[CK] Kidney stone 1) tamsulosin, 2) +- nifedipine or tadalafil or sildosin. 3) pain control: NSAID, analgesic.

In addition to tamsulosin and nifedipine, tadalafil and silodosin can be used as MET [117,118]. In a trial, 285 patients with distal ureteral stones sized 5 to 10 mm in diameter were randomly assigned to tamsulosin (0.4 mg/day), silodosin (8 mg/day), or tadalafil (10 mg/day) until stone passage or for a maximum of four weeks [118]. Silodosin resulted in significantly higher rates of stone expulsion (83 compared with 64 percent with tamsulosin and 67 percent with tadalafil) and significantly faster mean expulsion times (15 days versus 17 days with tamsulosin and 16 days with tadalafil). Additional studies are needed to evaluate the safety and efficacy of tadalafil and silodosin as MET.

International guidelines from the American Urological Association and the European Association of Urology on the management of ureteral calculi suggest that:

●"In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are controlled, observation with periodic evaluation is an option for initial treatment. Such patients may be offered an appropriate medical therapy to facilitate stone passage during the observation period. In a choice between active stone removal and conservative treatment with MET, it is important to take into account all individual circumstances that may affect treatment decisions. A prerequisite for MET is that the patient is reasonably comfortable with that therapeutic approach and that there is no obvious advantage of immediate active stone removal" [51,119].

Patients will typically require analgesics such as ketorolac. Concurrent antibiotics are used by some groups but have not been studied to determine their value in the setting of a patient receiving MET. Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant obstruction, or who have not passed the stone after four to six weeks should be referred to urology for potential intervention.

UROLOGY CONSULTATION — Urgent urologic consultation is warranted in patients with urosepsis, acute kidney injury, anuria, and/or unyielding pain, nausea, or vomiting [4,120]. Outpatient urology referral is indicated in patients with a stone >10 mm in diameter and in patients who fail to pass the stone after a trial of conservative management, including medical expulsive therapy (MET), particularly if the stone is >4 mm in diameter or if there is uncontrolled pain [87,121].