A 56-year-old woman comes to the emergency department with sudden-onset, severe pain on the left side of her abdomen. It is accompanied by nausea. The pain waxes and wanes in intensity, and she cannot find a comfortable position. Her temperature is 36.7 C (98 F), blood pressure is 140/90 mm Hg, and pulse is 104 /min. BMI is 28 kg/m². The cardiopulmonary examination is normal. There is no costovertebral angle tenderness. Serum creatinine and urine analysis are within normal limits. A CT scan of the abdomen shows an 8-mm stone in the left mid ureter with no hydronephrosis. The patient is started on normal saline at 100 mL/hr and receives analgesics. Her pain and nausea improve substantially. Which of the following is the most appropriate next step in management?

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Explanation: 11ec2b69_c09e_8fcb_8f63_b189eaa891f9_MD0005_00 Renal stones <5 mm usually pass spontaneously. Larger stones, particularly those ≥10 mm, have a lower chance of spontaneous passage. Stones ≥10 mm, uncontrolled pain, presence of acute renal failure, and urinary tract infection are indications for urgent urologic referral (Choice C) for consideration of intervention. Initial medical management is preferred for stones <10 mm in diameter. This includes intravenous hydration, pain control, and medications to facilitate stone passage, such as alpha blockers, particularly for stones 5-10 mm. Some (though not all) studies suggest more benefit for alpha-blockers for distal ureteral stones only; these medications are often considered regardless of stone location. If symptoms are effectively controlled and there are no indications for urologic consultation, the patient can be discharged safely (Choice A). Alpha blockers (eg, tamsulosin) are given for 4 weeks. Imaging may then be repeated if the stone has not passed. Management options include lithotripsy (eg, shock wave) or percutaneous nephrolithotomy, with laparoscopic stone removal only used in rare cases. (Choice B) Forced intravenous hydration with high fluid rates has not shown to be superior to minimal fluid administration. (Choice D) Intravenous antibiotics are indicated if there is evidence of infection (eg, fever, costovertebral angle tenderness, pyuria), like pyelonephritis, and/or sepsis. Educational objective: Stones <5 mm usually pass spontaneously. Stones up to 10 mm can be given a trial of medical therapy (gentle hydration, pain control, alpha blockers) and do not require hospital admission if symptoms are controlled. Indications for removal are stones ≥10 mm, persistent pain, acute renal failure, or urinary tract infection. Antibiotics are indicated in the presence of infection. References: Flexible ureteroscopy and laser lithotripsy for stones >2?cm: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22642568) Recent finding and new technologies in nephrolithiasis: a review of the recent literature. (http://www.ncbi.nlm.nih.gov/pubmed/23413950) Association of pyuria and clinical characteristics with the presence of urinary tract infection among patients with acute nephrolithiasis. (http://www.ncbi.nlm.nih.gov/pubmed/23850311)

A 56-Year-Old Woman Comes to the Emergency Department with Sudden-Onset