A 28-year-old man has a single 6 mm radio-opaque calculus at the vesicoureteric junction with mild hydronephrosis. Pain is controlled with oral analgesics and he is haemodynamically well. What is the most appropriate initial management?

• A Immediate extracorporeal shock wave lithotripsy
• B Urgent ureteroscopic laser lithotripsy within 48 hours
• C Percutaneous antegrade removal through a nephrostomy track
• D Medical expulsive therapy with tamsulosin for up to 4 weeks with serial imaging ✓

Explanation

Distal ureteric stones up to about 10 mm with controlled pain and no infection are managed initially with medical expulsive therapy; alpha blockers relax the smooth muscle of the distal ureter and improve stone expulsion rates. Stones under 5 mm often pass spontaneously even without drugs. Intervention is reserved for failure of passage, uncontrolled pain, infection, or deteriorating renal function. Shock wave lithotripsy and ureteroscopy are second line here, and antegrade access is unnecessary for a distal stone.

Reference: Campbell-Walsh Urology, 12th ed.

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Written and medically reviewed by the StethoPrep medical team.