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Symptomatic distal ureteric calculus — MSRA MCQ

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HardUrologySymptomatic distal ureteric calculusMSRA

A 47-year-old man attends an emergency assessment unit with recurrent severe left renal colic. Low-dose non-contrast CT performed today shows an 11-mm distal left ureteric stone with mild hydronephrosis. He is afebrile, haemodynamically stable and has no dysuria; urine dipstick is positive for blood but negative for nitrites and leucocytes. Creatinine is 84 micromol/L, consistent with baseline. Despite diclofenac and intravenous paracetamol, his pain remains 8/10 and he cannot mobilise comfortably. What is the most appropriate next management step?

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

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Correct answer: D — Arrange urgent urological ureteroscopy within 48 hours

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

This patient has a ureteric stone measuring 11 mm and ongoing intolerable renal colic despite appropriate first-line analgesia. NICE recommends ureteroscopy (URS) as the preferred surgical treatment for adult ureteric stones measuring 10–20 mm. In addition, adults with ureteric stones and renal colic should receive surgical treatment within 48 hours when pain remains ongoing and not tolerated. Therefore, urgent urological referral to arrange URS within 48 hours is appropriate. A is unsafe because refractory pain is itself an indication for expedited definitive intervention rather than delayed community review. B is plausible because shockwave lithotripsy can be considered for 10–20 mm ureteric stones where local clearance within 4 weeks is feasible, but it does not meet the required urgency in someone with intolerable ongoing pain. C would be appropriate for an infected obstructed system, sepsis, or obstruction causing renal deterioration; none is present here. E may appear attractive in a distal stone, but current NICE guidance supports alpha blockers as an adjunct to shockwave lithotripsy for ureteric stones under 10 mm, not as expectant treatment for this 11-mm stone with uncontrolled pain.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Surgical treatments (2019; checked August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Timing of surgical treatment (2019; checked August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations NICE NG118: Renal and ureteric stones: assessment and management — Medical expulsive therapy as an adjunct to SWL (2019; checked August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations