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uro.urolithiasis.v1PRODUCTION
uro.urolithiasis.v1

Urolithiasis (kidney / ureteral stones)

urologyacutechronicadult
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Adult with sudden severe flank/CVA pain ± groin radiation ± N/V ± hematuria — concern for urolithiasis. Exclude aortic catastrophe (older smokers), pyelonephritis (fever pattern), ovarian torsion / ectopic (reproductive-age women) (AUA 2016)

Inputs
3
Actions
0
Advance rule
Set
Advance when

urolithiasis differential framed

Patient inputs (22)

Older patients (>50) — broaden differential to AAA / aortic dissection; pediatric stones rare and demand metabolic workup (AUA 2016)

Reproductive-age women — exclude ovarian torsion + ectopic in pelvic-flank pain differential (AUA 2016)

Hypotension + fever + obstruction → septic shock (SCC 2026 sepsis bundle)

Tachycardia — pain vs sepsis discriminator (AUA 2016)

Recurrent stones → 24-h urine metabolic workup at 6 wk (Curhan 2007)

Single functioning kidney or transplant kidney + obstruction → emergent decompression regardless of infection (AUA 2016)

Loop diuretic, topiramate, acetazolamide, indinavir, vitamin C megadose predispose; identify and counsel (AUA 2016)

Sudden severe colic peaks at 2–4 h then plateaus; duration informs urgency (AUA 2016)

CVA → groin migration classic; suprapubic + dysuria → distal ureteral stone (AUA 2016)

Pregnancy → ultrasound first-line imaging; NSAIDs avoided after 30 wk; stent if obstruction (EAU 2016)

Gross or microscopic hematuria 80–90% sensitive; absence does NOT exclude stone (AUA 2016 / EAU 2016)

Hematuria, pH (uric acid pH <5.5; cystine alkaline; struvite alkaline + crystals), leuk-esterase/nitrite for infection, crystals for composition pivot (AUA 2016)

eGFR for contrast / NSAID dosing; AKI from obstruction → emergent decompression (KDIGO AKI 2026 draft)

WBC elevation + UA pyuria → infection in setting of obstruction (AUA 2016)

Fever + obstruction = urosepsis emergency — decompression within hours (AUA 2016)

Direct organism identification when obstruction + infection suspected; culture-directed abx (AUA 2016)

Strong family history or pediatric stones → cystinuria / primary hyperoxaluria considerations (EAU 2016)

Roux-en-Y bypass + IBD predispose to enteric hyperoxaluria + calcium oxalate stones (Curhan 2007)

Hypercalcemia → primary hyperparathyroidism workup for recurrent calcium stones (Curhan 2007)

Hyperuricemia + low urine pH → uric acid stones; allopurinol prevention (Curhan 2007)

Gold standard for ureteral stones in non-pregnant adults; Hounsfield units predict composition (Smith-Bindman NEJM 2014 PMID 25229916 — verify)

First-line in pregnancy / pediatric / repeat imaging concerns; lower sensitivity (~60–70%) but adequate to detect hydronephrosis (Smith-Bindman 2014)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (16)

16 need judgement
  • informationallife_threateningobstruction_with_infection
    Obstructing stone WITH infection (fever + WBC + UA leuk-esterase / nitrite + hydronephrosis) — UROLOGIC EMERGENCY (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestone_gt_10mm
    Stone >10 mm — spontaneous-passage probability <20%; intervention indicated (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestaghorn_calculus
    Staghorn calculus (filling renal pelvis + calyces) — usually struvite; urease-producing organisms (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomposition_struvite
    Struvite stones (Mg-ammonium-phosphate) — staghorn shape; urease-producers (Proteus, Klebsiella, Pseudomonas, Providencia) on culture (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomposition_cystine
    Cystine stones — autosomal recessive cystinuria; hexagonal crystals on UA; positive cyanide-nitroprusside (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresingle_kidney_or_transplant_obstruction
    Solitary functioning kidney OR transplant kidney with obstruction — emergent decompression regardless of infection (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_obstruction_with_aki
    Bilateral ureteral obstruction with KDIGO ≥Stage 1 AKI — emergent decompression of at least one side (KDIGO AKI 2026 draft)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestone_5_to_10mm
    Stone 5–10 mm — spontaneous-passage probability ~40–50% (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestone_renal_pelvis
    Renal-pelvis stone — often asymptomatic; large stones may obstruct UPJ (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestone_proximal_ureter
    Proximal ureteral stone (above iliac vessels) — lower spontaneous-passage probability than distal (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatestone_distal_ureter
    Distal ureteral stone (below iliac vessels) — highest MET responsiveness (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecomposition_calcium_oxalate
    Calcium oxalate stones (~70% of all stones) — HU >800 on CT; pH 5.5–6.5 (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecomposition_uric_acid
    Uric acid stones — HU <500 on CT; pH <5.5 (low urine pH); often hyperuricosuria (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_with_stone
    Pregnant patient with symptomatic stone — ultrasound first-line; avoid NSAID after 30 wk; stent if obstruction (EAU 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_stones
    Recurrent stones (≥2 lifetime stone events OR strong family history with adolescent first stone) — metabolic workup indicated (Curhan 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildstone_le_5mm
    Stone ≤5 mm — spontaneous-passage probability ~70–80% (AUA 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Urolithiasis — acute analgesia + MET + obstruction-with-infection + composition-targeted prevention (AUA 2016 + EAU 2016)
axis: urolithiasis_acute_and_preventionstep 1 - Tier 1 — Acute pain + antiemetic (Pathan Lancet 2016 — NSAID first-line)
Selected step "Tier 1 — Acute pain + antiemetic (Pathan Lancet 2016 — NSAID first-line)" — Acute renal colic presentation (ED or outpatient)
  • ketorolac
    first line
    NSAID
    30 mg IV (15 mg IV if eGFR 30–60 mL/min/1.73m²; avoid if eGFR <30 or active bleeding) • IV • q6h × ≤5 days (max: 120 mg/day; total course ≤5 days)
    triggers: acute_renal_colic, no_renal_impairment, no_bleeding_diathesis
    NSAID superior to IV morphine/paracetamol for renal colic at 30 min; ketorolac is the IV NSAID of choice (Pathan Lancet 2016 PMID 26993881)
    rxcui 35827
  • morphine
    rescue
    opioid
    0.1 mg/kg IV (typical 4–10 mg adult) • IV • q3–4h PRN
    triggers: breakthrough_pain, NSAID_contraindicated, severe_pain
    Breakthrough analgesia / NSAID-contraindicated patients (Pathan Lancet 2016 second-line)
    rxcui 7052
  • ondansetron
    first line
    serotonin_5HT3_antagonist
    4 mg IV • IV • q8h PRN
    triggers: nausea_vomiting
    Antiemetic for renal colic-associated emesis (AUA 2016)
    rxcui 26225
  • acetaminophen
    add on
    analgesic
    1 g PO/IV • PO/IV • q6h scheduled, max 4 g/day adult
    triggers: multimodal_analgesia
    Opioid-sparing multimodal adjunct (AUA 2016)
    rxcui 161

outpatient playbook — drug actions (5)

  1. 1. tamsulosin if MET retained
    0.4 mg PO daily × 4–6 wk • PO • once daily
    trigger: Distal ureteral 5–10 mm stone retained
    MET (AUA 2016)
  2. 2. potassium citrate
    30–60 mEq/d PO divided • PO • BID-TID
    trigger: Hypocitraturia OR uric acid stones OR cystine alkalinization needed
    Alkalinization + citrate replacement (AUA 2016)
  3. 3. hydrochlorothiazide
    25 mg PO daily • PO • once daily
    trigger: Hypercalciuric recurrent calcium stones
    Reduces urinary Ca (AUA 2016; Curhan 2007)
  4. 4. allopurinol
    100–300 mg PO daily • PO • once daily
    trigger: Uric acid stones + hyperuricosuria + recurrent gout
    Reduces urinary uric acid (AUA 2016)
  5. 5. tiopronin
    800–1200 mg/d PO divided • PO • TID-QID
    trigger: Cystinuria refractory to hydration + alkalinization
    Reduces urinary cystine via disulfide exchange (AUA 2016; EAU 2016)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden severe unilateral flank / CVA pain ± groin radiation (AUA 2016 PMID 27238616); Renal colic with nausea / vomiting (AUA 2016 PMID 27238616); Hematuria + flank pain — stone vs UTI vs pyelo (EAU 2016 PMID 27506951).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Urolithiasis (kidney / ureteral stones)** (uro.urolithiasis.v1).
Phenotype framing: Renal colic vs aortic dissection / AAA (real `cardio.aortic-dissection.core.v1` for older smokers) vs pyelonephritis (fever pattern) vs ovarian torsion (real `gyn.ovarian-torsion.v1`) vs ectopic pregnancy (real `ob.ectopic-pregnancy.v1`) vs appendicitis (real `gi.acute-appendicitis.core.v1`) vs musculoskeletal back pain vs herpes zoster (dermatomal vesicles) vs renal vein thrombosis (AUA 2016)
Scope: Adult with sudden severe flank/CVA pain ± groin radiation ± N/V ± hematuria — concern for urolithiasis. Exclude aortic catastrophe (older smokers), pyelonephritis (fever pattern), ovarian torsion / ectopic (reproductive-age women) (AUA 2016)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Urolithiasis — acute analgesia + MET + obstruction-with-infection + composition-targeted prevention (AUA 2016 + EAU 2016)** — step "Tier 1 — Acute pain + antiemetic (Pathan Lancet 2016 — NSAID first-line)".
1. ketorolac 30 mg IV (15 mg IV if eGFR 30–60 mL/min/1.73m²; avoid if eGFR <30 or active bleeding) IV q6h × ≤5 days (NSAID, first line) — NSAID superior to IV morphine/paracetamol for renal colic at 30 min; ketorolac is the IV NSAID of choice (Pathan Lancet 2016 PMID 26993881)
2. morphine 0.1 mg/kg IV (typical 4–10 mg adult) IV q3–4h PRN (opioid, rescue) — Breakthrough analgesia / NSAID-contraindicated patients (Pathan Lancet 2016 second-line)
3. ondansetron 4 mg IV IV q8h PRN (serotonin_5HT3_antagonist, first line) — Antiemetic for renal colic-associated emesis (AUA 2016)
4. acetaminophen 1 g PO/IV PO/IV q6h scheduled, max 4 g/day adult (analgesic, add on) — Opioid-sparing multimodal adjunct (AUA 2016)

Setting playbook (outpatient) — Confirm passage / definitive intervention + metabolic workup if recurrent + composition-targeted prevention + dietary counselling + activity reclearance (AUA 2016; Curhan 2007; EAU 2016)
5. tamsulosin if MET retained 0.4 mg PO daily × 4–6 wk PO once daily — Distal ureteral 5–10 mm stone retained (MET (AUA 2016))
6. potassium citrate 30–60 mEq/d PO divided PO BID-TID — Hypocitraturia OR uric acid stones OR cystine alkalinization needed (Alkalinization + citrate replacement (AUA 2016))
7. hydrochlorothiazide 25 mg PO daily PO once daily — Hypercalciuric recurrent calcium stones (Reduces urinary Ca (AUA 2016; Curhan 2007))
8. allopurinol 100–300 mg PO daily PO once daily — Uric acid stones + hyperuricosuria + recurrent gout (Reduces urinary uric acid (AUA 2016))
9. tiopronin 800–1200 mg/d PO divided PO TID-QID — Cystinuria refractory to hydration + alkalinization (Reduces urinary cystine via disulfide exchange (AUA 2016; EAU 2016))

Non-pharmacologic actions:
- Hydration ≥2.5–3 L/d (4 L/d for cystinuria) (AUA 2016)
- Sodium <2 g/d (AUA 2016; Curhan 2007)
- Normal dietary calcium 1000–1200 mg/d — do NOT restrict (avoids enteric hyperoxaluria) (Curhan 2007)
- Reduce animal protein — lower urinary acid + uric acid + calcium load (AUA 2016)
- Increase fruits and vegetables — natural citrate + alkali load (AUA 2016)
- Activity reclearance — return to baseline; no specific restriction beyond procedure-specific recovery (AUA 2016)
- Patient education — recurrent symptoms → STAT ED if fever / anuria / severe pain (AUA 2016)
- School / sport / occupational note if intervention recovery in progress

AVOID / contraindication checks:
- Ketorolac_avoid_in_egfr_lt_30 (AUA 2016)
- Ketorolac_max_5_day_course (AUA 2016)
- Ketorolac_avoid_in_active_bleeding_diathesis (AUA 2016)
- Tamsulosin_orthostatic_hypotension (AUA 2016)
- Tamsulosin_floppy_iris_syndrome_if_cataract_surgery_planned (AUA 2016)
- NSAIDs_avoid_third_trimester_pregnancy (EAU 2016)
- Allopurinol_hypersensitivity_screen_HLA_B5801_in_Asian (AUA 2016)
- K_citrate_caution_in_hyperkalemia_ckd (AUA 2016)
- Thiazide_check_electrolytes_at_2_4_weeks (AUA 2016)

Monitoring

Regimen monitoring:
- pain at 1 to 4h post analgesia (Pathan Lancet 2016)
- creatinine at 24h if obstruction or aki (KDIGO AKI 2026)
- urinalysis post passage for composition (AUA 2016)
- 4 to 6wk imaging followup for passage confirmation (AUA 2016)
- 24h urine collection x2 at 6wk if recurrent (Curhan 2007)
- serum calcium PTH uric acid at 6wk if recurrent (AUA 2016)
- electrolytes at 2 4wk after thiazide or K citrate start (AUA 2016)
- allopurinol uric acid response at 3mo (AUA 2016)

Setting (outpatient) monitoring:
- 4–6 wk imaging (AUA 2016)
- 24-h urine × 2 at 6 wk if recurrent (Curhan 2007)
- Serum Ca, PTH, uric acid at 6 wk (AUA 2016)
- Electrolytes 2–4 wk after K-citrate or HCTZ start (AUA 2016)
- Allopurinol uric acid response at 3 mo (AUA 2016)
- Annual imaging in high-recurrence patients (AUA 2016)

Follow-up plan: 4–6 wk imaging follow-up (US or low-dose CT) to confirm passage; urology at 4–6 wk if non-passed; 24-h urine × 2 at 6 wk if recurrent (Curhan 2007 PMID 24857648); composition-targeted prevention (K-citrate / thiazide / allopurinol / alkalinization / tiopronin); hydration ≥2.5 L/d; Na <2 g/d (AUA 2016; EAU 2016)
- Close-out criterion: follow-up + prevention regimen scheduled

Monitoring phase: Pain re-evaluation at 1–4 h post-analgesia; UA + culture for any infection; urinalysis post-passage for composition; AKI surveillance post-decompression; hydration log (AUA 2016)

Disposition

Current setting: outpatient — Confirm passage / definitive intervention + metabolic workup if recurrent + composition-targeted prevention + dietary counselling + activity reclearance (AUA 2016; Curhan 2007; EAU 2016)

Disposition criteria:
- Maintenance prevention regimen + annual imaging if high-recurrence; discharge from active follow-up if 2 y stone-free + adherence to prevention (AUA 2016)

Escalation triggers (move to higher acuity):
- New recurrent flank pain / fever / anuria → STAT ED (AUA 2016)
- Abnormal 24-h urine + recurrence on prevention regimen → nephrology / urology multidisciplinary review (AUA 2016)
- Hypercalcemia on follow-up → endocrine / parathyroid workup (AUA 2016)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Obstructing stone WITH infection (fever + WBC + UA leuk-esterase / nitrite + hydronephrosis) — UROLOGIC EMERGENCY (AUA 2016)
- [SEVERE] Stone >10 mm — spontaneous-passage probability <20%; intervention indicated (AUA 2016)
- [SEVERE] Staghorn calculus (filling renal pelvis + calyces) — usually struvite; urease-producing organisms (AUA 2016)

Citations

- AUA/Endourological Society Surgical Management of Stones 2016 + AUA Medical Management of Kidney Stones 2014 (Pearle) + EAU MET for Ureterolithiasis 2016 (Türk) + SUSPEND MET RCT (Pickard Lancet 2015) + renal-colic analgesia RCT (Pathan Lancet 2016) + CT vs US NEJM (Smith-Bindman 2014) [PMID:27238616](https://pubmed.ncbi.nlm.nih.gov/27238616/)
- Cited evidence (PMID 24857648) [PMID:24857648](https://pubmed.ncbi.nlm.nih.gov/24857648/)
- Cited evidence (PMID 27506951) [PMID:27506951](https://pubmed.ncbi.nlm.nih.gov/27506951/)
- Cited evidence (PMID 25998582) [PMID:25998582](https://pubmed.ncbi.nlm.nih.gov/25998582/)
- Cited evidence (PMID 26993881) [PMID:26993881](https://pubmed.ncbi.nlm.nih.gov/26993881/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AUA/Endourological Society Surgical Management of Stones 2016 + AUA Medical Management of Kidney Stones 2014 (Pearle) + EAU MET for Ureterolithiasis 2016 (Türk) + SUSPEND MET RCT (Pickard Lancet 2015) + renal-colic analgesia RCT (Pathan Lancet 2016) + CT vs US NEJM (Smith-Bindman 2014) — PMID:27238616
  • Cited evidence (PMID 24857648) — PMID:24857648
  • Cited evidence (PMID 27506951) — PMID:27506951
  • Cited evidence (PMID 25998582) — PMID:25998582
  • Cited evidence (PMID 26993881) — PMID:26993881