Acute management of symptomatic nephrolithiasis

Abstract

Over half a million patients present to emergency departments and nearly 3 million patients visit healthcare providers annually due to problems associated with urolithiasis. Despite updated guidelines from the American Urological Association and European Association of Urology for the evaluation and management of nephrolithiasis, considerable variability still exists regarding treatment for acute symptomatic upper urinary tract stones. Therefore, this article will review the current evaluation and management of acute symptomatic nephrolithiasis. Initial management includes analgesia and antiemetics. Additionally, a urinalysis and creatinine are required laboratory evaluations. Acute imaging with a non-contrast computed tomography (CT) scan is the diagnostic imaging modality of choice. However, concerns over radiation exposure have led towards low-dose and even ultra-low-dose protocols for the detection of urinary calculi. Low-dose non-contrast CT scans are now standard of care for the initial diagnosis of renal colic in patients with a body mass index ≤ 30. Medical expulsive therapy is recommended for patients with a ureteral calculus < 10 mm and no signs of infection. Emergency urinary decompression is mandatory for a specific subset of patients, especially those with infection. Although limited data exists, emergency ureteroscopy or even shock wave lithotripsy may also be therapeutic options.

Keywords: Nephrolithiasis; Low-dose computed tomography scan; Medical expulsive therapy; Ureteroscopy; Extracorporeal shockwave lithotripsy

Core tip: Despite updated guidelines from the American Urological Association and European Association of Urology for the evaluation and management of nephrolithiasis, considerable variability still exists regarding treatment for acute symptomatic upper urinary tract stones, especially in regards to imaging modalities used in the emergency department. Acute imaging with a non-contrast computed tomography scan is the diagnostic imaging modality of choice. However, concerns over radiation exposure have led towards low-dose and even ultra-low-dose protocols for the detection of urinary calculi. Low-dose non-contrast computed tomography scans are now standard of care for the initial diagnosis of renal colic in patients with a body mass index ≤ 30.