Until the early 1980s, the treatment of choice for a kidney stone was “watchful waiting,” with hydration and pain management. A patient would be given a piece of cheesecloth or a basket, and instructed to urinate through it in order to “catch” the stone. When a stone finally passed, its chemical composition was analyzed. In patients with stones that were too large to pass or found in a location that made passage unlikely, surgical attempts were made to retrieve the stones. These surgeries could be open or “closed” (endoscopic), but they often caused permanent damage to the ureters and/or renal pelvis. Not surprisingly, the introduction of extracorporeal shock wave lithotripsy (ESWL) in the 1980s caused an immediate sensation.6
Stones can remain asymptomatic for some time—only to be found incidentally on radiologic exam for another condition.2 But when a patient presents with “classic” symptoms of kidney stones—colicky flank pain, hematuria, testicular pain (males only!), urinary frequency and urgency, nausea and vomiting—a helical CT is ordered to determine stone position; knowing this is vital to treatment. If the stone is non-obstructing and measures less than 10 mm, medical management is the first choice.7,8 This consists of IV or oral fluids, accompanied by narcotic and/or non-narcotic pain medications, as kidney stone pain can be excruciating. NSAIDs alone are rarely strong enough, and their use incurs a risk for intrinsic kidney damage.
If conservative care does not allow the stone to pass, alpha-adrenergic blockers and/or calcium channel blockers are added.9 In the case of cysteine stones, alkalization of the urine will help dissolve the stone.2 Only 20% of stones are found in the ureter; the vast majority (up to 70%) are lower urethral stones (LUS). Use of tamsulosin has been shown to move LUS stones at a faster rate, so long as they measure less than 10 mm.10
Before treating the stone patient with acute presentation, the urology practitioner may wait a couple of days to see whether the stone passes. The treatment choice then depends on the size of the stone and the position at presentation. If a stone measures less than 6 mm, medical management will be chosen.2 In fact, for smaller, nonobstructing stones, fluids, pain control, and alpha-blockers have been shown in the literature to produce a better outcome than other treatment options.9
For stones larger than 6 mm, or those causing an obstruction or a complication (pyelonephritis or urosepsis), removal is imperative.4 Modality choice depends on the position of the stone and the size of the patient. ESWL, the least invasive means, is the treatment of choice.2 However, as obesity becomes more prevalent (with its underlying metabolic abnormalities), the effectiveness of ESWL may be hindered by the obese patient’s body mass. That said, some manufacturers are increasing the reach of their lithotripsy machines for just this reason.11
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