Emergency Department Management of Pediatric Ureterolithiasis
Date First Published:
July 26, 2024
Last Updated:
July 26, 2024
Report by:
Dalton Grimm MD; Sean Farley MD, EM senior resident, EM core faculty (Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI)
Search checked by:
Jeffrey S. Jones MD, Corewell Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI
Three-Part Question:
In [pediatric patients presenting to the emergency department (ED) with uncomplicated urolithiasis], is [tamsulosin] more effective than [conservative therapy] for [expulsion of stones]?
Clinical Scenario:
A 14-year-old presents to the ED with acute flank pain and is found to have a 5 mm distal left ureteral calculus. There is no concern for significant hydronephrosis, renal insufficiency, or infected stone. Should tamsulosin be prescribed to help facilitate stone passage in this pediatric patient?
Search Strategy:
Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
Search Details:
[(ureteral obstruction OR ureteral calculi OR urolithiasis OR urinary colic) AND (tamsulosin.mp OR alpha blockers.mp)] Limit to English language and children (birth-18 years)
Outcome:
43 papers were found; one systematic review and two clinical studies addressed the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The Evidence Paradox of the Effectiveness between the Paediatric and Adult Stone-Forming Population: A Narrative Review Bourdoumis A, Durner L, Fullhase C, Drager D, Hakenberg OW, Buchholz N. Jan-19 UK, Germany, UAE | 28 studies (including two meta-analyses) addressing the safety and efficacy of alpha-blockers in children | Narrative review | Efficacy of medical expulsive treatment (MET) in children | Increases the probability of stone expulsion by 27% (OR 2.21) | Poor quality of included trials |
| Safety of MET in children | Somnolence, nausea and vomiting experienced by one patient | ||||
| Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway. Nelson R, Stamm J, Timmons Z, Grimsby GM. Apr-23 USA | 139 children age 2 months to 18 years with ureterolithiasis who presented to a children's hospital ED | Retrospective cohort | The rate of stone passage on MET | 45% versus 20% conservative tx (p = 0.0022) | Retrospective nature of the study; single institution;31% of patients seen in the ED did not follow up with urology. |
| Surgery for stone | 31% versus 39% conservative tx (p = 0.37) | ||||
| Length of hospitalization if admitted | No significant differences in the two groups | ||||
| Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study Soliman MG, El-Gamal O, El-Gamal S, Abdel Raheem A, Abou-Ramadan A, El-Abd A. Feb-21 Egypt | 167 pediatric patients who presented with distal ureteric stone less than 1 cm. Patients were randomized into 3 groups; group I received silodosin, group II received tamsulosin, while group III had placebo. | RCT | Stone expulsion rate | Group I (89.3%), group II (74.5%), and placebo (51.8%) [p =0.04]] | Off-label use of silodosin in children; small sample size |
| Time to stone expulsion | Group I (12.4 days), group II (16.2 days), and placebo (21.2 days) [p < 0.001] | ||||
| Pain episodes requiring analgesia | Statistically fewer in group I and II in contrast to placebo group [p < 0.001] | ||||
| Adverse effects | Comparable among all groups |
Author Commentary:
The rate of kidney stone passage in children depends on size and stone location in the urinary system. Agents that may promote the passage of stones and reduce symptoms, such as alpha-adrenergic blockers (tamsulosin, silodosin), have shown promising results in adults. Studies in children are limited; however, many previous studies have proved the safety of this group of drugs for treatment of voiding dysfunction in children [3]. Current literature shows a clear benefit in tamsulosin therapy in terms of rate of stone expulsion and time to expulsion, without having significant side effects compared to conservative management.
Bottom Line:
Given the benefits of alpha-adrenergic blockers to increase the rate of spontaneous stone passage, and the safety profile, it may be considered first line therapy for treatment of children with ureterolithiasis.
References:
- Bourdoumis A, Durner L, Fullhase C, Drager D, Hakenberg OW, Buchholz N. . The Evidence Paradox of the Effectiveness between the Paediatric and Adult Stone-Forming Population: A Narrative Review
- Nelson R, Stamm J, Timmons Z, Grimsby GM. . Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway.
- Soliman MG, El-Gamal O, El-Gamal S, Abdel Raheem A, Abou-Ramadan A, El-Abd A. . Silodosin versus Tamsulosin as Medical Expulsive Therapy for Children with Lower-Third Ureteric Stones: Prospective Randomized Placebo-Controlled Study