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Diagnosis and acute management of suspected nephrolithiasis in adults

Gary C Curhan, MD, ScD
Mark D Aronson, MD
Glenn M Preminger, MD
Section Editors
Stanley Goldfarb, MD
Michael P O'Leary, MD, MPH
Jorge A Soto, MD
Deputy Editors
Albert Q Lam, MD
Susanna I Lee, MD, PhD


Renal and ureteral stones are a common problem in primary care practice [1]. Patients may present with the classic symptoms of renal colic and hematuria. Others may be asymptomatic or have atypical symptoms such as vague abdominal pain, acute abdominal or flank pain, nausea, urinary urgency or frequency, difficulty urinating, penile pain, or testicular pain.

Primary care clinicians need to be alert to the possibility of nephrolithiasis and its consequences to decide upon a diagnostic approach, therapy, and the need for referral to a urologist. These issues will be reviewed here. The epidemiology of nephrolithiasis and subsequent evaluation of such patients are discussed separately. (See "The first kidney stone and asymptomatic nephrolithiasis in adults" and "Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown".)


Eighty percent of patients with nephrolithiasis form calcium stones, most of which are composed primarily of calcium oxalate or, less often, calcium phosphate [2,3]. The other main types include uric acid, struvite (magnesium ammonium phosphate), and cystine stones. The same patient may have a stone that contains more than one crystal type (eg, calcium oxalate and uric acid) [4].

There are different theories regarding calcium stone formation, and the different stone types may have different initiating events. Stone formation occurs when normally soluble material (eg, calcium, oxalate) supersaturates the urine and begins the process of crystal formation (eg, calcium oxalate crystal). For some calcium stones, particularly calcium oxalate, it appears that an important initiating event occurs in the renal medullary interstitium [5-7]. Calcium phosphate crystals may form in the interstitium and eventually erode through the renal papillary epithelium, forming the classic Randall's plaque [6,7]. Calcium oxalate or calcium phosphate crystals may then deposit on top of this nidus, remaining attached to the papilla. Calcium phosphate stones might also form initially in dilated ducts of Bellini and then grow out into the urinary space [8].

The pathogenesis of struvite, cystine, and uric acid stones is discussed separately. (See "Pathogenesis and clinical manifestations of struvite stones" and "Uric acid nephrolithiasis" and "Cystine stones".)

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Literature review current through: Nov 2017. | This topic last updated: Jul 07, 2017.
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  1. Fwu CW, Eggers PW, Kimmel PL, et al. Emergency department visits, use of imaging, and drugs for urolithiasis have increased in the United States. Kidney Int 2013; 83:479.
  2. Singh P, Enders FT, Vaughan LE, et al. Stone Composition Among First-Time Symptomatic Kidney Stone Formers in the Community. Mayo Clin Proc 2015; 90:1356.
  3. Lieske JC, Rule AD, Krambeck AE, et al. Stone composition as a function of age and sex. Clin J Am Soc Nephrol 2014; 9:2141.
  4. Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med 2004; 350:684.
  5. Evan AP, Lingeman JE, Coe FL, et al. Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle. J Clin Invest 2003; 111:607.
  6. Kim SC, Coe FL, Tinmouth WW, et al. Stone formation is proportional to papillary surface coverage by Randall's plaque. J Urol 2005; 173:117.
  7. Evan AP, Coe FL, Rittling SR, et al. Apatite plaque particles in inner medulla of kidneys of calcium oxalate stone formers: osteopontin localization. Kidney Int 2005; 68:145.
  8. Evan AP, Worcester EM, Coe FL, et al. Mechanisms of human kidney stone formation. Urolithiasis 2015; 43 Suppl 1:19.
  9. Ferraro PM, Curhan GC, Gambaro G, Taylor EN. Total, Dietary, and Supplemental Vitamin C Intake and Risk of Incident Kidney Stones. Am J Kidney Dis 2016; 67:400.
  10. Hiatt RA, Ettinger B, Caan B, et al. Randomized controlled trial of a low animal protein, high fiber diet in the prevention of recurrent calcium oxalate kidney stones. Am J Epidemiol 1996; 144:25.
  11. Kocvara R, Plasgura P, Petrík A, et al. A prospective study of nonmedical prophylaxis after a first kidney stone. BJU Int 1999; 84:393.
  12. Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med 2002; 346:77.
  13. Uribarri J, Oh MS, Carroll HJ. The first kidney stone. Ann Intern Med 1989; 111:1006.
  14. Ferraro PM, Curhan GC, D'Addessi A, Gambaro G. Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature. J Nephrol 2017; 30:227.
  15. Curhan GC, Willett WC, Rimm EB, Stampfer MJ. Family history and risk of kidney stones. J Am Soc Nephrol 1997; 8:1568.
  16. Lloyd SE, Pearce SH, Fisher SE, et al. A common molecular basis for three inherited kidney stone diseases. Nature 1996; 379:445.
  17. Goodyer P, Saadi I, Ong P, et al. Cystinuria subtype and the risk of nephrolithiasis. Kidney Int 1998; 54:56.
  18. Bollée G, Dollinger C, Boutaud L, et al. Phenotype and genotype characterization of adenine phosphoribosyltransferase deficiency. J Am Soc Nephrol 2010; 21:679.
  19. Asplin JR, Coe FL. Hyperoxaluria in kidney stone formers treated with modern bariatric surgery. J Urol 2007; 177:565.
  20. Nelson WK, Houghton SG, Milliner DS, et al. Enteric hyperoxaluria, nephrolithiasis, and oxalate nephropathy: potentially serious and unappreciated complications of Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005; 1:481.
  21. Duffey BG, Pedro RN, Makhlouf A, et al. Roux-en-Y gastric bypass is associated with early increased risk factors for development of calcium oxalate nephrolithiasis. J Am Coll Surg 2008; 206:1145.
  22. Kopp JB, Miller KD, Mican JA, et al. Crystalluria and urinary tract abnormalities associated with indinavir. Ann Intern Med 1997; 127:119.
  23. Sasson JP, Dratch PL, Shortsleeve MJ. Renal US findings in sulfadiazine-induced crystalluria. Radiology 1992; 185:739.
  24. Carr MC, Prien EL Jr, Babayan RK. Triamterene nephrolithiasis: renewed attention is warranted. J Urol 1990; 144:1339.
  25. Avci Z, Koktener A, Uras N, et al. Nephrolithiasis associated with ceftriaxone therapy: a prospective study in 51 children. Arch Dis Child 2004; 89:1069.
  26. Taylor EN, Stampfer MJ, Curhan GC. Diabetes mellitus and the risk of nephrolithiasis. Kidney Int 2005; 68:1230.
  27. Gillen DL, Coe FL, Worcester EM. Nephrolithiasis and increased blood pressure among females with high body mass index. Am J Kidney Dis 2005; 46:263.
  28. Gillen DL, Worcester EM, Coe FL. Decreased renal function among adults with a history of nephrolithiasis: a study of NHANES III. Kidney Int 2005; 67:685.
  29. Rodgers AL, Greyling KG, Noakes TD. Crystalluria in marathon runners. III. Stone-forming subjects. Urol Res 1991; 19:189.
  30. Taylor EN, Stampfer MJ, Curhan GC. Obesity, weight gain, and the risk of kidney stones. JAMA 2005; 293:455.
  31. Ferraro PM, Curhan GC, Sorensen MD, et al. Physical activity, energy intake and the risk of incident kidney stones. J Urol 2015; 193:864.
  32. Pearle MS, Calhoun EA, Curhan GC, Urologic Diseases of America Project. Urologic diseases in America project: urolithiasis. J Urol 2005; 173:848.
  33. Scales CD Jr, Curtis LH, Norris RD, et al. Changing gender prevalence of stone disease. J Urol 2007; 177:979.
  34. Lotan Y, Antonelli J, Jiménez IB, et al. The kidney stone and increased water intake trial in steel workers: results from a pilot study. Urolithiasis 2017; 45:177.
  35. Daudon M, Traxer O, Conort P, et al. Type 2 diabetes increases the risk for uric acid stones. J Am Soc Nephrol 2006; 17:2026.
  36. Ekeruo WO, Tan YH, Young MD, et al. Metabolic risk factors and the impact of medical therapy on the management of nephrolithiasis in obese patients. J Urol 2004; 172:159.
  37. Abate N, Chandalia M, Cabo-Chan AV Jr, et al. The metabolic syndrome and uric acid nephrolithiasis: novel features of renal manifestation of insulin resistance. Kidney Int 2004; 65:386.
  38. Cameron MA, Maalouf NM, Adams-Huet B, et al. Urine composition in type 2 diabetes: predisposition to uric acid nephrolithiasis. J Am Soc Nephrol 2006; 17:1422.
  39. Taylor EN, Curhan GC. Body size and 24-hour urine composition. Am J Kidney Dis 2006; 48:905.
  40. Glowacki LS, Beecroft ML, Cook RJ, et al. The natural history of asymptomatic urolithiasis. J Urol 1992; 147:319.
  41. Elton TJ, Roth CS, Berquist TH, Silverstein MD. A clinical prediction rule for the diagnosis of ureteral calculi in emergency departments. J Gen Intern Med 1993; 8:57.
  42. Bove P, Kaplan D, Dalrymple N, et al. Reexamining the value of hematuria testing in patients with acute flank pain. J Urol 1999; 162:685.
  43. Press SM, Smith AD. Incidence of negative hematuria in patients with acute urinary lithiasis presenting to the emergency room with flank pain. Urology 1995; 45:753.
  44. Kobayashi T, Nishizawa K, Mitsumori K, Ogura K. Impact of date of onset on the absence of hematuria in patients with acute renal colic. J Urol 2003; 170:1093.
  45. Teichman JM, Long RD, Hulbert JC. Long-term renal fate and prognosis after staghorn calculus management. J Urol 1995; 153:1403.
  46. Manjunath A, Skinner R, Probert J. Assessment and management of renal colic. BMJ 2013; 346:f985.
  47. Sarma DP, Deiparine EM, Weilbaecher TG. Partially calcified renal cell carcinoma mimicking renal calculus. J La State Med Soc 1990; 142:24.
  48. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA 2013; 309:1722.
  49. Jones EE. Ectopic pregnancy: common and some uncommon misdiagnoses. Obstet Gynecol Clin North Am 1991; 18:55.
  50. Jones WA, Cooper TP, Kiviat MD. Munchausen syndrome presenting as urolithiasis. West J Med 1978; 128:185.
  51. Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. J Urol 2007; 178:2418.
  52. Metzler IS, Smith-Bindman R, Moghadassi M, et al. Emergency Department Imaging Modality Effect on Surgical Management of Nephrolithiasis: A Multicenter, Randomized Clinical Trial. J Urol 2017; 197:710.
  53. Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J Urol 2013; 189:1203.
  54. Pfister SA, Deckart A, Laschke S, et al. Unenhanced helical computed tomography vs intravenous urography in patients with acute flank pain: accuracy and economic impact in a randomized prospective trial. Eur Radiol 2003; 13:2513.
  55. Smith RC, Verga M, McCarthy S, Rosenfield AT. Diagnosis of acute flank pain: value of unenhanced helical CT. AJR Am J Roentgenol 1996; 166:97.
  56. Ulahannan D, Blakeley CJ, Jeyadevan N, Hashemi K. Benefits of CT urography in patients presenting to the emergency department with suspected ureteric colic. Emerg Med J 2008; 25:569.
  57. Niemann T, Kollmann T, Bongartz G. Diagnostic performance of low-dose CT for the detection of urolithiasis: a meta-analysis. AJR Am J Roentgenol 2008; 191:396.
  58. Kim BS, Hwang IK, Choi YW, et al. Low-dose and standard-dose unenhanced helical computed tomography for the assessment of acute renal colic: prospective comparative study. Acta Radiol 2005; 46:756.
  59. Liu W, Esler SJ, Kenny BJ, et al. Low-dose nonenhanced helical CT of renal colic: assessment of ureteric stone detection and measurement of effective dose equivalent. Radiology 2000; 215:51.
  60. Tack D, Sourtzis S, Delpierre I, et al. Low-dose unenhanced multidetector CT of patients with suspected renal colic. AJR Am J Roentgenol 2003; 180:305.
  61. Ciaschini MW, Remer EM, Baker ME, et al. Urinary calculi: radiation dose reduction of 50% and 75% at CT--effect on sensitivity. Radiology 2009; 251:105.
  62. Poletti PA, Platon A, Rutschmann OT, et al. Low-dose versus standard-dose CT protocol in patients with clinically suspected renal colic. AJR Am J Roentgenol 2007; 188:927.
  63. Sohn W, Clayman RV, Lee JY, et al. Low-dose and standard computed tomography scans yield equivalent stone measurements. Urology 2013; 81:231.
  64. Kulkarni NM, Uppot RN, Eisner BH, Sahani DV. Radiation dose reduction at multidetector CT with adaptive statistical iterative reconstruction for evaluation of urolithiasis: how low can we go? Radiology 2012; 265:158.
  65. Colistro R, Torreggiani WC, Lyburn ID, et al. Unenhanced helical CT in the investigation of acute flank pain. Clin Radiol 2002; 57:435.
  66. Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography. Radiology 1995; 194:789.
  67. Varanelli MJ, Coll DM, Levine JA, et al. Relationship between duration of pain and secondary signs of obstruction of the urinary tract on unenhanced helical CT. AJR Am J Roentgenol 2001; 177:325.
  68. Williams JC Jr, Paterson RF, Kopecky KK, et al. High resolution detection of internal structure of renal calculi by helical computerized tomography. J Urol 2002; 167:322.
  69. Batchelar DL, Chun SS, Wollin TA, et al. Predicting urinary stone composition using X-ray coherent scatter: a novel technique with potential clinical applications. J Urol 2002; 168:260.
  70. Oehlschläger S, Hakenberg OW, Froehner M, et al. Evaluation of chemical composition of urinary calculi by conventional radiography. J Endourol 2003; 17:841.
  71. Zilberman DE, Ferrandino MN, Preminger GM, et al. In vivo determination of urinary stone composition using dual energy computerized tomography with advanced post-acquisition processing. J Urol 2010; 184:2354.
  72. Matlaga BR, Kawamoto S, Fishman E. Dual source computed tomography: a novel technique to determine stone composition. Urology 2008; 72:1164.
  73. Boll DT, Patil NA, Paulson EK, et al. Renal stone assessment with dual-energy multidetector CT and advanced postprocessing techniques: improved characterization of renal stone composition--pilot study. Radiology 2009; 250:813.
  74. Ferrandino MN, Pierre SA, Simmons WN, et al. Dual-energy computed tomography with advanced postimage acquisition data processing: improved determination of urinary stone composition. J Endourol 2010; 24:347.
  75. Eiber M, Holzapfel K, Frimberger M, et al. Targeted dual-energy single-source CT for characterisation of urinary calculi: experimental and clinical experience. Eur Radiol 2012; 22:251.
  76. Fowler KA, Locken JA, Duchesne JH, Williamson MR. US for detecting renal calculi with nonenhanced CT as a reference standard. Radiology 2002; 222:109.
  77. Ulusan S, Koc Z, Tokmak N. Accuracy of sonography for detecting renal stone: comparison with CT. J Clin Ultrasound 2007; 35:256.
  78. Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med 2014; 371:1100.
  79. Jung SI, Kim YJ, Park HS, et al. Sensitivity of digital abdominal radiography for the detection of ureter stones by stone size and location. J Comput Assist Tomogr 2010; 34:879.
  80. Levine JA, Neitlich J, Verga M, et al. Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT. Radiology 1997; 204:27.
  81. Semins MJ, Feng Z, Trock B, et al. Evaluation of acute renal colic: a comparison of non-contrast CT versus 3-T non-contrast HASTE MR urography. Urolithiasis 2013; 41:43.
  82. Springhart WP, Marguet CG, Sur RL, et al. Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial. J Endourol 2006; 20:713.
  83. Johnson CM, Wilson DM, O'Fallon WM, et al. Renal stone epidemiology: a 25-year study in Rochester, Minnesota. Kidney Int 1979; 16:624.
  84. Coe FL, Parks JH, Asplin JR. The pathogenesis and treatment of kidney stones. N Engl J Med 1992; 327:1141.
  85. Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol 1999; 162:688.
  86. Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR Am J Roentgenol 2002; 178:101.
  87. Parekattil SJ, Kumar U, Hegarty NJ, et al. External validation of outcome prediction model for ureteral/renal calculi. J Urol 2006; 175:575.
  88. Cole RS, Fry CH, Shuttleworth KE. The action of the prostaglandins on isolated human ureteric smooth muscle. Br J Urol 1988; 61:19.
  89. Cordell WH, Wright SW, Wolfson AB, et al. Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic. Ann Emerg Med 1996; 28:151.
  90. Cordell WH, Larson TA, Lingeman JE, et al. Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic. Ann Emerg Med 1994; 23:262.
  91. Udén P, Rentzhog L, Berger T. A comparative study on the analgesic effects of indomethacin and hydromorphinechloride-atropine in acute, ureteral-stone pain. Acta Chir Scand 1983; 149:497.
  92. Holdgate A, Pollock T. Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic. BMJ 2004; 328:1401.
  93. Safdar B, Degutis LC, Landry K, et al. Intravenous morphine plus ketorolac is superior to either drug alone for treatment of acute renal colic. Ann Emerg Med 2006; 48:173.
  94. Preminger GM. Editorial comment. The value of intensive medical management of distal ureteral calculi in an effort to facilitate spontaneous stone passage. Urology 2000; 56:582.
  95. Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureter stones. Urology 2000; 56:579.
  96. Dellabella M, Milanese G, Muzzonigro G. Efficacy of tamsulosin in the medical management of juxtavesical ureteral stones. J Urol 2003; 170:2202.
  97. Saita A, Bonaccorsi A, Marchese F, et al. Our experience with nifedipine and prednisolone as expulsive therapy for ureteral stones. Urol Int 2004; 72 Suppl 1:43.
  98. Dellabella M, Milanese G, Muzzonigro G. Medical-expulsive therapy for distal ureterolithiasis: randomized prospective study on role of corticosteroids used in combination with tamsulosin-simplified treatment regimen and health-related quality of life. Urology 2005; 66:712.
  99. Dellabella M, Milanese G, Muzzonigro G. Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. J Urol 2005; 174:167.
  100. Porpiglia F, Ghignone G, Fiori C, et al. Nifedipine versus tamsulosin for the management of lower ureteral stones. J Urol 2004; 172:568.
  101. Hollingsworth JM, Rogers MA, Kaufman SR, et al. Medical therapy to facilitate urinary stone passage: a meta-analysis. Lancet 2006; 368:1171.
  102. Yilmaz E, Batislam E, Basar MM, et al. The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones. J Urol 2005; 173:2010.
  103. Vicentini FC, Mazzucchi E, Brito AH, et al. Adjuvant tamsulosin or nifedipine after extracorporeal shock wave lithotripsy for renal stones: a double blind, randomized, placebo-controlled trial. Urology 2011; 78:1016.
  104. Parsons JK, Hergan LA, Sakamoto K, Lakin C. Efficacy of alpha-blockers for the treatment of ureteral stones. J Urol 2007; 177:983.
  105. Campschroer T, Zhu Y, Duijvesz D, et al. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database Syst Rev 2014; :CD008509.
  106. Pickard R, Starr K, MacLennan G, et al. Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Lancet 2015; 386:341.
  107. Agrawal M, Gupta M, Gupta A, et al. Prospective randomized trial comparing efficacy of alfuzosin and tamsulosin in management of lower ureteral stones. Urology 2009; 73:706.
  108. Jayant K, Agrawal R, Agrawal S. Tamsulosin versus tamsulosin plus tadalafil as medical expulsive therapy for lower ureteric stones: a randomized controlled trial. Int J Urol 2014; 21:1012.
  109. Kumar S, Jayant K, Agrawal MM, et al. Role of tamsulosin, tadalafil, and silodosin as the medical expulsive therapy in lower ureteric stone: a randomized trial (a pilot study). Urology 2015; 85:59.
  110. Assimos D, Krambeck A, Miller NL, et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I. J Urol 2016; 196:1153.
  111. Portis AJ, Sundaram CP. Diagnosis and initial management of kidney stones. Am Fam Physician 2001; 63:1329.
  112. Parmar MS. Kidney stones. BMJ 2004; 328:1420.
  113. Gambaro G, Croppi E, Coe F, et al. Metabolic diagnosis and medical prevention of calcium nephrolithiasis and its systemic manifestations: a consensus statement. J Nephrol 2016; 29:715.