The likelihood of spontaneous passage of a ureteral stone is related to both stone size and location. Most stones ≤4 mm in diameter pass spontaneously. Stone diameter ≥5 mm is associated with a progressive decrease in the spontaneous passage rate, which is unlikely with stones ≥10 mm in diameter. Proximal ureteral stones are also less likely to pass spontaneously. The data supporting these conclusions are presented elsewhere. (See "Diagnosis and acute management of suspected nephrolithiasis in adults".)
The management of ureteral calculi by stone location within the ureter will be reviewed here. Further discussion regarding the techniques utilized to treat ureteral calculi (including associated complications), the diagnosis and acute management of nephrolithiasis, and the significance of residual stones after stone removal are presented separately. (See "Options in the management of renal and ureteral stones in adults" and "Diagnosis and acute management of suspected nephrolithiasis in adults" and "Clinical significance of residual stone fragments following stone removal".)
OVERVIEW OF MANAGEMENT OPTIONS
The optimal approach of managing ureteral calculi varies with the size and location of the stone, and the presence and/or absence of patient comorbidities.
Emergency therapy — In septic patients with obstructing stones, urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated in combination with appropriate antimicrobial therapy . Definitive treatment of the stone should be delayed until sepsis is resolved. Additional indications for urgent decompression include bilateral obstruction with acute kidney injury and unilateral obstruction with acute kidney injury in a solitary kidney.
Medical therapy — In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are controlled, observation with periodic evaluation is an option for initial treatment. Such patients may be offered an appropriate medical therapy to facilitate stone passage during the observation period. Patients who elect for an attempt at spontaneous passage or medical expulsive therapy should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve. Patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis. (See "Diagnosis and acute management of suspected nephrolithiasis in adults" and "Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown".)