Diagnosis and Acute Management of Suspected Nephrolithiasis in Adults - UpToDate

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Diagnosis and acute management of suspected

nephrolithiasis in adults
Authors: Gary C Curhan, MD, ScD, Mark D Aronson, MD, Glenn M Preminger, MD
Section Editors: Stanley Goldfarb, MD, Michael P O'Leary, MD, MPH, Jorge A Soto, MD
Deputy Editors: Albert Q Lam, MD, Susanna I Lee, MD, PhD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2019. | This topic last updated: Sep 21, 2018.
INTRODUCTION
Renal and ureteral stones are a common problem in primary care practice [1]. Patients may
present with the classic symptoms of renal colic and hematuria. Others may be asymptomatic
or have atypical symptoms such as vague abdominal pain, acute abdominal or flank pain,
nausea, urinary urgency or frequency, difficulty urinating, penile pain, or testicular pain.
Primary care clinicians need to be alert to the possibility of nephrolithiasis and its
consequences to decide upon a diagnostic approach, therapy, and the need for referral to a
urologist. These issues will be reviewed here. The epidemiology of nephrolithiasis and
subsequent evaluation of such patients are discussed separately. (See "The first kidney stone
and asymptomatic nephrolithiasis in adults" and "Evaluation of the adult patient with
established nephrolithiasis and treatment if stone composition is unknown".)
ETIOLOGY
Eighty percent of patients with nephrolithiasis form calcium stones, most of which are
composed primarily of calcium oxalate or, less often, calcium phosphate [2,3]. The other main
types include uric acid, struvite (magnesium ammonium phosphate), and cystine stones. The
same patient may have a stone that contains more than one crystal type (eg, calcium oxalate
and uric acid) [4].
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There are different theories regarding calcium stone formation, and the different stone types
may have different initiating events. Stone formation occurs when normally soluble material (eg,
calcium, oxalate) supersaturates the urine and begins the process of crystal formation (eg,
calcium oxalate crystal). For some calcium stones, particularly calcium oxalate, it appears that
an important initiating event occurs in the renal medullary interstitium [5-7]. Calcium phosphate
crystals may form in the interstitium and eventually erode through the renal papillary epithelium,
forming the classic Randall's plaque [6,7]. Calcium oxalate or calcium phosphate crystals may
then deposit on top of this nidus, remaining attached to the papilla. Calcium phosphate stones
might also form initially in dilated ducts of Bellini and then grow out into the urinary space [8].
The pathogenesis of struvite, cystine, and uric acid stones is discussed separately. (See
"Pathogenesis and clinical manifestations of struvite stones" and "Uric acid nephrolithiasis"
and "Cystine stones".)
Risk factors — The risk of nephrolithiasis is influenced by urine composition, which can be
affected by certain diseases and patient habits. For calcium oxalate stones, urinary risk factors
include higher urine calcium, higher urine oxalate, and lower urine citrate and dietary risk
factors such as a lower calcium intake, higher oxalate intake, higher animal protein intake,
lower potassium intake, higher sodium intake, or lower fluid intake (table 1). High intake of
vitamin C has been associated with a higher risk of stones in men but not women [9]. (See
"Risk factors for calcium stones in adults", section on 'Dietary risk factors'.)
There are numerous other factors potentially associated with an increased risk of stone
formation:
● A history of prior nephrolithiasis. The rate of stone recurrence is 10 to 30 percent at three

to five years among patients with idiopathic calcium oxalate stones [10-12]. A higher
recurrence rate of approximately 15 percent at one year, 35 to 40 percent at five years,
and 50 percent at 10 years was found in another study and was higher in men than women
[13,14] (see "The first kidney stone and asymptomatic nephrolithiasis in adults"). This
variability is due, in part, to differences in sensitivity of different types of imaging
modalities.
● Patients with a family history of stones have an increased risk of nephrolithiasis. This was
demonstrated in a report from the Health Professionals Follow-up Study, which found a
greater than twofold increased risk of stones among individuals with a positive family
history compared with those without such a history [15]. Furthermore, a strong family
history of nephrolithiasis in siblings can suggest the presence of rare inherited forms of
nephrolithiasis, such as Dent disease (a hypercalciuric form of nephrolithiasis), adenine
phosphoribosyltransferase deficiency, and cystinuria [16-18]. The diagnosis of cystinuria is

suspected if the pathognomonic hexagonal cystine crystals are seen on urinalysis (picture
1). (See "Dent disease (X-linked recessive nephrolithiasis)" and "Cystine stones".)
● The risk of stones increases in individuals with enhanced enteric oxalate absorption, often
in the setting of malabsorption (eg, gastric bypass procedures, bariatric surgery, short
bowel syndrome). Studies suggest that even patients with "modern" bariatric surgery
excrete higher levels of oxalate and have increased saturation of calcium oxalate salts than
typical stone formers [19,20]. A prospective trial of patients undergoing Roux-en-Y gastric
bypass surgery demonstrated a significant increase in urinary oxalate excretion and
increase in the relative supersaturation of calcium oxalate, suggesting an increased risk of
stone formation [21].
● Less common causes include frequent upper urinary tract infections (eg, as a result of
spinal cord injuries) and use of medications that may crystallize in the urine such as
indinavir, acyclovir, sulfadiazine, and triamterene [22-24]. Drug-related nephrolithiasis has
also been reported in children receiving prolonged ceftriaxone therapy [25]. (See "Crystal-
induced acute kidney injury".)
● Stone disease is more common in individuals with diabetes, obesity, gout, and
hypertension. Excessive physical exercise (including marathon running) may increase
crystalluria and, possibly, the risk of stones in predisposed individuals [26-30], but more
typical physical activity is not associated with higher risk [31]. Studies suggest that
changes in lifestyle and obesity have significantly increased the incidence of stones in
women, thereby changing the previous gender ratio of male to female stone formation from
3:1 to 1.3 to 1.6:1 [32,33].
● Low fluid intake is associated with increased stone risk. The type of fluid taken in may be
important, although data are sometimes conflicting [34]. (See "Risk factors for calcium
stones in adults", section on 'Type of fluid'.)
● A persistently acidic urine (pH ≤5.5) promotes uric acid precipitation and leads to the
formation of uric acid stones. An acidic urine is seen in chronic diarrheal states in which
bicarbonate loss and volume depletion lead to a concentrated acid urine or with other
metabolic defects, including gout, diabetes, insulin resistance, and obesity [30,35-39]. In
addition to having acidic urine, patients with gout and these other metabolic defects may
have increased uric acid excretion, but higher urine uric acid excretion is less important
than the persistently acidic urine. (See "Uric acid nephrolithiasis".)
● Struvite stones only form in patients with an upper urinary tract infection due to a urease-
producing organism such as Proteus or Klebsiella. Classic symptoms of nephrolithiasis

are uncommon. The diagnosis is suggested in a patient with recurrent urinary tract
infections, mild flank pain, or hematuria, who has a persistently alkaline urine pH (>7.0),
often with magnesium ammonium phosphate crystals in the urine sediment (picture 2).
(See "Pathogenesis and clinical manifestations of struvite stones".)
CLINICAL MANIFESTATIONS
Patients may occasionally be diagnosed with asymptomatic nephrolithiasis when an imaging

exam of the abdomen is performed for other purposes or when surveillance imaging is done in
those with a prior history of stones. (See "The first kidney stone and asymptomatic
nephrolithiasis in adults".)
The asymptomatic phase is more likely to persist in those who have never had a clinical
episode of renal colic. A study of 107 patients with asymptomatic stones, for example, found
that almost 70 percent remained symptom free during the 31 months of follow-up; a linear
association was noted between the development of a symptomatic event and the number of
previous stones [40].
Symptoms — Patients occasionally present after having passed gravel or a stone. Patients
who form uric acid stones frequently describe passing gravel, but uric acid stones can also
produce acute obstruction.
Symptoms may develop when stones initially pass from the renal pelvis into the ureter. Pain is
the most common symptom and varies from a mild and barely noticeable ache to discomfort
that is so intense that it requires parenteral analgesics. The pain typically waxes and wanes in
severity and develops in waves or paroxysms. Paroxysms of severe pain usually last 20 to 60
minutes. Pain is thought to occur primarily from urinary obstruction with distention of the renal
capsule. Consequently, pain due to a kidney stone typically resolves quickly after passage of
the stone.
The site of obstruction determines the location of pain. Upper ureteral or renal pelvic
obstruction lead to flank pain or tenderness, whereas lower ureteral obstruction causes pain
that may radiate to the ipsilateral testicle or labium. The location of the pain may change as the
stone migrates. Many patients familiar with the symptoms are able to predict whether the stone
has passed through the ureter. However, stones that are impacted or do not migrate cannot be
localized with certainty based on symptoms alone. In addition, a variable location of pain can
be misleading and occasionally mimics an acute abdomen or dissecting aneurysm. In some
patients with chronic back pain, the diagnosis of acute colic may be difficult without an imaging
exam.
Hematuria — Gross or microscopic hematuria occurs in the majority of patients presenting

with symptomatic nephrolithiasis (but is also often present in asymptomatic patients). Other
than passage of a stone or gravel, this is the single most discriminating predictor of a kidney
stone in patients presenting with unilateral flank pain. One study, for example, found that acute,
unilateral flank pain, hematuria, and a positive plain film of the abdomen are present in 90
percent of patients presenting to an emergency department with a stone [41]. (See 'Diagnostic
imaging' below.)
On the other hand, the absence of hematuria in the setting of acute flank pain does not exclude
the presence of nephrolithiasis [4,42]. Hematuria is not detected in approximately 10 to 30
percent of patients with documented nephrolithiasis [43,44]. One factor that may undermine the
sensitivity of hematuria is the interval from the onset of acute pain to the time of urine
examination. In a retrospective study of over 450 patients with computed tomography (CT)-
documented acute ureterolithiasis, hematuria was present in 95 percent on day 1 and 65 to 68
percent on days 3 and 4 [44].
Other — Other symptoms that are commonly seen include nausea, vomiting, dysuria, and
urgency. The last two complaints typically occur when the stone is located in the distal ureter.
Complications — Nephrolithiasis may lead to persistent renal obstruction, which could cause
permanent renal damage if left untreated.
Staghorn calculi themselves do not typically produce symptoms unless the stone results in
urinary tract obstruction or infection. However, they can lead to renal failure over years if they
are present bilaterally. One study found that deterioration in renal function occurred in 28
percent of patients with staghorn calculi over an eight-year period [45]. (See "Pathogenesis
and clinical manifestations of struvite stones".)
DIFFERENTIAL DIAGNOSIS
Several conditions may mimic flank pain caused by nephrolithiasis [46]:
● Bleeding within the kidney can produce clots that lodge temporarily in the ureter. Thus,
renal cell carcinoma rarely presents with renal colic [47]. By comparison, glomerular
bleeding does not lead to clot formation or symptoms of renal colic. (See "Etiology and
evaluation of hematuria in adults", section on 'Glomerular versus nonglomerular bleeding'.)
● Pyelonephritis frequently presents with flank pain, fever, and pyuria. Fever is uncommon in
patients with uncomplicated stone disease. (See "Acute complicated urinary tract infection
(including pyelonephritis) in adults".)
● Pain due to an ectopic pregnancy can occasionally be mistaken for renal colic. The
underlying cause of the pain can usually be clarified by obtaining a renal and a pelvic
ultrasound [48,49]. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)
● Rupture or torsion of an ovarian cyst may present with flank pain. Such patients can usually
be identified with ultrasound. (See "Evaluation and management of ruptured ovarian cyst".)
● Dysmenorrhea, which rarely presents with flank pain, begins just before or concurrent with
the onset of menses. In the correct clinical setting, dysmenorrhea is diagnosed after other
disorders are excluded. (See "Primary dysmenorrhea in adult women: Clinical features
and diagnosis".)
● Patients with an aortic aneurysm are rarely misdiagnosed as having renal colic. (See
"Clinical features and diagnosis of abdominal aortic aneurysm".)
● Acute intestinal obstruction, diverticulitis, or appendicitis may present with colic but usually
not in association with hematuria. In addition, nausea and vomiting are characteristic of
intestinal obstruction, and abdominal tenderness is characteristic of diverticulitis and
appendicitis but not nephrolithiasis. (See "Epidemiology, clinical features, and diagnosis
of mechanical small bowel obstruction in adults" and "Clinical manifestations and
diagnosis of acute diverticulitis in adults" and "Acute appendicitis in adults: Clinical
manifestations and differential diagnosis".)
● Biliary colic and cholecystitis can be associated with flank pain but usually not in
association with hematuria. (See "Acute calculous cholecystitis: Clinical features and
diagnosis".)
● Acute mesenteric ischemia rarely produces abdominal pain that can be confused with
renal colic; in addition, mesenteric ischemia is often associated with metabolic acidosis
but not hematuria. (See "Overview of intestinal ischemia in adults".)
● Herpes zoster may produce pain in the flank but is usually accompanied by a rash and not
by hematuria. (See "Epidemiology, clinical manifestations, and diagnosis of herpes
zoster".)
● Individuals seeking attention or narcotics may pretend to have renal colic and may have
self-inflicted hematuria [50]. In addition, there may be drug-seeking individuals who actually
have renal stones, but they are in the kidney and not obstructing.
Nephrolithiasis can usually be distinguished from the disorders listed above after a
confirmatory radiologic test is performed (usually a noncontrast computed tomography [CT]).
(See 'Diagnostic imaging' below.)
The differential diagnosis of abdominal discomfort is discussed elsewhere. (See "Causes of

abdominal pain in adults".)
DIAGNOSTIC IMAGING
When a diagnosis of nephrolithiasis is clinically suspected, imaging of the kidneys, ureters, and
bladder should be performed to confirm the presence of a stone and assess for signs of urinary
obstruction (eg, hydronephrosis). If a ureteral stone is detected, stone size and location are
used to predict the likelihood of spontaneous passage and to guide management (algorithm 1)
[51]. In addition, the density and appearance of a stone on computed tomography (CT) can
sometimes be used to predict its mineral composition, which is important in informing
treatment. Recent passage of a ureteral stone can also be suggested by imaging findings of
pyeloureteral dilatation. (See "Management of ureteral calculi".)
Selection of modality — CT of the abdomen and pelvis without contrast performed using
low-radiation-dose scanning protocols is the preferred exam for most adults with suspected
nephrolithiasis. If low-dose CT scan technology is not available, standard-dose abdominopelvic
CT or ultrasound of the kidneys and bladder are the two second-line options for initial imaging.
The choice between standard-dose CT and ultrasound is determined by considerations of
diagnostic accuracy, cumulative radiation dose over time, and the need for treatment planning
information should the exam prove positive. Other available, but less frequently used,
modalities for evaluating patients with suspected nephrolithiasis include abdominopelvic
radiography, intravenous pyelography (IVP), and magnetic resonance imaging (MRI) of the
abdomen and pelvis (table 2).
Women who could potentially be pregnant should undergo screening for pregnancy (ie, a urine
or serum pregnancy test) before CT, abdominal radiography, or IVP. (See "Clinical
manifestations and diagnosis of early pregnancy", section on 'Types of pregnancy tests'.)
Choice of imaging should include consideration of the following:
● CT of the abdomen and pelvis without contrast performed using low-radiation-dose

scanning technology is the preferred exam for most adults as it reliably detects
hydronephrosis and demonstrates the highest diagnostic accuracy for nephrolithiasis. This
exam is available at most sites. If positive, CT also accurately describes stone size and
location for treatment planning. It also provides accurate information on the size and
number of other stones in the kidneys. Reasons not to perform a low-dose CT, even if
available, are as follows:
• If the patient is pregnant, an ultrasound is the preferred modality. (See

"Nephrolithiasis during pregnancy", section on 'Diagnosis'.)
• If the patient has a body mass index (BMI) >30 kg/m2, or weighs more than 130 kg
(male) or 115 kg (female), then a standard-dose CT is performed.
● If low-radiation-dose CT technology is not available, standard-dose, noncontrast CT of the

abdomen and pelvis or ultrasound of the kidneys and bladder are the two second-line
alternatives. Both reliably detect hydronephrosis. In patients who have undergone or are
likely to undergo multiple CT exams for nephrolithiasis, and in pregnant women, ultrasound
is preferred as it minimizes the cumulative radiation dose over time. However, compared
with CT, ultrasound is less sensitive for detecting stones and does not provide reliable
stone size or number measurements or localization. Thus, many patients who initially
undergo ultrasound will require a follow-up CT to either identify a stone or to guide
management. Noncontrast CT is preferred over ultrasound in patients with large body
habitus or end-stage renal disease.
Point-of-care renal ultrasound at the bedside is performed in many emergency departments

within the United States. While it is followed by CT for the majority of cases requiring
intervention, this does not result in significant care delay. A multicenter trial in which patients
were randomly assigned to ultrasonography performed by an emergency department clinician
or a radiologist demonstrated that those in the former arm were 2.6 times more likely to
undergo CT prior to intervention [52].
Noncontrast CT — Computed tomography (CT) of the abdomen and pelvis without contrast
reliably detects hydronephrosis and demonstrates the best diagnostic performance for
nephrolithiasis. For detecting ureteral calculi, sensitivity and specificity of CT using
conventional radiation doses is >0.94 and >0.97, respectively (image 1A-B) [53-56]. CT
performed using low-radiation-dose protocols (image 2) demonstrate comparably high
diagnostic accuracies with pooled sensitivity and specificity of 0.97 (95% CI, 0.95–0.98) and
0.95 (95% CI, 0.92–0.97), respectively [53,54,57-60]. Low-dose CT may be less reliable for
detecting small stones (<2 mm) and ureteral stones in obese patients (body mass index [BMI]
>30). However, sensitivity for detection of stones >3 mm is not altered with dose reduction in
nonobese patients [61,62]. For assessing stone size, low- and standard-dose CT exams yield
equivalent measurements [63].
The effective radiation dose of a standard, noncontrast abdominopelvic CT is usually 10 to 12

mSv. By convention, the upper limit of effective radiation dose for low-dose, noncontrast CT is
4 mSv, although most exams fall in the 2 to 3 mSv range, a dose that is slightly higher than that
conferred by radiography (see 'Abdominal radiography' below). Imaging is performed on a
multidetector CT scanner with 1 to 5 mm slice thickness. Techniques for lowering radiation
dose while maintaining image quality include automated tube current modulation and iterative
reconstruction [64].
Intravenous contrast is usually not administered, as it decreases sensitivity for small stones.
However, for detecting stones >3 mm, contrast-enhanced CT demonstrates 0.95 sensitivity and
is comparable with noncontrast CT. Thus, if a contrast-enhanced CT exam has already been
performed, it is useful in detecting clinically significant stones.
Occasionally, a contrast-enhanced abdominopelvic CT will follow a low-dose, noncontrast CT

to differentiate a high-density focus as a ureteral stone rather than a periureteral phlebolith [65].
Contrast excretion maps the ureteral lumen unambiguously and enables localization of a high-
density focus to within, rather than alongside, the ureter.
Noncontrast CT can usually detect secondary signs of urinary tract obstruction [66,67]. The
likelihood of detecting these findings varies with the duration of pain. In a report of 227 patients
with acute nephrolithiasis, ureteral dilatation was seen in 84 and 97 percent at two and eight
hours, respectively, and moderate to severe perinephric stranding in 5 and 51 percent at two
and eight hours, respectively [67].
Determination of stone composition — The appearance, density, and location of a stone

on CT may suggest its composition. In general, uric acid, cystine, and struvite stones can
usually be distinguished from calcium oxalate calculi. Density is measured in Hounsfield units
by drawing regions of interest on CT images. However, CT cannot differentiate the various
forms of calcium oxalate (ie, dihydrate versus monohydrate) or distinguish calcium oxalate from
calcium phosphate [68-70].
● Although magnesium ammonium phosphate and cystine stones are often radiopaque on
CT, they are not as dense as stones composed of calcium oxalate or calcium phosphate.
Uric acid stones tend to demonstrate lower density than calcium stones.
● Large calculi in the renal pelvis favor struvite stones (image 1B).
● Nephrocalcinosis, suggestive of renal tubular acidosis, is associated with calcium

phosphate stones.
● Medullary sponge kidney with bilateral calcifications at the corticomedullary junction is

associated with calcium oxalate or calcium phosphate stones (image 3).
Dual energy CT (DECT) may better characterize stone composition. DECT utilizes scanners
that emit two separate radiograph energy sets to differentiate the attenuation properties of
matter [71-75].
Ultrasound of the kidneys and bladder — Ultrasound of the kidneys and bladder reliably
detects hydronephrosis and does not involve ionizing radiation. It is the preferred initial imaging
modality in pregnant patients. In practice settings where low-radiation-dose CT scan
technology is not available, ultrasound may represent a reasonable alternative to standard-
dose CT of the abdomen and pelvis without contrast. This minimizes the cumulative radiation
dose in patients undergoing multiple episodes of imaging for nephrolithiasis.
Ultrasound is less sensitive and demonstrates greater diagnostic variability than CT of the
abdomen and pelvis without contrast for the diagnosis of nephrolithiasis. Ultrasound detects 24
to 57 percent of stones seen with CT [76,77]. Consequently, a CT is sometimes performed
after a negative ultrasound to evaluate for a stone if the index of clinical suspicion remains high.
Ultrasound is less accurate than CT at measuring stone size and defining ureteral location.
Thus, a positive ultrasound often leads to a follow-up CT to enable treatment planning.
Ultrasound has been compared with standard-dose abdominopelvic CT for diagnostic

performance and cumulative population-level radiation dose. A multicenter trial of 2759
emergency department patients clinically suspected to have nephrolithiasis were randomly
assigned to initial imaging with a standard-dose, noncontrast CT, ultrasound performed by a
radiologist, or ultrasound performed at the bedside by an emergency clinician [78]. After the
initial imaging exam, subsequent evaluation and care was at the discretion of the treating
clinicians. The key findings from this trial were as follows:
● The sensitivity of ultrasound for stone detection was 54 percent (if performed by an
emergency clinician) and 57 percent (if performed by a radiologist). The sensitivity of CT
was 88 percent. A CT scan was performed in 41 percent of patients who initially
underwent ultrasound, whereas only 5 percent of patients who initially underwent CT
subsequently underwent ultrasound.
● The cumulative radiation exposure after six months was approximately 70 percent higher
with initial CT.
● The rate of important missed diagnoses resulting in complications, such as pyelonephritis

with sepsis or diverticular abscess, were comparable between the two groups (0.5 percent
with ultrasound versus 0.3 percent with CT). Serious adverse events and return visits to the
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emergency department after discharge were also similar.
Less frequently used tests — Abdominal radiography, IVP, and MRI are used as adjunct or
follow-up exams. They are rarely used in the initial diagnosis of nephrolithiasis.
Abdominal radiography — Abdominal radiography, also called abdominal plain x-ray,

does not detect hydronephrosis and is less accurate than CT for stone detection and
localization. The exam enables stone size measurements and is most often used either alone
or in combination with ultrasound to follow patients being managed for nephrolithiasis.
Abdominal radiography detects 29 to 59 percent of stones seen on noncontrast CT [79,80].

Sensitivity depends on a number of factors including stone composition, location, and size, as
well as patient body habitus and bowel contents. While large radiopaque stones such as
calcium, struvite, and cystine stones are seen (image 4), uric acid stones as well as small (<5
mm) stones, which are radiolucent on abdominal plain x-ray of the kidneys, ureter, and bladder
(KUB), are often missed. False positives, such as phleboliths and vascular calcifications
mistaken for renal stones, also limit the specificity of the exam.
The effective radiation dose from a single abdominal radiograph is 0.8 mSv.
Intravenous pyelography — IVP, also called intravenous urography (IVU), involves

radiographic imaging of the kidneys, ureters, and bladder before and after the administration of
intravenous iodinated contrast. The exam reliably detects hydronephrosis but is less sensitive
and specific than CT for the detection of stones. Noncontrast CT or ultrasound, where available,
is recommended rather than IVP for nephrolithiasis.
The effective radiation dose from an IVP is 3 mSv.
Magnetic resonance imaging — MRI of the abdomen and pelvis, also called magnetic
resonance urography (MRU), is rarely used for nephrolithiasis. Stones are poorly seen on MRI
as they can only be detected as signal voids in the urine [81]. Because the exam does not
involve ionizing radiation, MRI is used to localize the obstruction in pregnant women with
hydronephrosis seen on ultrasound. Intravenous gadolinium contrast is usually not administered
and should be avoided entirely in the pregnant patient. (See "Nephrolithiasis during
pregnancy".)
ACUTE THERAPY
Many patients with acute renal colic can be managed conservatively with pain medication and
hydration until the stone passes (algorithm 1). Most patients with acute renal colic can be
managed conservatively with pain medication. Forced intravenous hydration does not seem to
be more effective in reducing the amount of pain medication required or increasing stone
passage compared with minimal intravenous hydration [82].
Urgent urologic consultation is warranted in patients with urosepsis, acute kidney injury, anuria,
and/or unyielding pain, nausea, or vomiting [83,84]. (See 'Urology consultation' below.)
The likelihood that ureteral stones will pass depends upon the size and location of the stone;
smaller and more distal stones are more likely to pass without intervention [85-87]. (See 'Stone
passage' below.)
Straining urine — Patients should be instructed to strain their urine for several days and bring
in any stone that passes for analysis. This will enable the clinician to better plan preventive
therapy. (See "Interpretation of kidney stone composition analysis".)
Pain control — Patients can be managed at home if they are able to take oral medications
and fluids. Hospitalization is required for those who cannot tolerate oral intake or who have
uncontrollable pain or fever.
NSAIDs and opioids — Both nonsteroidal antiinflammatory drugs (NSAIDs) and opioids
have traditionally been used for pain control in patients with acute renal colic. NSAIDs have the
possible advantage of decreasing ureteral smooth muscle tone, thereby directly treating the
mechanism by which pain is thought to occur (ureteral spasm) [88].
Prospective, randomized, controlled studies suggest that NSAIDs are at least as effective as
opiates [4,89-91]. This was illustrated in the following studies:
● In a double-blind study, 51 patients with renal colic were randomly assigned to receive
indomethacin (100 mg) by rectal suppository or intravenous morphine (5 mg loading dose
and up to two additional 2.5 mg doses if needed) [90]. Morphine recipients reported more
pain relief at 10 minutes, but there was no significant difference between the two groups by
20 to 30 minutes.
● Another randomized, double-blind trial found that intravenous ketorolac (initial dose 60 mg)
was associated with improved pain relief compared with intravenous meperidine (50 mg
initial dose) [89].
To better assess the relative efficacy of NSAIDs or opioids in the treatment of renal colic, a
systematic review of 20 trials with 1613 participants was published in 2004 [92]. Both NSAIDs
and opioids had clinically significant analgesic benefits, including the ability to achieve
complete short-term pain relief.
Some relative benefits with NSAIDs may be a lower requirement for rescue analgesia and a
lower incidence of adverse effects, particularly nausea and vomiting [92,93]. In addition,
treatment with NSAIDs discourages opiate-seeking patients who may spuriously present with
symptoms of renal colic. On the other hand, in patients with preexisting renal disease or severe
volume depletion, NSAIDs may interfere with the kidney's autoregulatory response to acute
obstruction and induce acute kidney injury. (See "NSAIDs: Acute kidney injury (acute renal
failure)".)
A randomized trial suggested that NSAIDs and opioids may be superior to either agent alone.
Among 130 patients with renal colic, combination therapy with intravenous morphine (5 mg)
and ketorolac (15 mg) was associated with a greater reduction in pain at 40 minutes compared
with either agent alone [93]. In addition, patients who received combination therapy were more
likely to have complete relief of pain at 20 minutes (30 versus 11 and 16 percent with ketorolac
and morphine alone, respectively) and less likely to require rescue morphine (16 versus 33 and
42 percent, respectively). However, the relatively low dose of ketorolac used (standard dose is
30 mg) may have partially accounted for these results.
NSAIDs should be stopped three days before anticipated shock wave lithotripsy (SWL) to
minimize the risk of bleeding. Standard doses of opiates will relieve pain in those who do not
respond to NSAIDs.
Stone passage — Stone size is the major determinant of the likelihood of spontaneous stone
passage, although stone location is also important [85-87]. Most stones ≤5 mm in diameter
pass spontaneously. For stones larger than 4 mm in diameter, there is a progressive decrease
in the spontaneous passage rate, which is unlikely with stones ≥10 mm in diameter. Proximal
ureteral stones are also less likely to pass spontaneously (algorithm 1).
This was illustrated in a review of 75 patients with ureteral calculi, with the following
observations [85]:
● Among 41 patients with a stone diameter ≤2 mm, only two (5 percent) required
intervention. The average time to stone passage in the remaining patients was 8.2 days,
and 95 percent of stones passed in 31 days.
● Among 18 patients with a stone diameter between 2 and 4 mm, three (17 percent)
required intervention. The average time to stone passage in the remaining patients was
12.2 days, and 95 percent of stones passed in 40 days.
● Among 16 patients with a stone diameter between 4 and 6 mm, eight (50 percent)
required intervention. The average time to stone passage in the remaining patients was 22
days, and 95 percent of stones passed in 39 days.
Similar findings were noted in another report of 172 patients with ureteral stones [86]. The
likelihood of spontaneous stone passage was 87 percent for 1 mm stones, 76 percent of 2 to 4
mm stones, 60 percent for 5 to 7 mm stones, 48 percent for 7 to 9 mm stones, and 25 percent
of stones ≥9 mm. Spontaneous passage was also affected by stone location, ranging from 48
percent for stones in the proximal ureter to 79 percent of stones at the ureterovesical junction.
Facilitating stone passage — Several different medical interventions increase the passage
rate of ureteral stones, including alpha blockers, calcium channel blockers, and antispasmodic
agents, which have been used in combination with or without glucocorticoids [94-112]. Based
upon data suggesting higher rates of stone passage with alpha blockers versus conservative
therapy alone, we initiate treatment with the alpha blocker tamsulosin (0.4 mg once daily) for up
to four weeks to facilitate spontaneous stone passage in patients with ureteral stones >5 mm
and ≤10 mm in diameter. Although the calcium channel blocker nifedipine has also been
shown to be effective at facilitating stone passage, we prefer alpha blockers, given data that
suggest faster stone passage with an alpha blocker versus calcium channel blockers. Patients
are then reimaged if spontaneous passage has not occurred. Routine use of other medical
expulsive therapies (MET), such as tadalafil (a phosphodiesterase type 5 inhibitor), silodosin (a
selective alpha-1A receptor blocker), and glucocorticoids, is not recommended pending further
data showing safety and efficacy.
The benefits of MET have been examined in several meta-analyses, most of which have
analyzed the use of alpha blockers [101,105,106,110,112,113]:
● In a 2018 meta-analysis of 67 trials that enrolled 10,509 patients, ureteral stone passage
was significantly more likely with alpha blocker therapy than with conservative treatment
alone (relative risk [RR] 1.45, 95% CI 1.36-1.55), although the beneficial effect was smaller
among trials that compared alpha blocker therapy with a placebo control (RR 1.16, 95% CI
1.07-1.25) [112]. Stone passage occurred an average of 3.4 days faster with alpha
blocker therapy. In a subgroup analysis, alpha blocker therapy was less effective for stone
clearance in patients with smaller stones (≤5 mm; RR 1.06) than in those with larger stones
(>5 mm; RR 1.45); there were no differences in effectiveness based upon stone location or
alpha blocker type. Although treatment with an alpha blocker did not significantly increase
the risk of major adverse events in the overall analysis, a slightly increased risk (RR 2.09,
95% CI 1.13-3.86) was seen with alpha blockers in the subset of placebo-controlled trials.
● Similar findings were reported in another meta-analysis of 55 randomized controlled trials

that included 5990 patients with a mean stone size of 5.7 mm [105]. Compared with the
control group, patients treated with an alpha blocker (usually tamsulosin) had a 49 percent
greater likelihood of stone passage (RR 1.49, 95% CI 1.39-1.61). A subgroup analysis
found that the benefit of alpha blocker therapy was larger in patients with larger stones (RR
1.57, 95% CI 1.17-2.27) than in those with smaller stones (RR 1.19, 95% CI 1.00-1.48).
The risk of serious adverse events was similar between the treatment and control groups.
● In a meta-analysis of eight placebo-controlled trials that included 1384 patients with

radiologically confirmed ureteral stones of 10 mm or less, patients treated with the alpha
blocker tamsulosin were more likely to experience stone passage than those treated with
placebo (85 versus 66 percent; RR 1.22, 95% CI 1.07-1.40) [110]. The benefit of
tamsulosin was limited to patients with larger stones (5 to 10 mm), and no benefit was
seen in those with smaller stones (<4 to 5 mm). There were no differences between
tamsulosin and placebo in the percentage of patients experiencing dizziness or orthostatic
hypotension.
The value of these meta-analyses is emphasized given that the results of individual, large,
randomized trials have been conflicting, with some studies questioning the efficacy of alpha
blocker therapy as MET and others demonstrating benefit but only in patients with larger
ureteral stones (between 5 and 10 mm). The following studies illustrate the range of findings
[104,108,109,114]:
● In a multicenter, double-blind, placebo-controlled trial, 512 adult patients presenting to the

emergency department with a symptomatic ureteral stone demonstrated on computed
tomography (CT) were randomly assigned to four weeks of therapy with tamsulosin (0.4
mg once daily) or placebo [114]. All patients had a stone size of 9 mm or less, and 74
percent had a stone size of less than 5 mm. At four weeks, there was no difference in rates
of stone passage (as determined by visualization/capture by the patient) between the
treatment arms (50 versus 47 percent for the tamsulosin and placebo groups,
respectively). Treatment-related adverse effects were similar between the two groups,
except for an increase in ejaculatory dysfunction among men treated with tamsulosin
compared with placebo (18 versus 7 percent). In subgroup analyses, stone passage rates
did not differ between the treatment groups when patients were stratified by stone size (<5
mm versus ≥5 mm) or location (upper versus lower ureter). However, the study was not
adequately powered to detect significant differences within these subgroups.
● Similar results were reported in another multicenter trial of 403 patients with distal ureteral
stones of 10 mm of less who were randomly assigned to tamsulosin (0.4 mg) or placebo
daily for four weeks [108]. At four weeks, there was no significant difference in stone
passage rates between tamsulosin- and placebo-treated patients (87 versus 82 percent).
However, in a prespecified subgroup analysis, patients with larger stones (5 to 10 mm)

experienced higher stone passage rates with tamsulosin compared with placebo, a
benefit that was not seen in those with smaller stones (<5 mm).
● By contrast, in a large, multicenter trial of 3296 Chinese patients with distal ureteral stones,
treatment with tamsulosin (0.4 mg once daily for four weeks) increased stone passage
rates (86 versus 79 percent) compared with placebo [109]. In the subgroup analysis, the
benefit of tamsulosin was primarily observed in patients with larger distal ureteral stones
(>5 mm) as there was no difference in stone passage rates between those treated with
tamsulosin who had stones <5 mm and those treated with placebo.
Collectively, these studies suggest that treatment with alpha blockers (tamsulosin) for up to four
weeks, in addition to conservative therapy, may facilitate spontaneous stone passage in
patients presenting with ureteral stones >5 and ≤10 mm in diameter. As the cost of this
treatment is low and significant side effects are uncommon, we believe that there is little
downside to attempting MET with tamsulosin in such patients, provided that the patient has
sufficient pain control and is without fever. Different alpha blockers appear to be similarly
effective [102,115].
Nifedipine has also been shown to facilitate stone passage [101] but is used less commonly.
Studies directly comparing nifedipine with tamsulosin have reported similar rates of stone
passage, although rates were slightly higher with tamsulosin [99-101,103,116]. A potential
advantage of tamsulosin is somewhat faster stone passage and fewer hospitalizations and
procedures.
In addition to tamsulosin and nifedipine, tadalafil and silodosin can be used as MET [117,118].
In a trial, 285 patients with distal ureteral stones sized 5 to 10 mm in diameter were randomly
assigned to tamsulosin (0.4 mg/day), silodosin (8 mg/day), or tadalafil (10 mg/day) until stone
passage or for a maximum of four weeks [118]. Silodosin resulted in significantly higher rates
of stone expulsion (83 compared with 64 percent with tamsulosin and 67 percent with tadalafil)
and significantly faster mean expulsion times (15 days versus 17 days with tamsulosin and 16
days with tadalafil). Additional studies are needed to evaluate the safety and efficacy of
tadalafil and silodosin as MET.
International guidelines from the American Urological Association and the European
Association of Urology on the management of ureteral calculi suggest that:
● "In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are
controlled, observation with periodic evaluation is an option for initial treatment. Such
patients may be offered an appropriate medical therapy to facilitate stone passage during
the observation period. In a choice between active stone removal and conservative
treatment with MET, it is important to take into account all individual circumstances that
may affect treatment decisions. A prerequisite for MET is that the patient is reasonably
comfortable with that therapeutic approach and that there is no obvious advantage of
immediate active stone removal" [51,119].
Patients will typically require analgesics such as ketorolac. Concurrent antibiotics are used by
some groups but have not been studied to determine their value in the setting of a patient
receiving MET. Patients with stones larger than 10 mm in diameter, patients with significant
discomfort, those with significant obstruction, or who have not passed the stone after four to six
weeks should be referred to urology for potential intervention.
UROLOGY CONSULTATION
Urgent urologic consultation is warranted in patients with urosepsis, acute kidney injury, anuria,
and/or unyielding pain, nausea, or vomiting [4,120]. Outpatient urology referral is indicated in
patients with a stone >10 mm in diameter and in patients who fail to pass the stone after a trial
of conservative management, including medical expulsive therapy (MET), particularly if the
stone is >4 mm in diameter or if there is uncontrolled pain [87,121].
Patients who do not pass the stone may need imaging if it has not already been performed. If
only ultrasound or intravenous pyelogram (IVP) has been obtained and the stone has not been
identified, a noncontrast computed tomography (CT) should be performed.
Current options for therapy of stones that do not pass include shock wave lithotripsy (SWL),
ureteroscopic lithotripsy with electrohydraulic or laser probes, percutaneous nephrolithotomy,
and laparoscopic stone removal. Open surgical stone removal is rarely needed. SWL is the
treatment of choice in 75 percent of patients and works best for stones in the renal pelvis and
upper ureter. With the newer machines, most patients tolerate the procedure reasonably well.
Approximately one-third have transient mild fever, with obstruction by the stone fragments or
urinary tract infection occurring in less than 10 percent of cases. Both SWL and ureteroscopy
are considered first-line management options for ureteral stones that require removal, with
ureteroscopy yielding higher stone-free rates but with an increased incidence of complications
over SWL [51,119].
For patients with larger renal calculi (eg, >1.5 cm), renal stones of harder composition (eg,
cystine or calcium oxalate monohydrate), or stones in complex renal or ureteral locations (eg,
lower pole calyx or mid-ureter), SWL is only successful in approximately 50 percent of cases. In
these settings, endoscopic stone fragmentation with a percutaneous or ureteroscopic
approach is preferred. (See "Management of ureteral calculi" and "Renal complications of

extracorporeal shock wave lithotripsy".)
EVALUATION AND SUBSEQUENT TREATMENT
Once the acute stone episode is over and the stone, if retrieved, is sent for analysis, the patient
should be evaluated for possible underlying causes of stone disease, including hypercalcemia
(most often due to primary hyperparathyroidism), and 24-hour urine composition. How and
when this evaluation should be performed is discussed elsewhere. If the presenting event was
the first episode of stone passage, the presence of other stones in the kidney demonstrate
recurrent stone formation, and the patient should undergo further evaluation. (See "Evaluation
of the adult patient with established nephrolithiasis and treatment if stone composition is
unknown" and "Interpretation of kidney stone composition analysis".)
Subsequent therapy is based upon the type of stone and the biochemical abnormalities that
are present. However, it remains uncertain whether evaluation and therapy are warranted after
the first stone or only in patients with active stone disease, which is defined as the formation of
new stones, increase in size of old stones, or the continued passage of gravel. A consensus
conference has suggested that a full metabolic evaluation after the first stone should be
considered in patients with risk factors for recurrent stone formation, such as a positive family
history of stone formation, young age, solitary kidney, nephrocalcinosis, chronic kidney disease
or skeletal diseases, history of bowel disease or bowel surgery, certain jobs (such as pilot or
frequent business traveler), difficult to treat stones (eg, those with urinary tract abnormalities),
and immunocompromised conditions [122]. (See "Evaluation of the adult patient with
established nephrolithiasis and treatment if stone composition is unknown".)
Once it has been determined that therapy to prevent new stone formation is required, the
following guidelines can be used:
● Most patients require increased fluid intake. (See "Prevention of recurrent calcium stones
in adults".)
● Dietary recommendations tailored to the individual's habits and urine composition may be
beneficial. (See "Prevention of recurrent calcium stones in adults".)
● Patients with calcium stones who cannot be solely managed with dietary modifications can
be treated with a thiazide diuretic and low-sodium diet for high urine calcium, potassium
citrate for hypocitraturia, and, occasionally, allopurinol for high urine uric acid. (See
"Prevention of recurrent calcium stones in adults".)
● Patients with uric acid stones can be treated with potassium citrate or potassium
bicarbonate to alkalinize the urine and occasionally allopurinol (for patients with severe
hyperuricosuria). (See "Uric acid nephrolithiasis".)
● Patients with cystine stones can be treated with a high fluid intake, urinary alkalinization,
and drugs such as tiopronin. (See "Cystine stones".)
● Struvite stones typically require complete stone removal with percutaneous

nephrolithotomy and aggressive prevention and treatment of future urinary tract infections.
(See "Management of struvite or staghorn calculi".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Kidney stones".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topic (see "Patient education: Kidney stones in adults (The Basics)")
● Beyond the Basics topic (see "Patient education: Kidney stones in adults (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
● Eighty percent of patients with nephrolithiasis form calcium stones, most of which are
composed primarily of calcium oxalate or, less often, calcium phosphate. The other main
types include uric acid, struvite (magnesium ammonium phosphate), and cystine stones. A
patient may have a stone with more than one component (eg, a stone containing both
calcium oxalate and uric acid). (See 'Etiology' above.)
● The risk of nephrolithiasis is influenced by urine composition, which can be affected by

certain diseases and patient habits. These are summarized in the following table (table 1).
In addition, patients with a personal or family history of kidney stones and those who have
had certain types of bowel surgery (eg, gastric bypass, bariatric surgery, short bowel
syndrome) are at high risk for nephrolithiasis. (See 'Risk factors' above.)
● Patients may occasionally be diagnosed with asymptomatic nephrolithiasis when an

imaging exam of the abdomen is performed for other purposes or when surveillance
imaging is done in those with a prior history of stones. (See 'Clinical manifestations'
above.)
● Although stones (or gravel) may pass asymptomatically, symptoms may develop when
stones initially pass from the renal pelvis into the ureter. The following are the most
common symptoms (see 'Symptoms' above):
• Pain, which varies from a mild and barely noticeable ache to discomfort that is so
intense that it requires parenteral analgesics. The pain typically waxes and wanes in
severity and develops in waves or paroxysms that are related to movement of the
stone in the ureter and associated ureteral spasm (renal colic). Paroxysms of severe
pain usually last 20 to 60 minutes. (See 'Symptoms' above.)
• Gross or microscopic hematuria occurs in the majority of patients presenting with

symptomatic nephrolithiasis (70 to 90 percent). Other than visualization of a stone or
gravel, this is the single most discriminating predictor of a kidney stone in patients
presenting with unilateral flank pain. On the other hand, the absence of hematuria in
the setting of acute flank pain does not exclude the presence of nephrolithiasis. (See
'Hematuria' above.)
• Other symptoms that are commonly seen include nausea, vomiting, dysuria, and
urinary urgency. (See 'Other' above.)
• Nephrolithiasis may lead to persistent renal obstruction, which could cause permanent
renal damage if left untreated. (See 'Complications' above.)
● Several conditions may mimic renal colic with or without hematuria. (See 'Differential
diagnosis' above.)
● The diagnosis of nephrolithiasis is confirmed with imaging of the kidneys, ureters, and
bladder to look for stones and signs of urinary obstruction (eg, hydronephrosis). If
hydronephrosis is observed, stone size and ureteral location are used to predict likelihood
of spontaneous stone passage and to guide management. (See 'Diagnostic imaging'
above.)
• Computed tomography (CT) of the abdomen and pelvis without contrast performed
using low-radiation-dose scanning technology is the preferred exam for most adults
as it reliably detects hydronephrosis and demonstrates the highest diagnostic
accuracy for nephrolithiasis. This exam is available at most sites. If positive, CT also
accurately describes stone size and location for treatment planning.
• If low-radiation-dose CT technology is not available, standard-dose, noncontrast CT of

the abdomen and pelvis or ultrasound of the kidneys and bladder are the two second-
line alternatives. Both reliably detect hydronephrosis. In patients who have undergone
or are likely to undergo multiple CT exams for nephrolithiasis, ultrasound is preferred
as it minimizes the cumulative radiation dose over time. However, compared with CT,
ultrasound is less sensitive for stones and does not provide reliable stone size
measurements or localization.
● Most patients with acute renal colic can be managed conservatively with pain medication
and hydration until the stone passes (algorithm 1). Nonsteroidal antiinflammatory drugs
(NSAIDs) appear to be at least as effective as opiates. Patients can be managed at home
if they are able to take oral medications and fluids. Hospitalization is required for those
who cannot tolerate oral intake or who have uncontrollable pain or fever. (See 'Acute
therapy' above and 'Pain control' above.)
● Urgent urologic consultation is warranted in patients with urosepsis, acute kidney injury,
anuria, and/or unyielding pain, nausea, or vomiting. (See 'Acute therapy' above and
'Urology consultation' above.)
● Stone size is the major determinant of the likelihood of spontaneous stone passage,
although stone location is also important. Most stones ≤5 mm in diameter pass
spontaneously. For stones larger than 4 mm in diameter, there is a progressive decrease
in the spontaneous passage rate, which is unlikely with stones ≥10 mm in diameter.
Proximal ureteral stones are also less likely to pass spontaneously. (See 'Stone passage'
above.)
● Both tamsulosin and nifedipine have been shown to increase the likelihood of stone
passage, with tamsulosin showing slightly better results. In patients with stones >5 and ≤10
mm in diameter, we suggest treatment with tamsulosin for up to four weeks to facilitate
stone passage (Grade 2B). Patients are then reimaged if spontaneous passage has not
definitively occurred. (See 'Facilitating stone passage' above.)
● Patients with stones larger than 10 mm in diameter, patients with significant discomfort,
those with significant obstruction, or who have not passed the stone after four to six weeks
should be referred to urology for potential intervention. (See 'Facilitating stone passage'
above and 'Urology consultation' above.)
● Patients should be instructed to strain their urine for several days and bring in any stone
that passes for analysis. This will enable the clinician to better plan preventive therapy.
(See 'Straining urine' above.)
● Once the acute stone episode is over and the stone, if retrieved, is sent for analysis, the
patient should be evaluated for possible underlying causes of stone disease. (See
'Evaluation and subsequent treatment' above.)
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Topic 7366 Version 28.0
GRAPHICS
Major risk factors for calcium stones
Urinary
Lo we r vo lum e
Highe r ca lcium
Highe r o x a la te (C a O x sto ne s)
Lo we r citra te
Highe r pH (C a P sto ne s)
Anatomic
Me dulla ry spo nge k idne y
Ho rse sho e k idne y
Diet
Lo we r fluid inta k e
Lo we r die ta ry ca lcium
Highe r o x a la te
Lo we r po ta ssium
Highe r so dium
Highe r sucro se
Highe r fructo se
Lo we r phyta te
Highe r vita m in C
Other medical conditions

P rim a ry hype rpa ra thyro idism
Go ut
O be sity
Dia be te s m e llitus
Dista l re na l tubula r a cido sis
Infla m m a to ry bo we l dise a se
Ma la bso rptive ba ria tric surge ry
Sho rt bo we l syndro m e
C aOx: calcium oxalate; C aP: calcium phosphate.
Graphic 78303 Version 5.0
Urine sediment showing cystine crystals
Urine sediment show ing hexagonal cystine crystals that are essentially
pathognomonic of cystinuria.
Courtesy of Harvard Medical School.
Urine sediment showing struvite (magnesium ammonium

phosphate) crystals
Urine sediment show ing multiple "coffin lid" magnesium ammonium

phosphate crystals (struvite) that form only in an alkaline urine (pH
usually above 7.0) caused by an upper urinary tract infection w ith a
urease-producing bacteria.
Courtesy of Harvard Medical School.
Management of acute symptomatic nephrolithiasis
C T: computed tomography; ESWL: extracorporeal shock wave lithotripsy; URS:

ureteroscopy.
Imaging modalities for nephrolithiasis
Advantages Disadvantages
Abdomen Accurate stone size measurements Low to moderate sensitivity and wide
radiograph and ureteral localization for variability in diagnostic
treatment planning performance; detects 29 to 59% of
stones seen with C T [1,2]
Does not detect hydronephrosis
Ionizing radiation; effective dose 0.8
mSv with each view
Intravenous Reliably detects hydronephrosis Diagnostic performance not

pyelography (IVP) Accurate stone size measurements quantified; less accurate than C T
and ureteral localization for Ionizing radiation; effective dose 12
treatment planning mSv
Intravenous contrast required
Ultrasound No ionizing radiation; lower Low to moderate sensitivity and wide

kidneys and cumulative radiation dose in patients variability in diagnostic
bladder undergoing repeated imaging in performance; detects 24 to 57% of
settings where low-dose C T is not stones seen with C T [3,4]
available Inaccurate stone size measurements
Reliably detects hydronephrosis and ureteral localization for
treatment planning
Likely nondiagnostic in patients with
large body habitus (men >285 lb,
women >250 lb), or those with end-
stage renal disease
Noncontrast C T Highest diagnostic accuracy; pooled Ionizing radiation; effective dose 2

abdomen and sensitivity 0.97 and specificity 0.95 to 3 mSv with low-dose and 10 to 12
pelvis for low-dose exam [5] mSv with standard-dose exam
Reliably detects hydronephrosis Rarely, a second set of images after
Accurate stone size measurements intravenous contrast are needed for
and ureteral localization for definitive diagnosis of urolithiasis*
treatment planning
MRI abdomen and No ionizing radiation Very low sensitivity as stones are
pelvis Reliably detects hydronephrosis nearly invisible
Accurately localizes the site of Inaccurate stone size measurements
ureteral obstruction for treatment for treatment planning
planning Requires patient lie still in enclosed
scanner for 10 to 20 minutes
C T: computed tomography; MRI: magnetic resonance imaging.

* To distinguish ureteral stones from phleboliths.
References:
1. Jung SI, Kim YJ, Park HS, et al. Sensitivity of digital abdominal radiography for the detection of ureter
stones by stone size and location. J Comput Assist Tomogr 2010; 34:879.
2. Levine JA, Neitlich J, Verga M, et al. Ureteral calculi in patients with flank pain: correlation of plain
radiography with unenhanced helical CT. Radiology 1997; 204:27.
3. Fowler KA, Locken JA, Duchesne JH, Williamson MR. US for detecting renal calculi with nonenhanced
CT as a reference standard. Radiology 2002; 222:109.
4. Ulusan S, Koc Z, Tokmak N. Accuracy of sonography for detecting renal stone: Comparison with CT. J
Clin Ultrasound 2007; 35:256.
5. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of
urolithiasis: a meta-analysis. AJR Am J Roentgenol 2008;191:396.
CT of a ureteral stone
Ureterolithiasis w ith obstruction. Image of the abdomen from a CT w ith

intravenous contrast show s a stone (arrow ) in the proximal left ureter
w ith slight delayed enhancement and mild hydronephrosis of the left
kidney. The right kidney is normal w ith high density contrast excretion in
the right ureter (arrow head).
C T: computed tomography.
Courtesy of Jonathan Kruskal, MD.
CT of renal stone
Nephrolithiasis. Image of abdomen from a noncontrast CT show s a stone

(arrow ) in the right renal pelvis.
Courtesy of Mark D Aronson, MD.
Low-radiation-dose CT of renal stone
Nephrolithiasis. Coronal reconstruction image of the abdomen from a

noncontrast CT performed w ith low -radiation-dose protocol show s a 3 mm
stone (arrow ) in the right renal calyx.
Courtesy of Kasra Mojtahed MD.
CT of medullary sponge kidney
Medullary sponge kidney. Coronal reconstruction image of the abdomen

from a noncontrast CT show s bilateral nephrocalcinosis (arrow s) at the
corticomedullary junction.
Courtesy of Susanna I Lee MD, PhD.
Abdominal radiograph of renal stones
Nephrolithiasis. Abdominal radiograph anteroposterior projection show s a staghorn

calculus in the right renal pelvis and smaller stones (arrow s) in the left kidney.
Contributor Disclosures
Gary C Curhan, MD, ScD Grant/Research/Clinical Trial Support: Allena Pharmaceuticals [Oxalate].
Consultant/Advisory Boards: Allena Pharmaceuticals [Oxalate, nephrolithiasis]; Decibel Therapeutics
(Hearing loss/tinnitus); Shire [hypoparathyroidism]; RenalGuard [Acute kidney injury]; AstraZeneca
[Hyperkalemia (Sodium zirconium cyclosilicate)]. Consultant/Advisory Boards (spouse/partner): Decibel
Therapeutics (Hearing loss, tinnitus)]. Equity Ownership/Stock Options: Allena Pharmaceuticals. Mark
D Aronson, MD Nothing to disclose Glenn M Preminger, MD Consultant/Advisory Boards: Retrophin
[Cystine stones (Tiopronin)]; Boston Scientific [Surgical stone management (Endourology
equipment)]. Stanley Goldfarb, MD Nothing to disclose Michael P O'Leary, MD, MPH Nothing to
disclose Jorge A Soto, MD Nothing to disclose Albert Q Lam, MD Nothing to disclose Susanna I
Lee, MD, PhD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these
are addressed by vetting through a multi-level review process, and through requirements for references
to be provided to support the content. Appropriately referenced content is required of all authors and
must conform to UpToDate standards of evidence.
Conflict of interest policy

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Diagnosis and acute management of suspected

● A history of prior nephrolithiasis. The rate of stone recurrence is 10 to 30 percent at three

phosphoribosyltransferase deficiency, and cystinuria [16-18]. The diagnosis of cystinuria is

producing organism such as Proteus or Klebsiella. Classic symptoms of nephrolithiasis

Patients may occasionally be diagnosed with asymptomatic nephrolithiasis when an imaging

Hematuria — Gross or microscopic hematuria occurs in the majority of patients presenting

Several conditions may mimic flank pain caused by nephrolithiasis [46]:

The differential diagnosis of abdominal discomfort is discussed elsewhere. (See "Causes of

Choice of imaging should include consideration of the following:

● CT of the abdomen and pelvis without contrast performed using low-radiation-dose

• If the patient is pregnant, an ultrasound is the preferred modality. (See

● If low-radiation-dose CT technology is not available, standard-dose, noncontrast CT of the

Point-of-care renal ultrasound at the bedside is performed in many emergency departments

The effective radiation dose of a standard, noncontrast abdominopelvic CT is usually 10 to 12

Occasionally, a contrast-enhanced abdominopelvic CT will follow a low-dose, noncontrast CT

Determination of stone composition — The appearance, density, and location of a stone

● Nephrocalcinosis, suggestive of renal tubular acidosis, is associated with calcium

● Medullary sponge kidney with bilateral calcifications at the corticomedullary junction is

associated with calcium oxalate or calcium phosphate stones (image 3).

Ultrasound has been compared with standard-dose abdominopelvic CT for diagnostic

● The rate of important missed diagnoses resulting in complications, such as pyelonephritis

emergency department after discharge were also similar.

Abdominal radiography — Abdominal radiography, also called abdominal plain x-ray,

Abdominal radiography detects 29 to 59 percent of stones seen on noncontrast CT [79,80].

Intravenous pyelography — IVP, also called intravenous urography (IVU), involves

The effective radiation dose from an IVP is 3 mSv.

days, and 95 percent of stones passed in 39 days.

● Similar findings were reported in another meta-analysis of 55 randomized controlled trials

● In a meta-analysis of eight placebo-controlled trials that included 1384 patients with

● In a multicenter, double-blind, placebo-controlled trial, 512 adult patients presenting to the

However, in a prespecified subgroup analysis, patients with larger stones (5 to 10 mm)

approach is preferred. (See "Management of ureteral calculi" and "Renal complications of

EVALUATION AND SUBSEQUENT TREATMENT

● Struvite stones typically require complete stone removal with percutaneous

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● The risk of nephrolithiasis is influenced by urine composition, which can be affected by

● Patients may occasionally be diagnosed with asymptomatic nephrolithiasis when an

• Gross or microscopic hematuria occurs in the majority of patients presenting with

• If low-radiation-dose CT technology is not available, standard-dose, noncontrast CT of

Use of UpToDate is subject to the Subscription and License Agreement.

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11. Kocvara R, Plasgura P, Petrík A, et al. A prospective study of nonmedical prophylaxis

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gastric bypass. Surg Obes Relat Dis 2005; 1:481.

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rational clinical examination systematic review. JAMA 2013; 309:1722.

52. Metzler IS, Smith-Bindman R, Moghadassi M, et al. Emergency Department Imaging

56. Ulahannan D, Blakeley CJ, Jeyadevan N, Hashemi K. Benefits of CT urography in

57. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the

60. Tack D, Sourtzis S, Delpierre I, et al. Low-dose unenhanced multidetector CT of patients

with suspected renal colic. AJR Am J Roentgenol 2003; 180:305.

70. Oehlschläger S, Hakenberg OW, Froehner M, et al. Evaluation of chemical composition

75. Eiber M, Holzapfel K, Frimberger M, et al. Targeted dual-energy single-source CT for

78. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed

91. Udén P, Rentzhog L, Berger T. A comparative study on the analgesic effects of

95. Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort

96. Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosin in the medical

98. Dellabella M, Milanese G, Muzzonigro G. Medical-expulsive therapy for distal

99. Dellabella M, Milanese G, Muzzonigro G. Randomized trial of the efficacy of tamsulosin,