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Kidney Stones (cont.)

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 antiinflammatory 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 antiemetic 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 antiinflammatory 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 facilitate urination in men with enlargement of the prostate) may be used to help facilitate the passage of stones 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 fragments to allow the smaller pieces to pass 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.

Complications

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, it acts like an abscess and 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 decide to place a stent or remove the stone.