🧭 REBEL Rundown
👉 Bottom Line Up Top
In large ureteral calculi 5mm or greater, Tamsulosin is recommended for facilitating stone expulsion and decreasing associated pain.
🤕 Case
A 47-year-old woman presents with 10/10 sharp left-sided back pain radiating to her groin with associated nausea that started about 20 minutes prior to presentation. Vital signs are unremarkable. The patient’s pain is improved with 15 mg IV ketorolac and 10 mg IV metoclopramide. A non-contrast CT scan shows a 3.5 mm stone at the left ureterovesical junction and the urinalysis shows blood with no other abnormalities. The patient’s pain is well controlled and her nausea is resolved. You are preparing to discharge the patient and you contact your friendly neighborhood urologist to arrange a follow-up. The urologist requests that you start the patient on Tamsulosin prior to discharge home, but you are unsure about the utility of that intervention.
🗣️ What Your Gut Says
Urology feels pretty strongly about the utility of tamsulosin for stone passage. May as well just start it.
📝 Introduction
Procalcitonin is a protein that is upregulated during inflammatory states. An elevation in procalcitonin should be specific to bacterial infections. Viral infections should result in decreased procalcitonin levels thus allowing us to differentiate bacterial from viral and help guide antibiotic prescription. However, this differentiation isn’t what we see in real life data.
📈 What The Evidence Says
pontaneous stone passage depends on many factors, the most important being stone size. A 2021 retrospective cohort study demonstrated spontaneous passage in 68% of stones ≤ 5 mm (95% CI: 46–85%), and 47% of stones 5-10mm (95% CI: 36–59%). In the group of patients with stones < 5 mm, rates may be as high as 95% depending on exact size. Urology often advises the use of alpha-blockers such as tamsulosin as part of medical expulsive therapy (MET) to facilitate stone passage in all patients regardless of stone size. Despite the routine recommendation to prescribe alpha-blockers to patients with stones of any size, the published data is less clear.
The SUSPEND trial, a large multicenter RCT, compared four-week spontaneous stone passage in 1,167 patients given either Tamsulosin, Nifedipine, or a placebo and demonstrated nearly identical passage rates (Placebo 80%, Tamsulosin 81%, Nifedipine 80% OR for MET vs placebo = 1.04; 95% CI: 0.77–1.43). Secondary outcomes (pain scores, analgesic use, time to passage, quality of life) also showed no differences between groups (Pickard 2015).
Smaller, more targeted studies published around the same time have challenged this discussion, showing that the benefit of Tamsulosin is directly correlated to stone size. A multicenter RCT in 2015 found a significant difference in spontaneous stone passage with the addition of tamsulosin in patients with stones 5-10 mm in size, but no significant difference in spontaneous passage in patients with smaller stones <5 mm (Furyk 2015).
To address these differences, larger studies were conducted, including a metaanalysis that supported higher passage rates for larger stones and little to no benefit in passage rates for smaller stones <5mm (Ye 2018), (Wang 2015). The data are consistent in finding a benefit for larger, distal ureteral stones, which raises a critical point: to identify the patient group that would benefit from the treatment, a CT scan would be necessary. While many patients presenting with ureteral colic symptoms will require a CT scan, not all patients will. A multispecialty consensus statement (endorsed by ACEP, The American Urology Association and The American College of Radiology) lays out a number of patient groups that don’t require advanced imaging in their evaluation (Moore 2019). Obtaining a CT scan when the diagnosis is clear for the purpose of determining stone size and location is not endorsed by any of the sponsoring groups.
Current guidelines recommend use of MET with tamsulosin 0.4mg daily for up to four weeks in patients with ureteral calculi measuring 5-10 mm, but not in smaller stones measuring < 5 mm (Wang 2015)
🚨 Clinical Bottom Line
The published data is clear that distal ureteral stones > 5 mm in diameter benefit from MET with tamsulosin but both smaller and more proximal stones do not. If the patient requires a CT scan for their evaluation and is found to have a small stone in any location or a proximal stone, they are unlikely to benefit from tamsulosin
📚 References
- Wang H et al.
Comparative efficacy of tamsulosin versus nifedipine for distal ureteral calculi: a meta-analysis.
Drug Des Devel Ther. 2016;
PMID: 27099471 - Wang RC et al.
Effect of Tamsulosin on Stone Passage for Ureteral Stones: A Systematic Review and Meta-analysis.
Ann Emerg Med. 2017 Mar 6.
PMID: 27616037 - Pickard R et al.
Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin) (the SUSPEND trial).
Health Technol Assess. 2015 Aug;19.
PMID: 26244520 - Furyk JS et al.
Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized, Multicenter Trial.
Ann Emerg Med. 2016 Jan
PMID: 26194935 - Ye Z et al.
Efficacy and Safety of Tamsulosin in Medical Expulsive Therapy for Distal Ureteral Stones with Renal Colic: A Multicenter, Randomized, Double-blind, Placebo-controlled Trial.
Eur Urol. 2018 Mar.
PMID: 29137830 - Moore CL et al.
Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus.
Ann Emerg Med. 2019 Sep
PMID: 31402153
Guest Post
🔎 Your Deep-Dive Starts Here
Alpha Blockers in Renal Colic: A Systematic Review
Background: Ureteric (renal) colic is a common, painful condition encountered ...
Medical Expulsion Therapy in Ureteral Colic: An Update
Back in August 2014, we posted an in depth review ...
Does Use of Tamsulosin in Renal Colic Facilitate Stone Passage?
Renal colic is a common ED presentation. Rarely does a ...
