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Distal ureteric calculus with imminent cataract surgery — MSRA MCQ

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HardNephrolithiasisDistal ureteric calculus with imminent cataract surgeryMSRA

A 58-year-old man is reviewed by his GP on the day after emergency department assessment for renal colic. Low-dose non-contrast CT showed a 6 mm distal left ureteric stone at the vesicoureteric junction with mild hydroureteronephrosis. He is afebrile, has negative urine culture, normal renal function and satisfactory pain control with diclofenac. Urology has advised a trial of conservative management and asked the GP to consider medical expulsive therapy. He is due to undergo elective cataract extraction in 8 days. He has no lower urinary tract symptoms and takes no regular medicines. What is the most appropriate management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Continue conservative management with NSAID analgesia, but do not initiate tamsulosin before cataract surgery

Explanation lettering: E = shown as A · A = shown as B · D = shown as C · C = shown as D · B = shown as E

This patient is suitable for ongoing conservative management: he has a distal ureteric stone smaller than 10 mm, controlled pain, no infection and no acute kidney injury. NICE says that alpha blockers may be considered for distal ureteric stones under 10 mm, but this is not a requirement where observation is otherwise appropriate. The decisive exception is his imminent cataract surgery. Tamsulosin is associated with intraoperative floppy iris syndrome (IFIS). Its SmPC states that initiating tamsulosin is not recommended in people scheduled for cataract or glaucoma surgery. Therefore, the appropriate plan is NSAID-based analgesia, safety-netting for fever, escalating pain, vomiting or reduced urine output, and no new tamsulosin prescription before the operation. A is attractive because the stone meets NICE criteria for considering an alpha blocker, but it misses the ophthalmic contraindication to initiation. B would be appropriate if pain remained intolerable or the stone were judged unlikely to pass, neither of which applies here. D is plausible because calcium-channel blockers have historically been used for medical expulsive therapy, but NICE recommends alpha blockers rather than nifedipine. E recognises the IFIS risk but does not address the SmPC advice not to initiate tamsulosin when cataract surgery is already scheduled.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (Published 8 January 2019; current NICE guidance checked August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations Tamsulosin prolonged release tablets 400 microgram — Summary of Product Characteristics (Revised 19 June 2026) — https://www.medicines.org.uk/emc/product/102038/smpc