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Symptomatic distal ureteric calculus — MSRA MCQ

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HardNephrolithiasisSymptomatic distal ureteric calculusMSRA

A 76-year-old man is assessed 18 hours after low-dose non-contrast CT confirmed an 8 mm radiopaque distal ureteric calculus with mild hydroureteronephrosis. He remains afebrile, urine culture is negative, renal function is unchanged from baseline, and there is no solitary kidney. Despite oral diclofenac and paracetamol, he has ongoing colic that he cannot tolerate. The stone is targetable with shockwave lithotripsy (SWL), which is available tomorrow. He is not taking an alpha blocker and is scheduled for elective phacoemulsification cataract surgery in 12 days. What is the most appropriate management plan?

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

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Correct answer: A — Arrange SWL tomorrow without initiating tamsulosin.

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

This man requires definitive treatment within 48 hours because his ureteric stone is causing ongoing, intolerable renal colic. For an adult with a ureteric stone smaller than 10 mm, NICE recommends SWL where feasible; ureteroscopy is principally considered when SWL cannot achieve clearance within 4 weeks, is contraindicated, is not targetable, or has failed. None applies here. NICE advises that an alpha blocker may be considered as an adjunct to SWL for ureteric stones smaller than 10 mm. However, this is optional rather than mandatory. Crucially, the tamsulosin SmPC states that initiating tamsulosin is not recommended in people scheduled for cataract or glaucoma surgery because of the association with intraoperative floppy iris syndrome, including after prior exposure. Therefore, the prescribing safety exception outweighs the potential adjunctive benefit. A is unnecessarily invasive when prompt, targetable SWL is available. B is wrong because routine pre-treatment stenting before adult SWL should not be offered, and tamsulosin should not be initiated. C overlooks the forthcoming cataract surgery. D inappropriately delays treatment despite uncontrolled pain and an available next-day intervention.

Reference: NICE NG118: Renal and ureteric stones: assessment and management — Recommendations (Published 2019; updated May 2026) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations Tamsulosin hydrochloride SUN Pharma 400 micrograms prolonged-release hard capsules — Summary of Product Characteristics (2025) — https://www.medicines.org.uk/emc/product/2508/smpc