindications to SWL treatment include pregnancy, aortic and/or renal artery aneurysms, uncontrolled hypertension, disorders of blood coagulation, and uncontrolled urinary tract infections.[90]
Ureteroscopy involves placing a small semi-rigid or flexible scope per urethra and into the ureter and/or kidney. Once the stone is visualised, it can be fragmented using a laser and the fragments grasped with a stone retrieval device and removed. The procedure is more invasive than SWL, but is generally thought to have a higher stone-free rate.[91] [ ] The procedure can often be carried out as a day case. It can be safely performed in coagulopathic patients using a holmium laser. Single-use flexible ureteropyeloscopy (FURS) demonstrates comparable efficacy with reusable FURS in treating renal calculi.[92] Ureteroscopic stone-free rates are better and fewer auxiliary procedures are needed with FURS than SWL for distal ureteric stones regardless of size and for proximal ureteric stones >10 mm.[91][93][94] While PCNL is the first-line therapy for large stones, FURS has been reported to achieve a mean stone-free rate as high as 93.7% (77.0% to 96.7%) for stones >20 mm in size (mean 25 mm) with acceptable overall complication rates (10.1%).[95][96] However, ureteroscopic removal has a higher complication rate and longer hospital stay, and a greater number of total procedures on average are needed than with PCNL.[97][98][99] A ureteric stent, an internal tube extending from the kidney to the bladder, may be left temporarily in place after ureteroscopy to promote collecting system drainage while any oedema from the stone or the procedure resolves. Stents are recommended in cases of functionally or anatomically solitary kidneys, ureteric stricture, noted ureteral injury, or cases with a planned second stage procedure. Do not routinely use post-treatment stenting after uncomplicated ureteroscopy for ureteric stones <20 mm. Pre-stenting of the ureter may enhance the stone-free rate achieved with ureteroscopy, which may also reduce complications such as ureteric injury.[100][101][102]
Percutaneous nephrolithotomy (PCNL) is a minimally invasive form of treatment that is usually reserved for renal stones (particularly in the lower pole) and those that are large (>20 mm), have failed therapy with SWL and ureteroscopy, or are associated with complex renal anatomy.[103] Percutaneous access into the kidney is gained from the flank. Current evidence indicates that both fluoroscopy and ultrasound guidance may be successfully used for obtaining percutaneous renal access.[104] Combining ultrasound and fluoroscopy seems to improve the outcome, both with regard to success in achieving access and reducing complications.[105] Once access is gained, a sheath is placed into the kidney and a nephroscope is used to help remove the stone. At this point, stone or urine culture should be taken directly from the renal pelvis, if possible.[47] For larger stones, ultrasonic and/or ballistic lithotripsy is usually used to break and remove the stone. PCNL usually requires a hospital stay and has more potential complications than either SWL or ureteroscopy. In stones of 20-30 mm, SWL is associated with poor stone-free rates (34%) compared with those achieved with PCNL (90%).[106]
Mini-PCNL (which uses a smaller scope and sheath than standard PCNL) results in higher stone-free rates for stones 10-20 mm than ureteroscopy, but incurs greater blood loss and longer length of hospital stay as the procedure is more invasive.[107][108] Mini-PCNL may be an option for stones <20 mm, as some evidence suggests equivalent stone-free rate with fewer bleeding complications than standard PCNL (due to smaller tract size).[109][110][111] However, for an equivalent stone-free rate, mini-PCNL usually requires longer operating time than the standard procedure, due to the smaller size of operating equipment, because the scopes/sheaths are smaller.[111]
Laparoscopic stone removal is another minimally invasive method to remove ureteric or renal stones. However, it is still more invasive, requires a longer hospital stay, and has a much higher learning curve than ureteroscopy or SWL. With the advances in SWL and endourological surgery (i.e., ureteroscopy and PCNL) during the past 20 years, the indications for open stone surgery have markedly diminished. Laparoscopic or open surgical stone removal may still be indicated in rare cases where SWL, ureteroscopy, and percutaneous ureteroscopy fail or are unlikely to be successful; anatomical deformities preclude a minimally invasive approach; the patient requires concomitant open surgery, pyeloplasty, or a partial nephrectomy; or in patients with a large stone burden requiring a single clearance procedure.[47][103]

Renal stone <10 mm that fails to pass despite initial conservative management

If the patient is an adult:[16]

Offer shock wave lithotripsy (SWL)
- Do not give pre-treatment stenting to adults having SWL
Consider ureteroscopy if SWL is contraindicated, fails, or is not indicated because of anatomical reasons
Consider percutaneous nephrolithotomy (PCNL) if SWL and ureteroscopy are not suitable options or have failed.

If the patient is aged under 16 years:[16]

Consider ureteroscopy or SWL
Consider PCNL if SWL and ureteroscopy are not suitable options or have failed.

Renal stone 10-20 mm

If the patient is an adult:[16]

Consider ureteroscopy or SWL
- Do not give pre-treatment stenting to adults having SWL
Consider PCNL if SWL and ureteroscopy are not suitable options or have failed.

If the patient is aged under 16 years, consider ureteroscopy, SWL, or PCNL.[16]

Renal stone >20 mm (including staghorn stones)

If the patient is an adult:[16]

Offer PCNL
Consider ureteroscopy if PCNL is not a suitable option.

If the patient is a child aged under 16 years, consider ureteroscopy, SWL, or PCNL.[16]

Consider pre-treatment stenting for children and young people having SWL for renal staghorn stones.[16]

confirmed ureteric stone: no evidence of obstruction, non-pregnant

1st line – hydration and analgesia

Back

1st line –

hydration and analgesia

In the absence of urgent considerations, the main goal of initial treatment for an acute stone event is symptomatic relief with hydration and analgesia as needed.[67][68] [ ]

For pain management, give:

A non-steroidal anti-inflammatory drug (NSAID) by any route first-line[47][69][Evidence C]
- NSAIDS have been shown to offer effective pain relief from acute kidney stone related pain with fewer side effects than opioids and paracetamol.[67]
- Parenteral NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[67][75]
Intravenous paracetamol if NSAIDs are contraindicated or are not giving the patient sufficient pain relief.[16]

Do not use antispasmodics in patients with suspected renal colic.[16][47]

Primary options

ibuprofen: children: consult specialist for guidance on dose; adults: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

diclofenac sodium: children: consult specialist for guidance on dose; adults: 75 mg intramuscularly once or twice daily when required

diclofenac potassium: children: consult specialist for guidance on dose; adults: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

Secondary options

Tertiary options

Consider – antibiotic therapy

Consider – medical expulsive therapy

Back

Consider –

medical expulsive therapy

Additional treatment recommended for SOME patients in selected patient group

Prompt treatment of ureteric stones is important because of the risk of obstruction and kidney damage.

Medical expulsive therapy (MET) using an alpha-blocker is an option for distal ureteric stones <10 mm in adults and children.[16]

MET using an alpha-blocker such as tamsulosin or alfuzosin may be of benefit in promoting larger (but still <10 mm) distal ureteral stone passage; however, efficacy rates have been questioned.[76][77][78][79][80][81][82][83] In practice in the UK, tamsulosin is most commonly used.
These agents can cause ureteric relaxation of smooth muscle and antispasmodic activity of the ureter leading to stone passage.[84]
Discontinue treatment if complications develop (infection, refractory pain, or deteriorating renal function).[47]
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.

If there is spontaneous passage of stones, most pass within 4 to 6 weeks. The chance of spontaneous passage decreases with increasing stone size. Limited data estimate that 75% of stones <5 mm pass spontaneously, with an average time to stone passage of 17 days.[47]

Such patients in general are followed up with periodic imaging, with either a KUB and renal ultrasound or a non-contrast computed tomography (NCCT) abdomen and pelvis to monitor stone position and degree of hydronephrosis.
Surgical intervention is indicated in the presence of persistent obstruction, failure of stone progression, sepsis, or persistent or increasing colic.

If the patient is an adult with a ureteric stone with ongoing and intolerable pain or the ureteric stone is unlikely to pass, ensure they have surgical treatment within 48 hours of diagnosis or readmission.[16] See Surgical intervention below.

Primary options

tamsulosin: children: consult specialist for guidance on dose; adults: 0.4 mg orally once daily

alfuzosin: children: consult specialist for guidance on dose; adults: 10 mg orally (modified-release) once daily

Consider – surgical intervention

Back

Consider –

surgical intervention

Additional treatment recommended for SOME patients in selected patient group

Surgical intervention is needed for larger stones (≥10 mm), smaller stones that remain despite conservative therapies, and stones that are causing ongoing and intolerable pain.

More info: Surgical treatment

Shock wave lithotripsy (SWL) is the least invasive method of definitive stone treatment and is suitable for most patients with uncomplicated stone disease. In SWL, shock waves are generated by a source external to the patient's body and are then propagated into the body and focused on a stone. The shock waves break stones by both compressive and tensile forces. The stone fragments then pass out in the urine. Limitations to SWL include stone size and location. However, SWL is often done without any need for general anaesthesia so can usually be performed as an outpatient procedure. Adjunctive treatment with tamsulosin or a diuretic appears to be effective in assisting stone clearance in patients with renal and ureteric calculi.[86][87] While SWL has been shown to have limited success with lower pole stones, there is evidence to suggest that ancillary manoeuvres such as percussion, diuresis, and inversion increase stone-free rates.[88][89] Contraindications to SWL treatment include pregnancy, aortic and/or renal artery aneurysms, uncontrolled hypertension, disorders of blood coagulation, and uncontrolled urinary tract infections.[90]
Ureteroscopy involves placing a small semi-rigid or flexible scope per urethra and into the ureter and/or kidney. Once the stone is visualised, it can be fragmented using a laser and the fragments grasped with a stone retrieval device and removed. The procedure is more invasive than SWL, but is generally thought to have a higher stone-free rate.[91] [ ] The procedure can often be carried out as a day case. It can be safely performed in coagulopathic patients using a holmium laser. Single-use flexible ureteropyeloscopy (FURS) demonstrates comparable efficacy with reusable FURS in treating renal calculi.[92] Ureteroscopic stone-free rates are better and fewer auxiliary procedures are needed with FURS than SWL for distal ureteric stones regardless of size and for proximal ureteric stones >10 mm.[91][93][94] While PCNL is the first-line therapy for large stones, FURS has been reported to achieve a mean stone-free rate as high as 93.7% (77.0% to 96.7%) for stones >20 mm in size (mean 25 mm) with acceptable overall complication rates (10.1%).[95][96] However, ureteroscopic removal has a higher complication rate and longer hospital stay, and a greater number of total procedures on average are needed than with PCNL.[97][98][99] A ureteric stent, an internal tube extending from the kidney to the bladder, may be left temporarily in place after ureteroscopy to promote collecting system drainage while any oedema from the stone or the procedure resolves. Stents are recommended in cases of functionally or anatomically solitary kidneys, ureteric stricture, noted ureteral injury, or cases with a planned second stage procedure. Do not routinely use post-treatment stenting after uncomplicated ureteroscopy for ureteric stones <20 mm. Pre-stenting of the ureter may enhance the stone-free rate achieved with ureteroscopy, which may also reduce complications such as ureteric injury.[100][101][102]
Percutaneous nephrolithotomy (PCNL) is a minimally invasive form of treatment that is usually reserved for renal stones (particularly in the lower pole) and those that are large (>20 mm), have failed therapy with SWL and ureteroscopy, or are associated with complex renal anatomy.[103] Percutaneous access into the kidney is gained from the flank. Current evidence indicates that both fluoroscopy and ultrasound guidance may be successfully used for obtaining percutaneous renal access.[104] Combining ultrasound and fluoroscopy seems to improve the outcome, both with regard to success in achieving access and reducing complications.[105] Once access is gained, a sheath is placed into the kidney and a nephroscope is used to help remove the stone. At this point, stone or urine culture should be taken directly from the renal pelvis, if possible.[47] For larger stones, ultrasonic and/or ballistic lithotripsy is usually used to break and remove the stone. PCNL usually requires a hospital stay and has more potential complications than either SWL or ureteroscopy. In stones of 20-30 mm, SWL is associated with poor stone-free rates (34%) compared with those achieved with PCNL (90%).[106]
Mini-PCNL, which uses a smaller scope and sheath than standard PCNL, results in higher stone-free rates for stones 10-20 mm than ureteroscopy, but incurs greater blood loss and longer length of hospital stay as the procedure is more invasive.[107][108] Mini-PCNL may be an option for stones <20 mm, as some evidence suggests equivalent stone-free rate with fewer bleeding complications than standard PCNL (due to smaller tract size).[109][110][111] However, for an equivalent stone-free rate, mini-PCNL usually requires longer operating time than the standard procedure, due to the smaller size of operating equipment, because the scopes/sheaths are smaller.[111]
Laparoscopic stone removal is another minimally invasive method to remove ureteric or renal stones. However, it is still more invasive, requires a longer hospital stay, and has a much higher learning curve than ureteroscopy or SWL. With the advances in SWL and endourological surgery (i.e., ureteroscopy and PCNL) during the past 20 years, the indications for open stone surgery have markedly diminished. Laparoscopic or open surgical stone removal may still be indicated in rare cases where SWL, ureteroscopy, and percutaneous ureteroscopy fail or are unlikely to be successful; anatomical deformities preclude a minimally invasive approach; the patient requires concomitant open surgery, pyeloplasty, or a partial nephrectomy; or in patients with a large stone burden requiring a single clearance procedure.[47][103]

Ureteric stone <10 mm that fails to pass despite initial conservative management

If the patient is an adult:[16]

Offer shock wave lithotripsy (SWL)
- Do not give pre-treatment stenting to adults having SWL
Consider ureteroscopy if stone clearance is not possible within 4 weeks with SWL, SWL is contraindicated or fails, or the stone is not targetable with SWL.
- Do not routinely give post-treatment stenting to adults who have had ureteroscopy for ureteric stones <20 mm.

If the patient is aged under 16 years:[16]

Consider ureteroscopy or SWL.

Ureteric stone 10-20 mm

If the patient is an adult:[16]

Offer ureteroscopy
- Do not routinely give post-treatment stenting to adults who have had ureteroscopy for ureteric stones <20 mm.
Consider SWL if local facilities allow stone clearance within 4 weeks
- Do not give pre-treatment stenting to adults having SWL.
Consider PCNL for impacted proximal stones when ureteroscopy has failed.

If the patient is aged under 16 years, consider ureteroscopy or SWL.[16]

Ureteric stone >20 mm

Ureteric stones of this size are rarely seen in practice. Therefore, these stones are treated on a case-by-case basis depending on regionally available treatments and expertise.[16]

pregnant

1st line – specialist referral

Back

1st line –

specialist referral

A symptomatic stone occurs in 1 out of every 200 to 1500 pregnancies with 80% to 90% of these occurring in the second or third trimester.[112] It has been reported that 48% to 80% of stones pass spontaneously during pregnancy.[113] Patients with stone disease during pregnancy are at risk of adverse maternal and neonatal outcomes, such as preterm birth, C-section delivery, pre-eclampsia, and gestational diabetes.[114]

If the patient is pregnant, refer to a specialist (e.g., an obstetrician and/or urologist).[47] The specialist will consider either a ureteric stent or percutaneous nephrostomy tube if the patient is pregnant and:

Their renal colic is not controlled with oral analgesia
or
They have an obstructing stone and signs of infection (fever or urinalysis/urine culture showing a possible urine infection).

These tubes should be changed every 6 to 8 weeks due to concern for rapid encrustation as a result of the metabolic changes seen with pregnancy.

If the patient has no evidence of infection, the specialist will arrange ureteroscopy. Ureteroscopy has been demonstrated to be safe in pregnancy.[115]

Shock wave lithotripsy and percutaneous nephrolithotomy are contraindicated in pregnancy.

ONGOING

following an acute episode, non-pregnant

1st line – hydration and dietary modification

Back

1st line –

hydration and dietary modification

For all patients, dietary modification with adequate hydration is an essential aspect of ongoing management.[45]

Advise the patient (and their family or carers, as appropriate) to:

Drink 2.5 to 3 litres (adults) or 1 to 2 litres (children) of water each day[16][43][44]
- In patients who are known stone formers, a target urine output of 2 to 2.5 litres per day is recommended; intake volume may need to be up to 4 litres per day to achieve this.[71][72][73]
Add fresh lemon juice to drinking water[16]
- Lemon juice is high in citrate leading to higher urinary citrate, which may stop calcium from binding to other stone constituents, therefore preventing stone formation and recurrence.[16]
Not restrict calcium intake and maintain a normal calcium intake of 700-1200 mg/day for adults, and 350-1000 mg/day for children and young people (depending on age)[16]
- The patient should only restrict their calcium intake if there are very strong reasons to do so.
- This is to help prevent stone recurrence.[16] Dietary calcium restriction can lead to less binding of calcium to oxalate in the gastrointestinal tract, promoting hyperoxaluria and potentiating the risk for stone formation; furthermore, it could have detrimental effects on bone health.
Consume no more than 6 g of salt per day (adults) or 2-6 g of salt per day (children and young people, depending on age)[16]
- A high consumption of sodium causes hypercalciuria by reduced proximal tubular re-absorption of calcium. Urinary citrate is reduced. The risk of forming sodium urate crystals is increased and the effect of thiazide in reducing urinary calcium is counteracted by a high sodium intake.
Eat plenty of fruits, vegetables, and fibre.[47]
- Fruit and vegetable intake should be encouraged because of the beneficial effects of fibre.
- The alkaline content of a vegetarian diet also gives rise to a desirable increase in urinary pH.

People with nephrolithiasis are often advised to avoid a high protein diet. The European Association of Urology recommends limiting animal protein to 0.8 to 1 g/kg/day.[47] However, the National Institute for Health and Care Excellence (NICE) in the UK does not give a recommendation regarding protein intake based on its assessment that the evidence on the effectiveness of low protein intake in reducing stone recurrence is inconclusive.[16]

Encourage the patient to establish a healthy lifestyle, including physical activity habits, to achieve and maintain a healthy weight.[74]

Additional dietary advice may be given for specific patient groups (based on the types of stones they form) in a specialist metabolic clinic setting.

Consider – alkalinisation

Consider – preventative medical therapy

Back

Consider –

preventative medical therapy

Additional treatment recommended for SOME patients in selected patient group

If the patient has a specific metabolic abnormality, individualised preventative therapies may be required in addition to dietary modification.[47][71][116] These patients will need to be managed in a specialist metabolic clinic setting where they can be offered tailored advice and interventions. These abnormalities and recommended interventions include:

Uric acid stones: urinary alkalinisation with potassium citrate or sodium bicarbonate[47]
Hypercalciuria and recurrent stones that are more than 50% calcium oxalate: thiazide diuretic or potassium citrate (after the patient has restricted their sodium intake to no more than 6 g per day)[16]
Hypocitraturia and recurrent stones that are more than 50% calcium oxalate: urinary alkalinisation (e.g., potassium citrate); sodium bicarbonate or sodium citrate can be considered if the patient is at risk for hyperkalaemia[16][116]
Hyperoxaluria: oxalate chelator (e.g., calcium, magnesium, or colestyramine), potassium citrate, pyridoxine; a rare condition
Cystinuria: high fluid intake alongside urinary alkalinisation with potassium citrate, thiol binding agent (e.g., tiopronin which is tolerated better than d-penicillamine); a genetic abnormality requiring life-long management.[3]

Most of these strategies are applied to children with nephrolithiasis, although there are a limited number of well-designed trials in this age group.[117][118]

Use of this content is subject to our disclaimer

Nephrolithiasis

Treatment algorithm

acute renal colic, non-pregnant

hydration and analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

confirmed renal or ureteric stone: with evidence of obstruction, non-pregnant

with signs and symptoms of infection

urgent decompression

urgent antibiotic therapy

without signs and symptoms of infection

urgent decompression

confirmed renal stone: no evidence of obstruction, non-pregnant

hydration and analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

antibiotic therapy

watchful waiting

surgical intervention

More info: Surgical treatment

Renal stone <10 mm that fails to pass despite initial conservative management

Renal stone 10-20 mm

Renal stone >20 mm (including staghorn stones)

confirmed ureteric stone: no evidence of obstruction, non-pregnant

hydration and analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

antibiotic therapy

medical expulsive therapy

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

surgical intervention

More info: Surgical treatment

Ureteric stone <10 mm that fails to pass despite initial conservative management

Ureteric stone 10-20 mm

Ureteric stone >20 mm

pregnant

specialist referral

following an acute episode, non-pregnant

hydration and dietary modification

alkalinisation

preventative medical therapy