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Three Part Question

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]?

Clinical Scenario

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?

Search Strategy

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.}])

Search Outcome

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

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cervenakov I et al 2002 Slovak Republic	102 uncomplicated patients with symptomatic lower ureteric calculi equal to or < 10mm in size. 51 pt.'s Rx standard therapy, 51 pt.'s Rx standard therapy + alpha-blocker. Follow up duration: 7 days.	Prospective, randomised, control trial	Proportion of patients who had passed their stones by the end of the study	Control group: 62.8%, alpha-blocker group:80.4%	Patients kept as inpatients throughout study No statistical analysis Short follow up period
Resim S et al 2005 Turkey	60 uncomplicated patients with symptomatic lower ureteric calculi equal to or < 13mm in size. 30 pt.'s Rx standard therapy, 30 pt.'s Rx standard therapy + alpha-blocker. Follow-up duration: 6 weeks.	Prospective, randomised control trial	Proportion of patients who had passed their stones by the end of the study	Control group: 73.3% alpha-blocker group 86.6% (p=0.196)	Long follow up period Patients with stones > 10 mm in size were treated
			Mean number of colic episodes during study	Control group had more episodes vis alpha-blocker group (p= 0.038)
			Mean VAS pain scores during study	Control group had higher scores vis alpha-blocker group (p= 0.000)
De Sio M et al 2006 Italy	96 uncomplicated patients with symptomatic lower ureteric calculi equal to or < 10mm in size. 46 pt.'s Rx standard therapy, 50 Rx standard therapy + alpha-blocker. Follow up duration: 2 weeks.	Prospective, randomised control trial	Proportion of patients who had passed their stones by the end of the study	Control group: 58%, alpha-blocker group: 90% (p= 0.001)
			Expulsion time	Control group: 7.5 ± 1.8 days, alpha-blocker group:4.4 ± 2.1 days (p= 0.005)
			Analgesic usage during study	Control group required more than alpha-blocker group (p= 0.003)
			Need for hospitalization during study	Control group were readmitted more than alpha-blocker group (p= 0.01)

Comment(s)

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).

Clinical Bottom Line

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.

References

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. International Urology and Nephrology 2002; 34: 25-29.
2. Resim S, Ekerbicer H, Ciftci A. Effect of tamsulosin on the number and intensity of ureteral colic in patients with lower ureteral calculus. International Journal of Urology 2005; 12: 615-620.
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. Journal of Endourology 2006; 20 (1): 12-16.