Treatment Guideline Chart

 Urolithiasis is the formation of urinary stones in the kidney, bladder and/or urethra.

 It is a painful urologic disorder that occurs in 12% of the global population and has a high recurrence rate among male patients.

The hallmark of of obstruction in the ureter and renal pelvis is the sudden onset of excruciating, intermittent pain that radiates from the flank to the groin or to the genital area and inner thigh.

Lower urinary tract symptoms associated with urolithiasis include urgency, frequency, urge incontinence, dysuria, and hematuria (gross or microscopic).


Urolithiasis Treatment


  • For pain during acute episodes of renal colic, nonsteroidal anti-inflammatory drugs are recommended for treatment

Medical Expulsive Therapy

  • Recommended if active stone removal is not indicated
  • Increases stone expulsion rate of steinstrasse and reduces the requirement for endoscopic intervention
  • If complications of urolithiasis (eg infection, refractory pain, deterioration of renal function) develop, medical expulsive therapy should be discontinued and active stone removal should be performed

Alpha Blockers

  • Eg Doxazosin, Tamsulosin
  • Inhibit ureteral spasm and uncontrolled contraction which can reduce pain, accelerate and increase the likelihood of passage of stone preventing hospital admission or surgical intervention
  • Treatment option for patients with uncomplicated distal ureteral stones measuring ≤10 mm
  • May be given to patients who underwent shockwave lithotripsy to facilitate passage of stone fragments or as adjunctive treatment for patients undergoing  shockwave lithotripsy for ureteral stones <10 mm
  • Can be used in treatment of patients with distal ureteral stones >5 mm

Chemolitholysis and Drugs Used for Stone Prevention

Acetohydroxamic acid

  • Urease inhibitor
  • Treatment option for patients with residual or recurrent struvite stones after failure of surgical interventions

Alkaline Citrate (Sodium and Potassium)

  • A urinary alkalinizer used to prevent uric acid or cystine calculi formation
    • Potassium citrate is recommended as 1st-line therapy for patients with uric acid stones
  • Also used as an adjuvant with uricosuric agents in gout therapy
  • Potassium citrate may be a treatment option for patients with recurrent stones that are predominantly calcium oxalate and for children with hypercalciuria or hypocitraturia
  • Effective in correcting the acidosis of certain renal tubular disorders
  • Contraindicated in patients with severe renal impairment with oliguria or azotemia, untreated Addison’s disease and severe myocardial damage


  • Inhibits xanthine oxidase and reduces the production of uric acid without disrupting the biosynthesis of vital purines
  • Used in the prevention of gout, renal calculi due to uric acid or calcium oxalate, prophylaxis and treatment of uric acid nephropathy
  • Decreases the risk of recurrent calcium oxalate stones in the presence of hyperuricosuria (urinary uric acid excretion >800 mg/day)
  • May be used as an adjunct in patients with uric acid stones and when alkalinization of urine with Potassium citrate is not adequate or successful
  • Contraindicated in patients with idiopathic hemochromatosis and asymptomatic hyperuricemia


  • Treatment option to prevent stone recurrence in patients with calcium oxalate or uric acid stones and a 2nd-line treatment option for hyperuricosuria

Sodium Bicarbonate

  • Raises blood and urinary pH by dissociation to provide bicarbonate ions, which neutralizes the hydrogen ion concentration
  • Used to alkalinize the urine, dose is titrated to achieve the desired urinary pH
  • Used to dissolve uric acid stones
  • Contraindicated in patients with alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia and unknown abdominal pain

Thiazide Diuretics

  • May be used for recurrent stone formers with calcium oxalate or calcium phosphate stone or high-risk 1st-time stone formers such as patients with hypertension, solitary kidney or large stone burden, or those refractory to other risk-mitigating procedures
  • Chlorthalidone
    • A long-acting antihypertensive/diuretic that enhances the excretion of sodium, chloride ions and  water by interfering with the transport of sodium ions across the renal tubular epithelium
    • Used as treatment for hypercalciuria and calcium stone recurrence
    • Contraindicated in patients with known anuria and hypersensitivity to other sulfonamide-derived drugs
  • Hydrochlorothiazide
    • Inhibits the sodium reabsorption in the distal tubules and as a result, the excretion of sodium, water, potassium and hydrogen ions increases
    • Used as treatment for hypercalciuria and calcium stone recurrence
    • Contraindicated in patients with known anuria and hypersensitivity to other sulfonamide-derived drugs


  • Also known as alpha-mercaptopropionylglycine
  • An active reducing agent that undergoes a thiol-disulfide exchange with cystine and forms a tiopronin-cystine disulfide
  • Recommended for patients with cystine stones not responsive to dietary modifications and urinary alkalinization or with large recurrent stone burdens
  • It decreases the amount of soluble cystine in the urine and reduces the formation of cystine calculi
  • Contraindicated in patients with prior history of developing agranulocytosis, aplastic anemia or thrombocytopenia
Other Therapies

  • Also known as myo-inositol-1,2,3,4,5,6-hexakis dihydrogen phosphate (InsP6)
  • May lower the risk of stone formation
    • Has been shown to inhibit crystallization of calcium oxalate and calcium phosphate in urine
  • Present in legumes, whole grains, nuts and seeds
  • May be useful in preventing uric acid stone formation by inhibiting the nucleation and growth of uric acid crystal
  • Present in high amounts in cocoa and chocolate

Non-Pharmacological Therapy

Conservative Treatment/Observation

  • Since most stones are small, about 5 mm in size, the patient is advised for the passage of stones through normal urination, that usually happens within 2-3 days
  • A collection kit is provided with filter and the patient is instructed to collect the passed stone for testing and analysis
  • Option for patients with uncomplicated ureteral stones ≤10 mm
  • Option for adults and children with asymptomatic renal stones <5 mm

Lifestyle Modification

Diet therapy

  • All stone formers are advised to have a fluid intake that will achieve a urine volume of at least 2.5 liters daily
    • Good hydration is important for stone prevention
    • Advise patients to avoid carbonated drinks
  • Limit sodium intake to 3-5 g and consume 1,000-1,200 mg dietary calcium per day  
  • Limit the intake of oxalate-rich foods and maintain normal calcium consumption
  • Increase the intake of fruits and vegetables
    • Hypocitrituria is common among patients with stone disease, with a prevalence of 20-60%
      • Promoted by renal tubular acidosis, chronic diarrhea and carbonic anhydrase inhibitor
  • Limiting the intake of animal protein may help reduce stone recurrence
    • Patients with a history of uric acid stones should be counseled to:
      • Increase the intake of alkali and decrease the intake of acids
      • Increase the urine pH
      • Reduce the urinary acidity
Weight Management
  • Obese or overweight patients should achieve a normal body mass index through dietary modification and increased physical activity to prevent recurrent kidney
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