It's 4:00 on a Thursday afternoon, and you're taking the final signout from one of your colleagues: “Room 8 is a 23-year-old man with renal colic. He improved with 15 mg of ketorolac IV and 10 mg of metoclopramide. He should be able to go home with some ibuprofen and tamsulosin.”
Your colleague leaves, and you start writing up the discharge instructions when you think to yourself, “Does the patient really need tamsulosin for this episode of renal colic?”
Rarely a day goes by that we don't see a patient rocking and rolling in acute renal colic. We make the diagnosis and treat the pain, and then turn our our attention to disposition planning, follow-up, and outpatient medications. Most stones will pass spontaneously, but it would be nice if we could increase the passage rate and shorten the time to passage. This could reduce ED revisits and the number of invasive procedures and make patients happy.
Patients with any ureteral stone should be treated with alpha antagonists to facilitate stone passage. These inhibit contraction of ureteral muscles responsible for ureteral spasm, theoretically allowing for an increased rate of stone propagation. Alpha 1-adrenergic receptors are concentrated in the distal ureter, and distal stones should benefit most. Many urologists recommend treatment with these agents, and tamsulosin is preferred because of fewer lower side effects.
Medical expulsion therapy (MET) entered the collective EM mind after publication of a systematic review by Singh. (Ann Emerg Med 2007;50:552.) This concluded that the results “are encouraging for the use of an alpha-antagonist or calcium channel blocker to facilitate stone expulsion of moderately sized distal ureteral calculi; however, because of the limitation of methodologic quality with the studies reviewed, a large, well-done, randomized clinical trial is needed to confirm these results before uniform adoption can be recommended.”
The caveat at the end of their conclusions is vital, but appears to have been glossed over by many providers (myself included). This disclaimer appears because the quality of available studies was poor: randomization, blinding, and follow-up were all suboptimal. This study appears to have changed practice despite these limitations. Now, though, we have better evidence to guide decisions.
Is There a Role for Tamsulosin in the Treatment of Distal Ureteral Stones of 7 mm or Less? Results of a Randomised, Double-Blind, Placebo-Controlled Trial
Hermanns T, Sauermann P, et al.
Tamsulosin for Ureteral Stones in the Emergency Department: A Randomized, Controlled Trial
Ferre RM, Wasielewski
Ann Emerg Med
Tamsulosin Hydrochloride vs Placebo for Management of Distal Ureteral Stones: A Multicentric, Randomized, Double-Blind Trial
Vincendeau S, Bellissant E
Arch Intern Med
None of these studies was able to find any statistically significant benefit to tamsulosin for their primary outcomes. Hermanns, et al., and Ferre, et al., demonstrated no difference in passage rate at 21 days and 14 days respectively. Vincendeau, et al., looked at time to expulsion and again found no difference. No differences were seen in secondary endpoints within these studies either, including pain medication usage or representations to the ED.
A study in 2010 published in Urology represents the only randomized, controlled trial positive for tamsulosin (passage rate 82% vs. 61%), but it suffers from a number of methodological flaws, including that the primary outcome wasn't prespecified. (Urology 2010;75:4.) All of these studies suffered from the major issue of small sample size. Fortunately, two recent large studies have recently been published looking at MET.
Distal Ureteric Stones and Tamsulosin: A Double-Blind, Placebo-Controlled, Randomized Multicenter Trial
Furyk JS, Chu K, et al.
Ann Emerg Med
This randomized, controlled trial of 403 patients presenting to five EDs in Australia (stones <10 mm) demonstrated no benefit to tamsulosin versus placebo for stone expulsion at 28 days (87% vs. 81.9%). It did demonstrate a difference in the secondary endpoint of passage of stones 5-10 mm at 28 days (83.3% vs. 61%). This study was multicenter and larger than any prior RCT, but 21.5 percent of patients were lost to follow-up.
Medical Expulsive Therapy in Adults with Ureteric Colic: A Multicentre, Randomised, Placebo-Controlled Trial
Picard R, Starr K, et al.
This RCT performed in 24 UK hospitals including 1167 patients (evenly split between tamsulosin, nifedipine, and placebo) demonstrated no benefit for the primary outcome of need for urologic intervention to facilitate stone passage at four weeks when comparing tamsulosin with placebo (19% vs. 20%). Follow-up was excellent (98.2%). A secondary outcome found a benefit to stone passage in lower ureteral stones (86% vs. 82%) with tamsulosin.
What's the bottom line? The Picard and Furyk studies represent the highest quality evidence on the utility (or lack of) for tamsulosin in treating ureteral colic. Based on these data and those of the other randomized trials reviewed here, tamsulosin should not be standard care for patients presenting with ureteral colic. Both of these studies, however, show a benefit in the specific subgroup of patients with large or distal stones.
These studies may have finally identified a population who will benefit, but a CT scan will be required to identify this group. We recognize issues with CT overuse, particularly in patients with ureteric colic, and a return to scanning all of these patients would have an overall deleterious effect without a significant benefit. Scanning everyone looking for the small subgroup of patients that may benefit is nonsensical.
Suggested Reading: Ureteral Stones Clinical Guidelines Panel Summary Report on the Management of Ureteral Calculi. The American Urological Association. J Urol 1997;158(5):1915.Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.