Pain Control Medications for Ureteral Stones

First-Line Pain Management

The European Association of Urology recommends NSAIDs (diclofenac, ibuprofen, metamizole) as the primary analgesics for renal colic due to ureteral stones, with a strength of evidence level of high 1, 2, 3
NSAIDs reduce the need for additional analgesia compared to opioids and are more effective than antispasmodics in controlling pain, with a moderate strength of evidence 1
The lowest effective dose of NSAIDs should be used to minimize cardiovascular and gastrointestinal risks, with a high strength of evidence 1
NSAIDs may impact renal function in patients with low glomerular filtration rate, requiring caution in these patients, with a moderate strength of evidence 1, 2

The European Association of Urology recommends opioids as second-choice analgesics when NSAIDs are contraindicated or insufficient for pain control, with a high strength of evidence 1, 2
If an opioid is required, agents other than pethidine are recommended, such as hydromorphone, pentazocine, or tramadol, with a moderate strength of evidence 1, 2
Opioids, particularly pethidine, are associated with a higher rate of vomiting compared to NSAIDs and a greater likelihood of requiring additional analgesia, with a high strength of evidence 1, 2

Alpha-blockers (tamsulosin, terazosin, doxazosin) can be used as medical expulsive therapy (MET) for patients with ureteral stones, particularly those with stones >5 mm in the distal ureter, with a high strength of evidence 1, 4, 5
Alpha-blockers facilitate stone passage and may reduce stone-passage time and limit pain, with a moderate strength of evidence 4, 5
Alpha-blockers have shown a statistically significant 29% increase in stone passage rates compared to control patients, with a high strength of evidence 4, 5

In cases of sepsis and/or anuria in an obstructed kidney, urgent decompression via percutaneous nephrostomy or ureteral stenting is strongly recommended before definitive treatment, with a high strength of evidence 1, 2, 5
Patients should be counseled on the attendant risks of MET including associated drug side effects and should be informed that it is administered for an "off-label" use, with a moderate strength of evidence 6
Patients who elect for an attempt at spontaneous passage or MET should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve, with a high strength of evidence 6
For patients requiring stone removal, both shock wave lithotripsy (SWL) and ureteroscopy (URS) are acceptable first-line treatments, though URS yields significantly greater stone-free rates for most stone stratifications, with a high strength of evidence 6, 7

Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis, with a moderate strength of evidence 6
Regular assessment of pain intensity using visual analogue scales (VAS), verbal rating scale (VRS), or numerical rating scale (NRS) is recommended to evaluate treatment efficacy, with a high strength of evidence 8
Analgesics for chronic pain should be prescribed on a regular basis and not on an 'as required' schedule, with a moderate strength of evidence 8
Rescue doses of medications (as required) other than the regular basal therapy must be prescribed for breakthrough pain episodes, with a high strength of evidence 8