Red Flags
- Obstructing stone with infection (fever, leukocytosis, sepsis) — emergency urgent decompression (ureteric stent or percutaneous nephrostomy) and IV antibiotic; sepsis pathway[1]
- Bilateral obstruction or solitary kidney with obstruction — emergency urology, AKI prevention, decompression[1]
- Pregnancy with renal colic — ultrasound first; non-contrast MRI if needed; conservative management when possible; involve obstetric team[1]
- Recurrent stones, unusual stone composition (struvite, cystine), or family history of stones — full metabolic workup and specialist follow-up[1]
First-line treatment
Interventions
- Acute pain management for renal colic[1]NSAID (diclofenac IM 75 mg or IV) is first-line; opioid (morphine 0.1 mg/kg IV) if NSAID contraindicated or insufficient; antiemetic; IV fluid only for dehydration not forced diuresis
- Conservative management for uncomplicated stones[1]Stones <10 mm without sepsis, intractable pain, or persistent obstruction — observation with hydration, simple analgesia, and medical expulsive therapy; reassess at 4 weeks
- Surgical / interventional indications[1]Stones >10 mm, persistent obstruction at 4 weeks, recurrent severe pain, infection, or solitary kidney. Options: extracorporeal shock-wave lithotripsy (ESWL), ureteroscopy with laser fragmentation, percutaneous nephrolithotomy (PCNL) for staghorn or large stones
- Stone prevention by composition[1]Calcium oxalate: hydration to >2.5 L/day urine, dietary calcium normal not low, restrict oxalate and sodium, citrate. Uric acid: alkalinise urine pH 6.5–7, allopurinol if hyperuricaemia. Cystine: hydration, alkalinisation, tiopronin/penicillamine. Struvite: treat infection and remove stone completely
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Diclofenac (acute renal colic)[1] | NSAID | 75 mg IM or IV; or 50 mg PO TDS for 24–48 h | 1 mg/kg/dose every 8 h | First-line analgesia; faster onset and equal efficacy to opioids; avoid in CKD G3+, peptic ulcer, severe HF, anticoagulation |
| Tamsulosin (medical expulsive therapy)[1] | Selective alpha-1A adrenergic blocker | 0.4 mg PO daily for up to 4 weeks | — | Improves spontaneous passage of distal ureteric stones >5 mm; reduces analgesia need; orthostatic hypotension; informed consent for off-label use in some jurisdictions |
| Allopurinol (urate stones / hyperuricosuria)[1] | Xanthine oxidase inhibitor | 100–300 mg PO daily titrated to serum urate <6 mg/dL | 10 mg/kg/day | Hyperuricosuria with calcium oxalate or pure uric acid stones; renal dose adjustment; HLA-B*5801 screening in South Asian populations |
| Potassium citrate (oral chemolysis / hypocitraturia)[1] | Urinary alkaliniser | 10–30 mEq PO TDS targeting urine pH 6.5–7.0 | — | Uric acid stones (chemolysis), cystine stones, hypocitraturia; monitor potassium especially with ACEi/ARB; hyperkalaemia risk |
| Thiazide diuretic (hypercalciuria-driven calcium stones)[1] | Thiazide diuretic | Hydrochlorothiazide 25 mg PO daily; chlortalidone 12.5–25 mg PO daily; indapamide 1.5 mg PO daily | — | Recurrent calcium stones with hypercalciuria; reduces urinary calcium; check potassium and uric acid |
Diclofenac (acute renal colic)[1]
NSAID
- Adult
- 75 mg IM or IV; or 50 mg PO TDS for 24–48 h
- Paediatric
- 1 mg/kg/dose every 8 h
First-line analgesia; faster onset and equal efficacy to opioids; avoid in CKD G3+, peptic ulcer, severe HF, anticoagulation
Tamsulosin (medical expulsive therapy)[1]
Selective alpha-1A adrenergic blocker
- Adult
- 0.4 mg PO daily for up to 4 weeks
- Paediatric
- —
Improves spontaneous passage of distal ureteric stones >5 mm; reduces analgesia need; orthostatic hypotension; informed consent for off-label use in some jurisdictions
Allopurinol (urate stones / hyperuricosuria)[1]
Xanthine oxidase inhibitor
- Adult
- 100–300 mg PO daily titrated to serum urate <6 mg/dL
- Paediatric
- 10 mg/kg/day
Hyperuricosuria with calcium oxalate or pure uric acid stones; renal dose adjustment; HLA-B*5801 screening in South Asian populations
Potassium citrate (oral chemolysis / hypocitraturia)[1]
Urinary alkaliniser
- Adult
- 10–30 mEq PO TDS targeting urine pH 6.5–7.0
- Paediatric
- —
Uric acid stones (chemolysis), cystine stones, hypocitraturia; monitor potassium especially with ACEi/ARB; hyperkalaemia risk
Thiazide diuretic (hypercalciuria-driven calcium stones)[1]
Thiazide diuretic
- Adult
- Hydrochlorothiazide 25 mg PO daily; chlortalidone 12.5–25 mg PO daily; indapamide 1.5 mg PO daily
- Paediatric
- —
Recurrent calcium stones with hypercalciuria; reduces urinary calcium; check potassium and uric acid
Safety-net
- Drink 2.5–3 L of fluid (mostly water) per day to keep urine pale and reduce stone recurrence — single most important preventive measure[1]
- Strain urine to capture passed stones for analysis — composition guides prevention[1]
- Severe pain not controlled by analgesia, fever, vomiting, or inability to pass urine — same-day urology assessment[1]
Referral criteria
- Obstructing stone with infection / sepsis or bilateral obstructionEmergency department; urology for urgent decompression[1]
- Persistent obstruction or stone >10 mmUrology for ESWL, ureteroscopy, or PCNL planning[1]
- Recurrent stone formation, unusual composition, or family historyStone clinic for metabolic workup and individualised prevention[1]
- Pregnancy with renal colic or stonesJoint urology and obstetric clinic; conservative management when possible[1]
Clinical summary
Diagnosis, acute pain control, medical expulsive therapy, and intervention pathway for adults with kidney and ureteric stones.