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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
[(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)

Search Outcome

43 papers were found; one systematic review and two clinical studies addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bourdoumis A, et al. January 2019 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
Nelson R, et al. April 2023 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
Soliman MG, et al. February 2021 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

Comment(s)

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.

Clinical 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

1. 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 Urologia Internationalis Jan 2019;102(2):125-130
2. Nelson R, Stamm J, Timmons Z, Grimsby GM. Management of pediatric ureterolithiasis in the emergency room: A single institution review and new management pathway. J Pediatr Urol. 2023 Apr;19(2):177.e1-177.e6.
3. 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 Urol Int. 2021;105(7-8):568-573.