Pain Management in

Ureteric Obstruction
dr. Heri Budiono, Sp.U
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 Introduction
Background

The occurrence of urinary tract stones occupies

the third most urological case after urinary tract
infection (UTI) and benign prostatic hyperplasia
(BPH)

In addition, urinary tract stones also has the

potential cause various complication in the
future.

Therefore, urinary tract stones is a public health

problem that cannot be underestimated
The main symptom of urinary tract
stone is colic / renal colic pain.
The pain starts from the abdomen
and radiates to the hypochondrium
and recedes, it disappears and can
become heavy.

Therefore, the main goal of

conservative management is to
reduce pain
Pain Management in Acute Stone Colic
EAU Guideline 2018
NSAIDs and Paracetamol
Effective in patients with acute
stone colic and have better
analgesic efficacy than opioids.
NSAIDs (Diclofenac)
Contraindicated in patients with
Congestive Heart Failure (NYHA
class II-IV), ischaemic heart
disease and peripheral arterial
and cerebrovascular disease
Opioids (i.e Pethidine)
Associated with high rate of
vomiting and carry a greater
likelihood of further opioids
being needed. If an opioids is
used, it is recommended that it is
not pethidine
Antispasmodic
Addition of antispasmodic
does not result in better pain
control
 Other NSAIDs
Ketorolac
 IV Ketorolac 30-60 mg IV or IM bolus
 15 mg IV or IM / 6 hour
 PO 10-40 mg/4-6 hour
 Maximum for 5 days
 Precautions: Increase nitrogen urea
in blood & creatinine, inhibit
prostaglandin syntesys  decrease
GFR  induce AKI
 To avoid side effect  Monitor urine
output
 Prevention of Recurrent Obstruction Colic
EAU Guideline 2018
Drug of choices Medical expulsive therapy (MET)  More
likely to pass stone with fewer colic
episodes.
Alpha-blockers (Tamsulosin) showed an
Alpha-blockers overall superiority to Nifedipine for distal
ureteral calculi

No recommendation for the use of PDE-5

Ca-channel inhibitor Inhibitors or corticosteroids in
(Nifedipine)
combination with alpha-blocker in MET

Precautions:
Phosphodiesterase Tamsulosin side effects : retrograde
type 5 inhibitor ejaculation and hypotension
(Tadalafil)
 Prevention of Urinary Tract Stone
Campbell-Walsh Urology, 10th edition
Fluid Intake Balanced Diet Life Style
Amount of fluid: Avoid excessive Normal BMI
2,5 – 3 liters / vitamins
Sufficient
day
Rich in fibers physical activity
Circadian and vegetables
Avoid
drinking
Recommended dehydration
Diuresis: 2 – 2,5 calcium intake:
liters / day 1 – 1,2 gram /
day
Spesifik urine
weight < 1010 Recommended
animal protein
intake: 0,8 – 1
gram / kgBW /
day
References
Hadiansyah, H., Rodjani, A. 2013. Nyeri kolik dan hubungannya dengan
lokasi batu ureter pada penderita baru ureter unilateral. Fakultas
Kedokteran Universitas Indonesia, Jakarta.

Pearle M.S., Lotan Y. 2012. Urinary lithiasis: Etiology, epidemiology, and

pathogenesis. In: Kavoussi LR, Novick AC, Partin AW, Peters CA,
editor. Campbell-Walsh Urology. Tenth edition. Philadelphia: Elsevier-
Saunders; p.1257-83

Turk, C., Neisius, A., Petrik, A., Seitz, C., Skolarikos, A., Thomas, K., 2018.
EAU Guidelines on Urolithiasis, in: European Association of Urology
Guidelines.
Thank you