Commentary

Ureteral colic is an extremely painful and costly medical condition. Despite this, surprisingly few RCTs have examined non-invasive methods to speed stone passage. Traditionally, increased fluids (orally or intravenously) and pain control have been the mainstay of treatment. However, the benefits of increased fluids are uncertain.¹ While urological intervention is nearly always effective, the associated discomfort, risks, and costs preclude this treatment as routine first line therapy.

The meta-analysis by Hollingsworth et al highlights 2 inexpensive and widely available medications that increased the likelihood of stone passage. However, several issues should be considered. Firstly, in the setting of uncontrollable pain or infection, emergent urological intervention should not be delayed. Secondly, the long term effect on renal function of prolonged partial or complete ureteral obstruction needs clarification. It is not only the proportion of stones that eventually pass but also the time to passage that matters. Thirdly, the role of the other therapies used with the study drugs is uncertain. For several studies, ⩾1 intervention was used, thus making it difficult to separate the independent effects of the drugs of interest. Fourthly, the costs associated with delaying the urological intervention need to be determined. For example, do patients require more analgesics and still have to miss work while waiting for the stone to pass? Fifthly, while the title of the meta-analysis refers to “medical therapy,” it only addresses the role of calcium channel blockers and α blockers. In fact, the only calcium channel blocker studied was nifedipine and the results cannot necessarily be extrapolated to other calcium channel blockers. Finally, the authors conclude that “a high-quality randomized trial is necessary to confirm the efficacy of [these drugs],” implying that the studies included in the meta-analysis were not “high-quality.” I agree that this research question warrants further study because if these drugs are truly effective, they should become part of the standard treatment of ureteral stone disease. Based on the available evidence, it seems reasonable to try nifedipine or an α blocker to facilitate ureteral stone passage while waiting for definitive studies.