Tamsulosin in Ureteric Stone (Medical Expulsive Therapy)

Mechanism of Action

• Smooth muscle relaxation in the ureter wall - reduces basal tone and decreases the frequency and force of ureteral peristalsis
• Ureteral dilatation particularly at the level of the obstructing stone, increasing the lumen diameter around the stone
• Reduced spasm at the site of stone impaction - spasmolytic effect reduces pain and facilitates passage
• Vesicoureteral junction relaxation - the lower ureter (intramural and juxtavesical portions) has the highest density of alpha-1 receptors, making tamsulosin especially effective for distal ureteric stones

Indications and Stone Size

• Most effective for distal ureteric stones (where alpha-1 receptor density is highest)
• Best for stones 5-10 mm - smaller stones (≤5 mm) already have high spontaneous passage rates and benefit less
• Less evidence for proximal or mid-ureteric stones

Clinical Benefits

• Higher stone expulsion rate compared to conservative management alone
• Shorter time to stone expulsion
• Reduced analgesic requirement (fewer pain episodes)
• Better tolerance of ureteral stents when placed post-ESWL
• Adjunct to ESWL - tamsulosin improves expulsion of stone fragments post-lithotripsy

Dose

• Tamsulosin 0.4 mg orally once daily (typically taken at bedtime to reduce orthostatic hypotension)
• Duration: up to 4-6 weeks of observation

Comparison with Other Agents

• Tadalafil (PDE-5 inhibitor) showed a higher stone expulsion rate than tamsulosin for distal ureteric stones 5-10 mm (OR 0.55, 95% CI 0.38-0.80)
• No significant difference in time to expulsion or side effects (headache, dizziness, orthostatic hypotension) between the two drugs
• Tamsulosin remains superior to nifedipine (calcium channel blocker)
• Cochrane review (67 studies, 10,509 participants): alpha-blockers increase stone clearance and shorten expulsion time - effect was greater for stones >5 mm than ≤5 mm

Side Effects to Monitor

• Orthostatic hypotension / dizziness (most common)
• Retrograde ejaculation (due to alpha-1 blockade at bladder neck)
• Headache, rhinitis

Contraindications / Cautions

• Infection with obstruction (pyonephrosis, urosepsis) - requires urgent urologic drainage, not MET
• Stones >10 mm generally require ureteroscopy or ESWL rather than MET alone
• Failure to pass after 4 weeks is an indication for intervention (risk of ureteric stricture and renal deterioration increases beyond this point)

Summary

Latest 2024-2025 Clinical Guidelines: Ureteric Stone Management

• AUA 2025 Guideline: Surgical Management of Kidney and Ureteral Stones (published 2025, literature up to May 2025)
• EAU 2025 Guidelines on Urolithiasis (Skolarikos et al., Eur Urol, 2025 - PMID 40268592)
• EAU 2026 Pocket Guideline (updated version of 2025 recommendations)

1. Diagnosis

2. Pain Management (Acute Colic)

• NSAIDs (e.g., diclofenac, ketorolac) are first-line for analgesia - EAU Strong recommendation
• Opioids reserved as secondary option only
• IV hydration for nausea/vomiting; forced diuresis is NOT recommended

3. Medical Expulsive Therapy (MET) - Updated 2025

AUA 2025 Guideline Statements:

• 49 studies, >8,000 patients with distal ureteric stones ≤10 mm
• Alpha-blockers: RR 0.71 (95% CI 0.66-0.76) = 25 more passage events per 100 persons vs. control
• Significant reduction in pain episodes (MD: -0.59; 95% CI: -0.82 to -0.37)
• No significant benefit found for middle or proximal ureteric stones (RR: 0.84-0.88, CI crosses 1.0)

EAU 2025 Guideline:

• Offer alpha-blockers as MET for (distal) ureteric stones >5 mm - Strong recommendation
• MET most effective for stones 5-10 mm
• Silodosin appears more effective than tamsulosin as MET (new update vs. prior guidelines)
• Note: alpha-blockers remain off-label for this indication in most countries
• Combination therapy (phytotherapy + alpha-blockers) may be more beneficial than alpha-blockers alone

4. Indications for Active Stone Removal

EAU 2025 - Indications for intervention:

• Stones with low likelihood of spontaneous passage
• Persistent pain despite adequate analgesia
• Persistent obstruction
• Renal insufficiency (including solitary kidney)
• Infection with obstruction (emergency)
• Patient preference

5. Surgical Treatment - EAU 2025 Treatment Algorithm

URETERAL STONE (if removal indicated)
│
├── PROXIMAL URETERAL STONE
│   ├── >10 mm → 1st: URS (ante- or retrograde); 2nd: SWL
│   └── <10 mm → SWL or URS (equal options)
│
└── DISTAL URETERAL STONE
    ├── >10 mm → 1st: URS; 2nd: SWL
    └── <10 mm → SWL or URS (equal options)

AUA 2025 Guideline Statements:

6. URS vs. SWL - Key Comparison (2025 Guidelines)

7. Ureteroscopy Technical Recommendations (EAU 2025)

• Use Holmium:YAG (Ho:YAG) or Thulium Fiber Laser (TFL) for lithotripsy - Strong
• Stone extraction only under direct endoscopic visualisation - Strong
• Do NOT routinely insert a stent in uncomplicated cases - Strong
• Pre-treatment with alpha-blocker (1 week before URS) reduces need for active dilatation and improves stone-free rate
• Offer MET after laser lithotripsy to facilitate fragment passage - Strong

8. Observation / Conservative Management

• Observation is feasible in informed patients with no complications (EAU Strong)
• For newly diagnosed small stones: initial observation + periodic evaluation - EAU Strong
• AUA: confirm stone passage with follow-up imaging when passage is uncertain
• If stone not passed within 4-6 weeks - reassess for intervention (risk of stricture and renal deterioration)
• Emergency indications overriding observation: obstructed infected system (pyonephrosis/urosepsis) - urgent drainage mandatory

9. Recurrence Prevention

• Stone analysis mandatory for all formers (EAU/AUA)
• High fluid intake (urine volume >2.5 L/day) for all stone types
• Dietary modifications specific to stone composition
• Pharmacological prevention:
  • Potassium citrate (calcium oxalate, uric acid, cystine stones)
  • Thiazides (hypercalciuric stones)
  • Allopurinol (hyperuricosuric stones)
  • Theobromine (uric acid - new agent, ESD 2025)
• Genetic testing recommended for high-risk / hereditary stone formers (EAU 2025)

Quick Reference Summary

OPD Management of Renal Colic and Kidney Stone

Step 1: Initial Assessment in OPD

History

• Character of pain: Sudden onset severe flank/loin pain radiating to groin/ipsilateral testis or labia - classic ureteric colic
• Associated symptoms: Nausea, vomiting, haematuria, dysuria, urinary frequency (suggests stone at UVJ)
• Fever/chills - red flag: suggests infected obstructed system
• Duration of symptoms (important - long obstruction = irreversible nephron loss)
• Previous stone history, family history, medications

Examination

• Costovertebral angle tenderness
• Abdominal tenderness
• Vital signs - fever, hypotension = emergency, admit immediately
• Rule out differential diagnoses (AAA, appendicitis, ectopic pregnancy)

Step 2: Investigations in OPD

Imaging

Practical OPD point: Patients with known nephrolithiasis, typical presentation, NO fever, NO infection on UA, NO solitary kidney - can skip CT and manage without imaging. NCCT if diagnosis is uncertain or complications suspected. - Rosen's Emergency Medicine

Step 3: Immediate Pain Management

NSAIDs - First Line

• Greater reduction in pain scores
• Less need for rescue analgesia
• Less nausea and vomiting
• Mechanism: reduce collecting system pressure by decreasing renal blood flow (PGE-mediated); COX-2 inhibitors also prevent downregulation of aquaporin channels

• Renal insufficiency (exacerbates AKI by reducing RBF)
• Risk of GI bleeding (use COX-2 inhibitor or add PPI)
• Pregnancy (avoid in 3rd trimester)
• Cardiovascular disease (COX-2 inhibitors linked to MI/stroke risk)

Opioids - Second Line / Add-on

• Use when NSAIDs are contraindicated or pain is uncontrolled
• Options: tramadol, morphine, pethidine
• Side effects: nausea, vomiting, sedation, abuse potential
• Short prescription (3-5 days) if sent home with opioids

Antiemetics

• Add routinely for nausea/vomiting: metoclopramide, ondansetron, domperidone
• IV/IM route if vomiting prevents oral medication

Step 4: Decide - Admit or Discharge?

Criteria for ADMISSION (do not discharge):

Suitable for OPD discharge if:

• Pain controlled with oral analgesia
• No fever or signs of infection
• Tolerating oral fluids
• Normal or near-normal renal function
• Small stone (≤10 mm), especially distal ureteric
• Informed and reliable patient who can return if needed

Step 5: OPD Medical Expulsive Therapy (MET)

• Stones ≤5 mm: ~68% spontaneous passage
• Stones 6-10 mm: ~47% spontaneous passage
• Stones ≤10 mm at 4 weeks: ~80% in prospective studies
• Distal ureteric stones: 71% vs proximal stones: 22%
• MET for distal stones ≥5 mm: up to 57% increase in spontaneous passage

Step 6: Discharge Instructions to Patient

1. Strain all urine - void into a glass jar or stone-strainer to capture the stone for analysis
2. Maintain moderate fluid intake (~2-2.5 L/day) - forced over-hydration is NOT recommended
3. Take analgesia as needed - NSAID + antiemetic at home
4. Continue alpha-blocker (MET) daily
5. Activity as tolerated - no bed rest required; normal ambulation is fine
6. Return immediately if:
   • Fever or chills develop
   • Pain becomes severe and uncontrolled
   • Difficulty urinating or urinary retention
   • No stone passage after 4 weeks

Step 7: Follow-Up Plan

Step 8: Recurrence Prevention (Long-term OPD Management)

For ALL stone formers:

• High fluid intake - urine output >2 L/day (most important single intervention)
• Dietary sodium restriction - <2300 mg/day
• Moderate calcium intake - avoid low calcium diet (paradoxically increases oxalate absorption)
• Reduce animal protein intake
• Reduce oxalate-rich foods (spinach, nuts, tea, chocolate) if oxalate stones

Pharmacological prevention by stone type:

Summary Flowchart

Patient presents with renal colic
         ↓
Vitals, UA, Creatinine, USG/NCCT
         ↓
FEVER + OBSTRUCTION? → ADMIT → Emergency decompression + IV antibiotics
         ↓ No
Pain controlled? Tolerating oral? No infection? eGFR stable?
         ↓ Yes
DISCHARGE with:
  • NSAIDs ± antiemetic (oral)
  • Alpha-blocker (MET) if stone ≤10 mm
  • Urine straining instructions
  • Return precautions
  • Follow-up at 4 weeks
         ↓
4 weeks: Stone passed? → Stone analysis + metabolic work-up
         ↓ Not passed
Refer urology for URS / ESWL / PCNL

OPD Management of Varicella Zoster (VZV) Infections

Part A: PRIMARY VARICELLA (Chickenpox)

Clinical Diagnosis

• Prodrome: fever, malaise 1-2 days before rash
• Rash: Generalised, centripetal, pruritic - macules → papules → vesicles ("dewdrop on rose petal") → pustules → crusts, all stages simultaneously present (pathognomonic)
• Oral/mucosal involvement common
• Highly contagious (airborne + contact) from 2 days before rash until all lesions crusted

Investigations (usually clinical diagnosis)

• If confirmation needed: PCR from vesicle fluid - gold standard (highly sensitive and specific, can distinguish wildtype from vaccine strain)
• Tzanck smear (less specific - also positive in HSV)
• Direct fluorescent antibody - rapid but less sensitive than PCR
• Serology (ELISA) - for checking immune status / post-exposure prophylaxis need

Treatment Decision by Patient Group

1. Healthy Children (2-12 years) - OPD

• Antiviral not routinely recommended - varicella is benign and self-limited; acyclovir only modestly reduces symptoms by ~1 day
• Symptomatic treatment only:
  • Antipyretics: Paracetamol/acetaminophen for fever
  • AVOID ASPIRIN/SALICYLATES - risk of Reye syndrome
  • Pruritus relief: Calamine lotion, cool compresses, tepid baths with baking soda or colloidal oatmeal (3 cups/tub)
  • Oral antihistamines (e.g., chlorpheniramine, hydroxyzine) for itching
  • Keep nails short; discourage scratching (prevents secondary bacterial infection)
  • Do NOT use topical steroids or occlusive ointments

2. Adolescents, Adults, Pregnant (3rd trimester), Household contacts - OPD Antivirals Indicated

Key point: Start within 24 hours of rash onset for maximum benefit. Treatment beyond 24 hours is not effective for routine healthy children. - Fitzpatrick's Dermatology

Valacyclovir and famciclovir are preferred over oral acyclovir for adults because of superior pharmacokinetics and higher drug levels. - Goldman-Cecil Medicine

3. Groups Requiring IV Acyclovir (ADMIT, not OPD)

• Immunocompromised patients (IV acyclovir 10 mg/kg every 8 hours, 7-10 days)
• Varicella pneumonitis
• Varicella encephalitis
• Neonates (mothers developed varicella within 5 days before/2 days after delivery): IV acyclovir 10 mg/kg or 500 mg/m² every 8 hours for 10 days

Secondary Bacterial Infection

• Most common complication - Staph. aureus and Group A Streptococcus
• Minor infections: warm soaks
• Cellulitis: systemic antibiotics - amoxicillin-clavulanate, cefalexin, or flucloxacillin

Isolation / Infection Control (OPD Counselling)

• Keep patient away from school/work until all lesions are crusted (usually 5-7 days after rash onset)
• Avoid contact with: pregnant women, newborns, immunocompromised individuals, non-immune healthcare workers

Part B: HERPES ZOSTER (Shingles) - Reactivation

Clinical Diagnosis

• Prodrome: Dermatomal pain, burning, allodynia 2-3 days before rash
• Rash: Unilateral, dermatomal, does not cross midline - clusters of vesicles on erythematous base
• Most common: thoracic (50-70%), trigeminal (ophthalmic branch most common)
• Diagnosis is clinical in typical cases

Special Forms (flag at OPD)

Who to Treat with Antivirals in OPD?

Key principle: Start within 72 hours of rash onset for best effect. However, treatment may still benefit if new lesions continue to appear after 72 hours. - Goldman-Cecil Medicine

Antiviral Dosing for Herpes Zoster

Topical antivirals have NO role in treatment of varicella or herpes zoster. - Fitzpatrick's Dermatology

Pain Management in Zoster (OPD)

A 2024 meta-analysis (Ding et al., PMID 39029866) confirmed that delayed initial treatment (≥3 days) is a significant risk factor for developing postherpetic neuralgia (PHN). Early treatment is the single most important preventive step for PHN.

Wound/Skin Care

• Keep lesions clean and dry
• Saline soaks or wet compresses for comfort
• Non-adherent dressings if needed
• Prevent scratching - secondary bacterial superinfection

Part C: POST-HERPETIC NEURALGIA (PHN) - OPD Management

Evidence-Based Pharmacotherapy (RCT-proven):

These agents provide adequate pain relief (pain <3/10 or ≥50% reduction) in 30-60% of patients. - Fitzpatrick's Dermatology

Part D: CRITERIA FOR ADMISSION (Do NOT manage OPD)

Part E: PROPHYLAXIS & PREVENTION (OPD Counselling)

Post-exposure Prophylaxis (PEP)

Vaccination

Quick OPD Decision Summary

VARICELLA (Chickenpox)
├── Healthy child <12 yrs → Symptomatic only (calamine, paracetamol, NO aspirin)
├── Adolescent/Adult/Pregnant → Valacyclovir 1g TDS × 7d (start within 24h)
└── Immunocompromised/pneumonia/encephalitis → ADMIT, IV acyclovir

HERPES ZOSTER (Shingles)
├── Age <50, mild pain, uncomplicated → Symptomatic ± antiviral
├── Age ≥50 / moderate-severe pain → Valacyclovir 1g TDS × 7d + prednisolone
├── Ophthalmic/Ramsay Hunt → Urgent antiviral + specialist referral
└── Disseminated/encephalitis/immunocompromised → ADMIT, IV acyclovir

POST-HERPETIC NEURALGIA
└── Gabapentin/Pregabalin (first-line) + TCAs + Lidocaine patch