Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Diagnostic imaging

1.1.1

Offer urgent (within 24 hours of presentation) low-dose non-contrast CT to adults with suspected renal colic. If a woman is pregnant, offer ultrasound instead of CT.

1.1.2

Offer urgent (within 24 hours of presentation) ultrasound as first-line imaging for children and young people with suspected renal colic.

1.1.3

If there is still uncertainty about the diagnosis of renal colic after ultrasound for children and young people, consider low-dose non-contrast CT.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on diagnostic imaging.

Full details of the evidence and the committee's discussion are in evidence review B: imaging for diagnosis.

1.2 Pain management

1.2.1

Offer a non-steroidal anti-inflammatory drug (NSAID) by any route as first-line treatment for adults, children and young people with suspected renal colic.

1.2.2

Offer intravenous paracetamol to adults, children and young people with suspected renal colic if NSAIDs are contraindicated or are not giving sufficient pain relief.

1.2.3

Consider opioids for adults, children and young people with suspected renal colic if both NSAIDs and intravenous paracetamol are contraindicated or are not giving sufficient pain relief.

1.2.4

Do not offer antispasmodics to adults, children and young people with suspected renal colic.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pain management.

Full details of the evidence and the committee's discussion are in evidence review E: pain management.

1.3 Medical expulsive therapy

1.3.1

Consider alpha blockers for adults, children and young people with distal ureteric stones less than 10 mm.

In January 2019, this was an off-label use of alpha blockers. See NICE's information on prescribing medicines.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on medical expulsive therapy.

Full details of the evidence and the committee's discussion are in evidence review D: medical expulsive therapy.

1.4 Stenting before shockwave lithotripsy

1.4.1

Do not offer pre-treatment stenting to adults having shockwave lithotripsy (SWL) for ureteric or renal stones.

1.4.2

Consider pre-treatment stenting for children and young people having SWL for renal staghorn stones.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on stenting before shockwave lithotripsy.

Full details of the evidence and the committee's discussion are in evidence review H: stents before surgery.

1.5 Surgical treatments (including shockwave lithotripsy)

Renal stones

1.5.1

Consider watchful waiting for asymptomatic renal stones in adults, children and young people if:

  • the stone is less than 5 mm or

  • the stone is larger than 5 mm and the person (or their family or carers, as appropriate) agrees to watchful waiting after an informed discussion of the possible risks and benefits.

1.5.2

Follow the recommendations in table 1 for surgical treatment (including SWL) of renal stones in adults, children and young people.

Table 1 Surgical treatment (including SWL) of renal stones in adults, children and young people
Stone type and size Treatment for adults (16 years and over) Treatment for children and young people (under 16 years)

Renal stone less than 10 mm

Offer SWL

Consider URS:

  • if there are contraindications for SWL or

  • if a previous course of SWL has failed or

  • because of anatomical reasons, SWL is not indicated

Consider PCNL if SWL and URS have failed to treat the current stone or they are not an option

Consider URS or SWL

Consider PCNL if:

  • URS or SWL have failed or

  • for anatomical reasons, PCNL is the more favourable option

Renal stone 10 to 20 mm

Consider URS or SWL

Consider PCNL if URS or SWL have failed

Consider URS, SWL or PCNL

Renal stone larger than 20 mm, including staghorn stones

Offer PCNL

Consider URS if PCNL is not an option

Consider URS, SWL or PCNL

Abbreviations: PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.

Use clinical judgement when considering mini or standard PCNL for children and young people under 16 years with renal stones greater than 10 mm, including staghorn stones.

Use clinical judgement when considering tubeless, mini or standard PCNL, and supine and prone positions for adults (16 years and over) with renal stones greater than 20 mm, including staghorn stones.

Ureteric stones

1.5.3

Follow the recommendations in table 2 for surgical treatment (including SWL) of ureteric stones in adults, children and young people.

Table 2 Surgical treatment (including SWL) of ureteric stones in adults, children and young people
Stone type and size Treatment for adults (16 years and over) Treatment for children and young people (under 16 years)

Ureteric stone less than 10 mm

Offer SWL

Consider URS if:

  • stone clearance is not possible within 4 weeks with SWL or

  • there are contraindications for SWL or

  • the stone is not targetable with SWL or

  • a previous course of SWL has failed

Consider URS or SWL

Ureteric stone 10 to 20 mm

Offer URS

Consider SWL if local facilities allow stone clearance within 4 weeks

Consider PCNL for impacted proximal stones when URS has failed

Consider URS or SWL

Abbreviations: PCNL, percutaneous nephrolithotomy; SWL, shockwave lithotripsy; URS, ureteroscopy.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on surgical treatments (including shockwave lithotripsy).

Full details of the evidence and the committee's discussion are in evidence review F: surgical treatments.

Timing of surgical treatment (including SWL) for adults with ureteric stones and renal colic
1.5.4

Offer surgical treatment (including SWL) to adults with ureteric stones and renal colic within 48 hours of diagnosis or readmission, if:

  • pain is ongoing and not tolerated or

  • the stone is unlikely to pass.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on timing of surgical treatment.

Full details of the evidence and the committee's discussion are in evidence review G: timing of surgery.

Medical expulsive therapy as an adjunct to SWL for adults with ureteric stones less than 10 mm
1.5.5

Consider alpha blockers as adjunctive therapy for adults having SWL for ureteric stones less than 10 mm.

In January 2019, this was an off-label use of alpha blockers. See NICE's information on prescribing medicines.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on medical expulsive therapy as adjunctive to shockwave lithotripsy.

Full details of the evidence and the committee's discussion are in evidence review D: medical expulsive therapy.

1.6 Stenting after ureteroscopy for adults with ureteric stones less than 20 mm

1.6.1

Do not routinely offer post-treatment stenting to adults who have had ureteroscopy for ureteric stones less than 20 mm.

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on stenting after ureteroscopy.

Full details of the evidence and the committee's discussion are in evidence review I: stents after surgery.

1.7 Metabolic testing

1.7.1

Consider stone analysis for adults with ureteric or renal stones.

1.7.2

Measure serum calcium for adults with ureteric or renal stones.

1.7.3

Consider referring children and young people with ureteric or renal stones to a paediatric nephrologist or paediatric urologist with expertise in this area for assessment and metabolic investigations.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on metabolic testing.

Full details of the evidence and the committee's discussion are in evidence review A: metabolic investigations.

1.8 Preventing recurrence

Dietary and lifestyle advice

1.8.1

Discuss diet and fluid intake with the person (and their family or carers, as appropriate), and advise:

  • adults to drink 2.5 to 3 litres of water per day, and children and young people (depending on their age) 1 to 2 litres

  • adding fresh lemon juice to drinking water

  • avoiding carbonated drinks

  • adults to have a daily salt intake of no more than 6 g, and children and young people (depending on their age) 2 to 6 g

  • not restricting daily calcium intake, but maintaining a normal calcium intake of 700 to 1,200 mg for adults, and 350 to 1,000 mg per day for children and young people (depending on their age).

Potassium citrate

The following recommendations apply alongside the recommendations on dietary and lifestyle advice.

1.8.3

Consider potassium citrate for adults with a recurrence of stones that are predominantly (more than 50%) calcium oxalate.

In January 2019, this was an off-label use of potassium citrate. See NICE's information on prescribing medicines.

1.8.4

Consider potassium citrate for children and young people with a recurrence of stones that are predominantly (more than 50%) calcium oxalate, and with hypercalciuria or hypocitraturia.

Thiazides

The following recommendation applies alongside the recommendations on dietary and lifestyle advice.

1.8.5

Consider thiazides for adults with a recurrence of stones that are predominantly (more than 50%) calcium oxalate and hypercalciuria, after restricting their sodium intake to no more than 6 g a day.

In January 2019, this was an off-label use of thiazides. See NICE's information on prescribing medicines.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on preventing recurrence.

Full details of the evidence and the committee's discussion are in evidence review C: dietary interventions and evidence review K: prevention of recurrence.

Terms used in this guideline

Children and young people

People under 16 years.