Alpha-adrenergic antagonists in the medical management of lower ureteric calculi

April 14, 2007

August 22, 2007

Sayantana Patra, Resident in Emergency Medicine (All India Institute of Medical Sciences, New Delhi)

Debasis Das, All India Institute of Medical Sciences, New Delhi

In [patients presenting to the ED with uncomplicated lower ureteric calculi] are [alpha adrenergic antagonist agents] effective at [improving spontaneous stone passage and their symptoms during medical therapy]?

A 24 year old woman presents to the ED with left sided renal colic. She is not septic and following initial fluid and analgesic administration, an unenhanced CT demonstrates the presence of a 4 mm calculus adjacent to the left vesico-ureteric junction. There is only mild hydronephrosis and by the time the patient returns from X-ray, her symptoms are under control. Before you discharge her with oral analgesics and fluid advice, you ring Urology to arrange an outpatient's appointment. To your surprise, the Urologist on-call asks you to prescribe Tamsulosin, a drug normally used by elderly men in benign prostatic hyperplasia, to your young, female patient with a urinary calculus. You wonder whether there is any evidence behind this?

Ovid Medline 1950 - week 2, March 2007. Limit to human and English.

([{exp Ureteral Calculi/ or renal colic.mp. or exp Kidney Calculi} OR {ureteral colic.mp.}] AND [{exp Adrenergic alpha-Antagonists/ or alpha blocker.mp.} OR {tamsulosin.mp.}])

32 papers found, of which 29 were irrelevant or of insufficient quality. The remaining three papers have been systematically reviewed below.

50% of calculi in the lower ureter, and almost all of those equal to or < 4 mm in width, will pass spontaneously with medical management. Ureteric smooth muscle spasm is a feature of acute ureteric colic, and given the abundance of alpha-1 adrenoceptors in the smooth muscle cells of the distal ureter, it has been proposed that alpha-1 adrenoceptor antagonists, such as Tamsulosin, could facilitate stone passage by reducing such spasm.

All three studies reviewed above advocate this notion in stones equal to or <10 mm in size. De Sio et al, showed that patients treated with alpha-blockers as well as 'standard therapy' (levofloxacin 250 mg daily for one week, and oral Diclofenac 100mg, aescin 80mg, and Omeprazole 20mg daily for the duration of the study) achieved stone clearance more often, and took less time to do so than their control group counterparts (p=0.001 and p=0.005, respectively). Similarly, Resim et al showed that patients taking alpha-blockers as well as increased fluid intake and non-steroidals (oral Tenoxicam 20mg daily), had fewer colic episodes and recorded lower VAS pain intensity scores than patients on standard therapy alone (p=0.038 and p=0.000, respectively). This is further supported by De Sio et al, who record that their alpha-blocker patients required less analgesia and were re-admitted less frequently than patients in their control group (p= 0.003 and p= 0.01, respectively).

Alpha-1 adrenoceptor antagonists should be used to facilitate stone clearance in patients presenting to the ED with uncomplicated lower ureteric calculi equal to or < 10 mm in size.

1. Cervenakov I, Fillo J, Mardiak J, Kopecny M, Smirala J, et al.. Speedy elimination of ureterolithiasis in lower part of ureters with the alpha 1-blocker C Tamsulosin.
2. Resim S, Ekerbicer H, Ciftci A.. Effect of tamsulosin on the number and intensity of ureteral colic in patients with lower ureteral calculus.
3. De Sio M, Autorino R, Di Lorenzo G, Damiano R, Giordano D, et al.. Medical expulsive treatment of distal-ureteral stones using tamsulosin: a single-center experience.