A 35-year-old man presents with a 4-hour history of left loin-to-groin colicky pain radiating to the scrotum, nausea, and haematuria. KUB shows a 5 mm calculus at the vesico-ureteric junction (VUJ). eGFR is normal. The MOST appropriate initial management is:
- A Immediate ureteroscopy and laser lithotripsy
- B Emergency extracorporeal shock wave lithotripsy (ESWL) within 24 hours
- C Analgesia (NSAIDs + opioids), alpha-blocker (tamsulosin) for medical expulsive therapy, and watchful waiting for 4 weeks ✓
- D Open ureterolit hotomy as definitive treatment for VUJ stones
Explanation
A 5 mm ureteral stone has a >50% chance of spontaneous passage, particularly at the VUJ. Medical expulsive therapy (MET) with alpha-blockers (tamsulosin 0.4 mg daily) relaxes ureteral smooth muscle and significantly increases the probability of spontaneous stone passage. Combined with adequate analgesia (NSAIDs are most effective for ureteric colic), observation for 4 weeks is appropriate for uncomplicated ureteral stones <6 mm in the absence of sepsis, obstruction, or renal impairment. Ureteroscopy is reserved for failed conservative management, sepsis, or larger stones. Open surgery is obsolete for ureteral calculi.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.