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Acute distal ureteric calculus with refractory renal colic — MSRA MCQ

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HardNephrolithiasisAcute distal ureteric calculus with refractory renal colicMSRA

A 47-year-old man attends an acute assessment unit with CT-confirmed left renal colic. Low-dose non-contrast CT performed 6 hours earlier shows an 8 mm distal left ureteric stone with mild hydroureteronephrosis. He has no previous stones, normal baseline renal function and a creatinine of 78 micromol/L. Temperature is 36.8°C, observations are normal, and urine dipstick is positive for blood but negative for nitrites and leucocytes. He has received intramuscular diclofenac and intravenous paracetamol but continues to report severe, unremitting pain rated 9/10 and is unable to mobilise comfortably. He has no vomiting or contraindication to anaesthesia. What is the most appropriate next management?

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Correct answer: A — Arrange same-day urology assessment for surgical treatment, with shockwave lithotripsy offered within 48 hours

This patient requires urgent urological management for definitive treatment. He has a ureteric stone with ongoing pain that remains intolerable despite appropriate first-line NSAID treatment and intravenous paracetamol. NICE recommends surgical treatment, including shockwave lithotripsy (SWL), within 48 hours of diagnosis or readmission in this situation. For an adult ureteric stone smaller than 10 mm, SWL is the recommended first-line definitive intervention where suitable. Tamsulosin is a reasonable medical expulsive therapy option for a distal ureteric stone below 10 mm, but it is not an appropriate substitute where pain remains uncontrolled. Further opioid analgesia may be considered if NSAIDs and intravenous paracetamol have been insufficient, but it does not remove the indication for prompt definitive treatment. Percutaneous nephrostomy is used for urgent decompression when obstruction is infected or there is another compelling need for drainage; this patient has neither sepsis nor evidence of urinary infection. Primary ureteroscopy is an alternative when SWL is unsuitable, unavailable in an appropriate timeframe, or has failed, but it is not routinely first-line for an uncomplicated ureteric stone below 10 mm.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Timing of surgical treatment (2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Surgical treatment table (2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Pain management and medical expulsive therapy (2019; checked 15 August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations