Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In the emergency department, intravenous fluids may be provided to help with hydration and to allow the administration of medications to control pain and nausea. Ketorolac (Toradol), an injectable anti-inflammatory drug, and narcotics may be used for pain control, with the goal being to relieve suffering and not necessarily to make the patient pain free. Nausea and/or vomiting may be treated with anti-emetic medications like ondansetron (Zofran), promethazine (Phenergan), or droperidol (Inapsine).
The decision to send a patient home will depend upon
the response to medication. If the pain is intractable
(hard to control) or if vomiting persists, then admission to the hospital is necessary. Also, if an infection is associated with the stone, then admission to the hospital
will be considered.
Pain control at home follows the lead of the hospital treatment. Over-the-counter (OTC) ibuprofen is used as an anti-inflammatory medication, and narcotic pain pills may be provided. Anti-nausea medication may be prescribed either by mouth or by suppository. Tamsulosin (Flomax, a drug used to help urination in men with an enlarged prostate gland) may be used to help the stone pass from the ureter into the bladder.
Because of their size or location, some stones may not be able to be passed without help. If the stone is high up in the ureter, near the kidney, and is large, then a urologist may need to consider using lithotripsy, or shock
wave therapy (EWSL), to break the stone up into smaller fragments to allow those small pieces to pass more easily into the bladder. Shock waves work by vibrating the urine surrounding the stone and causing the stone to break up. Stones that are lodged nearer the bladder do not have surrounding urine to allow this procedure to work successfully.
If the stone is not located in a place where lithotripsy can work or if there is a need to relieve the obstruction emergently (an example would include the presence of an infection), the urologist may perform ureteroscopy, in which instruments are threaded into the ureter and can allow the physician to place a stent (a thin hollow tube) through the urethra, past the bladder, and into the ureter to bypass the obstructing stone. This stent may be left in place for a longer period of time. Occasionally, the urologist may be able to use instruments to grab the stone and remove it.
Since most patients have two kidneys, a temporary obstruction of one is not of great significance. For those patients with only one kidney, an obstructing stone can be a true emergency, and the need to relieve the obstruction becomes greater. A kidney that remains completely obstructed for a prolonged period of time may stop working.
Infection associated with an obstructing stone is
another emergent situation. When urine is infected and cannot drain, the
situation is like an
abscess that can spread the infection throughout the body (sepsis). Fever is a major sign of this complication, but urinalysis may show an infection and cause the urologist to consider placing a stent or removing the stone to relieve the obstruction.