Renal Stones: Management

Key points

• Analgesia: NICE recommends an NSAID first-line for suspected renal colic; use IV paracetamol if NSAIDs are contraindicated or insufficient, and opioids if both are unsuitable/insufficient. Do not offer antispasmodics.
• Medical expulsive therapy: consider an alpha-blocker for adults with distal ureteric stones <10 mm and as adjunctive therapy for adults undergoing SWL for ureteric stones <10 mm.
• Watchful waiting: consider for asymptomatic renal stones <5 mm; larger asymptomatic stones may also be observed after informed discussion. Ureteric-stone observation depends on likelihood of spontaneous passage and clinical status.
• Definitive treatment depends on size and site: NICE recommends SWL/URS according to stone size and location and PCNL for renal stones >20 mm, including staghorn stones. For adults with ureteric stones and renal colic, offer treatment within 48 hours of diagnosis/readmission if pain is ongoing/not tolerated or the stone is unlikely to pass.
• Investigations: adults with suspected renal colic should receive urgent low-dose non-contrast CT within 24 hours ; ultrasound is preferred in pregnancy. NICE recommends serum calcium and consideration of stone analysis; assess renal function and infection as clinically indicated.
• MRCP emergency: infected obstructed kidney (sepsis/fever + obstruction) requires urgent drainage and antibiotics; definitive stone treatment is generally delayed until infection is controlled.
• Imaging trap: adult suspected renal colic → low-dose non-contrast CT within 24 hours; pregnancy → ultrasound.

Decision points in this pathway

• Stone passes conservatively?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.