Treatment of Ureteric Stones
This section refers to stones that were originally in the kidney, but have now fallen into the ureter. Treatment of ureteric stones is different to treatment of stones which are still in the kidney.
Introduction

A stone within the ureter usually causes pain called renal colic. These stones always form within the kidney and while they are in the kidney, they frequently cause no symptoms. When a stone falls out of the kidney into the ureter, it often causes a blockage in the ureter and the backpressure of urine to the kidney causes severe pain.
The ureters are narrow tubes which transfer the urine made in the kidneys to the bladder. Very small stones, usually 1-2 mm, may pass through the ureter into the bladder without causing pain at all.
Stones which are 3mm or larger usually cause an obstruction to the ureter resulting in renal colic.
Stones which are up to 5mm usually can pass spontaneously without the need for surgical intervention, although they will frequently cause symptoms on their way out.
Calculi that are larger than 5 mm are unlikely to pass spontaneously and more often require intervention to extract the stone.
Pain Relief
A stone within the ureter can cause excruciating pain called renal colic, that many women describe as worse than labor pains. It is vital for the pain to be treated urgently to avoid unnecessary suffering. Sometimes these symptoms can be managed outside the hospital with tablets, but not infrequently the pain requires an injection (such as morphine) to relieve the agony and patients end up presenting to an Emergency Department.
Here is a list of some commonly used analgesics for kidney stones:
- Anti-inflammatories – Nurofen, Indocid, Voltaren, Brufen etc.
- These are more effective than codeine and do not cause constipation.
- They are usually available over the counter without prescription.
- Indocid suppositories can be used if a patient cannot keep the tablets down due to vomiting.
- Panadeine (without prescription) or Panadeine Forte (with prescription).
- These are combinations of paracetamol and codeine which can assist with moderate pain.
- Endone (Oxycodone).
- This is a more powerful oral opiate drug which requires prescription. It is usually the strongest painkiller which can be given without an injection.
- Morphine.
- This is given as an injection usually in a hospital setting. Morphine is a very powerful painkiller frequently used to treat episodes of renal colic.

Medical Expulsion Therapy
This refers to medicines that have been shown to increase the likelihood of a stone passing spontaneously through the ureter into the bladder.
MET may make it slightly more likely that a stone will pass spontaneously, but it is controversial as some studies show that MET is not useful at all.
The most important factor determining if a stone will pass is stone size, with stones greater than 5 mm being less likely to pass spontaneously.
MET is frequently used in association with painkillers in patients who present with renal colic. It is generally used for smaller stones in the ureter.
A number of medications have been used but the commonest by far is tamsulosin (Flomaxtra). This drug is usually used to improve urinary symptoms in men with prostate obstruction but was later shown in some studies to assist with stone passage in men and women.

Surgery versus Waiting
The key decision in patients who present with stones in the ureter is whether to operate or to treat expectantly with analgesia and Medical Expulsion Therapy.
Surgery is required for a stone in the ureter when:
- The stone in the ureter is associated with a fever. This is a surgical emergency as a blocked kidney in association with a urinary infection is a life-threatening emergency which requires urgent therapy to unblock the kidney.
- The stone in the ureter is in a patient who only has one functioning kidney.
- The stone in the ureter is causing the overall kidney functioning to be compromised significantly. This can be ascertained by a blood test.
- The stone in the ureter is causing ongoing severe pain which is intolerable or too persistent.
- The patient has had enough of pain and waiting for the stone to pass.
- The stone is larger than 5-6mm and is unlikely to pass spontaneously. It should be noted that some patients can pass stones larger than this (with pain).

Ureteroscopy
When a stone in the ureter requires surgical treatment, this is nearly always in the form of Ureteroscopy (also called Ureteropyeloscopy).
This therapy under a general anaesthetic involves fragmentation of the calculus, extraction of the pieces and insertion of a ureteric stent.
