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

Allopurinol

• 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

Febuxostat

• 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

Tiopronin

• 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

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

• Obese or overweight patients should achieve a normal body mass index through dietary modification and increased physical activity to prevent recurrent kidney