genitourinary disorders
Urinary Calculi
Treatment of Urinary Calculi
See also Analgesia Facilitate calculus passage, eg, with alpha-receptor blockers such astamsulosin(described as medical expulsive therapy) For persistent or infection-causing calculi, complete removal using primarily endoscopic techniques Renal colic may be relieved with opioids, such asmorphineand, for a rapid onset,fentanyl.Ketorolac30 mg IV is rapidly effective and nonsedating. Vomiting usually resolves as pain decreases, but persistent vomiting can be treated with an antiemetic (eg,ondansetron10 mg IV). Although increasing fluids (either oral or IV) has traditionally been recommended, increased fluid administration has not been proven to speed the passage of calculi. Patients with calculi<1 cm in diameter who have no infection or obstruction, whose pain is controlled with analgesics, and who can tolerate liquids can be treated at home with analgesics and alpha-receptor blockers (eg,tamsulosin0.4 mg orally once a day) to facilitate calculus passage. Calculi that have not passed within 6 to 8 weeks typically require removal. In patients with suspected infection and obstruction, initial treatment is relief of obstruction as soon as possible with a cystoscopically placed ureteral stent or percutaneous nephrostomy tube and treatment of the infection followed by removal of calculi as soon as possible. The technique used for removal depends on the location and size of the calculus. Techniques include extracorporeal shock wave lithotripsy and, to ensure complete removal or for larger calculi, endoscopic techniques. Endoscopic techniques may involve rigid or flexible ureteroscopes (endoscopes) and may involve direct-vision removal (basketing), fragmentation with some sort of lithotripsy device (eg, pneumatic, ultrasonic, laser), or both. Short-term ureteral stenting (eg, 4 to 7 days) is commonly used until resolution of any inflammation or edema caused by the stone or the procedure. Forsymptomatic calculi1 cm in diameter in the renal collecting system or proximal ureter, shock wave lithotripsy is a reasonable first option for therapy. Forlarger calculior if shock wave lithotripsy is unsuccessful, ureteroscopy (done in a retrograde fashion) with holmium or thulium laser lithotripsy is usually used. Sometimes removal is possible using an endoscope inserted anterograde through the kidney. For renal stones>2 cm, percutaneous nephrolithotomy, with insertion of a nephroscope directly into the kidney, is the treatment of choice. Formidureteral calculi, ureteroscopy with holmium laser lithotripsy is usually the treatment of choice. Shock wave lithotripsy is an alternative. Fordistal ureteral calculi, endoscopic techniques (ureteroscopy), such as direct removal and use of intracorporeal lithotripsy (eg, holmium or thulium laser, pneumatic), are considered by many to be the procedures of choice. Shock wave lithotripsy can also be used. (See also theAmerican Urological Association/Endourological Society Guideline, Part I.) Uric acid calculi in the upper or lower urinary tract occasionally may be dissolved by prolonged alkalinization of the urine withpotassium citrate20 mEq (20 mmol/L) orally 2 to 3 times a day, but chemical dissolution of calcium calculi is not possible and of cystine calculi is difficult. 