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Distal ureteric calculus — MSRA MCQ

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HardNephrolithiasisDistal ureteric calculusMSRA

A 56-year-old man presents with CT-confirmed renal colic from a 14 mm distal left ureteric calculus causing moderate hydroureteronephrosis. He is afebrile, haemodynamically stable, has a negative urine culture and normal renal function. His pain is controlled with oral NSAID and paracetamol. The stone is radiopaque and targetable with shockwave lithotripsy (SWL), but the local SWL service can perform an initial treatment tomorrow and a repeat treatment, if required, no earlier than 5 weeks later. Ureteroscopy (URS) is available within 48 hours. The stone is judged unlikely to pass spontaneously. What is the most appropriate definitive management plan?

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

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Correct answer: C — Arrange ureteroscopy with lithotripsy within 48 hours

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

This is a 14 mm ureteric stone, placing it in the 10–20 mm category. For adults in this group, NICE recommends URS as the first-line intervention; SWL is an alternative only where local facilities allow stone clearance within 4 weeks. Although the stone is targetable and an initial SWL session is available promptly, the stated pathway cannot achieve clearance within 4 weeks because any necessary repeat treatment is delayed until week 5. URS is therefore the appropriate definitive treatment. The stone is also judged unlikely to pass, so definitive surgical treatment should be offered within 48 hours of diagnosis or readmission even though analgesia is currently adequate. There is no sepsis, acute kidney injury or uncontrolled pain requiring emergency drainage. A is attractive because SWL is less invasive and available tomorrow, but its anticipated clearance timeline does not meet the NICE condition for a 10–20 mm ureteric stone. C is inappropriate: alpha blockers are considered for distal ureteric stones under 10 mm, not as definitive treatment for this 14 mm stone. D unnecessarily delays treatment of a stone unlikely to pass. E is not first-line; PCNL is considered for impacted proximal ureteric stones after failed URS.

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 (2019; checked August 2026) — https://www.nice.org.uk/guidance/ng118/chapter/recommendations