Tatalaksana Konservatif dan

Medikamentosa pada Batu Saluran

Kemih

Dr.dr. Nur Rasyid, SpU

Department of Urology, Cipto Mangunkusumo Hospital

Division of Urology, Department of Surgery

Faculty of Medicine University of Indonesia

 Renal Colic Pain

The pain typically
begins in the
abdomen and often
radiates to the
hypochondrium or the
groin.
The pain is often
colicky (comes in
waves) due to
ureteric peristalsis,
but may be constant.

Pathophysiology
Acute Unilateral Ureteral Obstruction (UUO)
Release of prostaglandins, especially E2,
1. vasodilation afferent arterioles
increase (RBF) & (GFR)
more urine is produced,
renal pelvis and ureter dilate
pain
2. contraction of ureteral smooth muscle pain
3. nociceptors to stimuli (bradykinins)
pain
visceral responses (nausea, vomiting)

The initial phase 1.5 hours

vasoconstriction efferent arterioles
afferent arterioles vasoconstrict,
decrease (RBF)
ureteral pressures fall

Distension release of ATP from epithelium lining the

tube or sac, which then acts on P2X3 and/or P2X2/3
receptors on subepithelial sensory nerves to convey
sensory/nociceptive information to the CNS.

Sources of ATP acting on

P2X3 and P2X2/3 :
- Sympathetic nerves
- Endothelial,
- Merkel, and
- Tumor cells.
Yellow dots ATP
Red dots adenosine.

A schematic showing the initiation of nociception

by ATP on primary afferent fibres in the periphery
and purinergic relay pathways in the spinal cord

 194 subjects
97 cases
97 controls
~ age and gender.
control
ophthalmology
outpatient
refraction
symptoms
SF-36

Follow-up Daily Hydrocodone Doses (mg) for Kidney Stone Pain

by Patient Race and Patient Gender for All Doctors
Hydrocodone
(mg)

Female

Male

Black

White

Black

White

Prescribed
total

173,8

(198,8)

(204,1)

188,8

daily

37,3

173,8 mg

(204,1 mg)
(46,4)

(40,2)
Treatment

< 0,05
< 0,05

37,6
(207,2)

157,3

< 0,05

Dipyrone (Novalgin)
Tramadol (Tramal),
Butylscopolamine (Buscopan),

Th/ :

- Normal saline 1 l for 2 hours,

- iv morphine in 2.5 mg aliquots at 5-minute intervals,
- 100 mg rectal indomethacin

Study group : + (20 mg iv Buscopan diluted to 10 ml)

Control group : + (10 ml intravenous saline)

= 85 ps
= 93 ps

There is no evidence that Buscopan :

reduces opioid requirements in acute renal colic.

n
n
n
n

Current practice patterns in U.S. emergency departments

135/173 email physicians responded, Mart 2008
Diagnosis : 90% NonContrast CT (NCCT)
Treatment : 63% alpha-blockers
13% EDs have guidelines for th/of renal colic
only 58% of guidelines alpha-blocker.
practicing < 5 years (81%)
> 10 years (56%).

n
n

Majority ketorolac & morphine effective analgesia

Knowledge : spontaneous stone passage
< 4mm (87%)
> 4mm (44%) ~ evidence-based values,
Counseling of patients with ureteral calculi.
28% follow-up with a primary care physician,
72% follow-up with a urologist.

March 2005, 170 questionnaires to Switzerland urologists

65%
intravenously.

81%

74%
opioid (pethidine) ~ acute second-line therapy
Follow-up (75%) NSIDs

n
n

Non-opioid analgesics for first-line

64% metamizol

This complies ~ The literature

Recommendations of EAU

Methods : Cochrane central register of controlled trials 2003;

Medline and PreMedline (1966 to 31 January 2003);
Embase (1980 to 31 January 2003);
Reference of nephrology textbooks, Review articles and
Abstracts nephrology meetings.

Resut s :
74 trials 20 trials with : 1613 participants
NSAIDs and Opioids ~ reductions pain scores
NSAIDs : - in six trials greater reduction in pain scores
- significantly less require rescue analgesia
(relative risk 0.75, 95% confidence interval 0.61 to 0.93).

less vomiting

(0.35, 0.23 to 0.53).

Opioids : higher incidence of adverse events

Pethidine higher rate of vomiting.

W. PATRICK SPRINGHART, M.D.,1 CHARLES G. MARGUET, M.D.,1 ROGER L. SUR, M.D.,1 REGINA D. NORRIS, M.D.,1
FERNANDO C. DELVECCHIO, M.D.,1 MATTHEW D. YOUNG, M.D.,1 PAULA SPRAGUE, M.D.,2 CHARLES A. GERARDO, M.D.,2
DAVID M. ALBALA, M.D.,1and GLENN M. PREMINGER, M.D.1

Minimal and forced fluid ~ symptoms acute renal colic.

Hydration status does not appear to affect stone passage.
Patients with vomiting or dehydration
replacement fluids +
maintenance requirements.

Rectal or Intravenous NSID

in Acute Renal Colic ?
n

Medline : 1966 maret 2005

179 study 2 double blind RCT relevant to Question

Recral group : 100 mg indometasin PR + plasebo iv
IV group
: plasebo PR + 50 mg indometacin iv

n Nelson CE, et all, 84 Patient

1988, Sweden
VAS 0, 10, 20, 30
Side Efect
+ Analgesia

37 rectal

47 iv

82, 41, 34, 22

74, 39, 22, 14

17%
43%

49%
21%

Nissen I, et all, IV : faster & significant improvement

1990, Denmark

adverse R : IV / PR = 55% / 37% p=0,03

+ analgesia : IV / PR = 9% / 27% p=0,018
Emerg. Med.J 2005;22:653-654

Basmah Safdar, MD, Linda C. Degutis, DrPH, Keala Landry, MD, Swarupa R. Vedere, MD, Harry C. Moscovitz, MD, Gail D Onofrio, MD

n
n

Methods :

(1) morphine 5 mg at 0 & 20 minutes,

(2) ketorolac 15 mg at 0 & 20 minutes
(3) combination of both.
Pain reduction & need for rescue analgesia at 40 minutes.

Mean difference in pain score :

Combination >< morphine : 1,8 (p<0,03)
Combination >< ketorolac : 2,2 (p< 0,03)
Need for rescue analgesia :
Combination >< morphine & ketorolac (p=0,07)
Ketorolac decreased RBF ipsilateral kidney
dyhidration ARF
Annals of Emergency Medicine Volume48, No.2 : August 2006

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014 p. 16.

Observation of Ureteral Stones

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p.19

Conservative

(IAUI Guidelines of Urolithiasis, 2007)

- Small size ureterolithiasis : 5mm, usually located in

distal of the ureter
- Partially obstructive
- No contraindication, such as urinary track infection,
intractable pain, or renal failure
1. Diuresis 2 L / day
2. lpha blocker (Tamsulosin)
3. NSAID
For 6 weeks

Herbal Supplement,
Is it necessary?

Dissolution Agent
n Alkalinizes

urine
n Depends on stone size, type, volume of
irrigant
n Oral alkalinizing agents : sodium or
potassium bicarbonate and potassium
citrate.
n Dietary modification orange juice

Tanagho Emil, McAninch Jack. Urinary Stone Disease. Smiths General Urology.
17th Edition. 2008. Mc.Graw Hill,USA

Medical Expulsive Therapy (MET)

Drugs theraphy for expeling stones, act by
relaxing ureteral smooth muscle through
inhibition of calcium channel pumps or -1
receptor blockade
n Meta analysis have shown a fewer renal colic
episode in patient treated with -1 bloker or
nifedipine
n

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p. 19

Medical Agent of METS

bloker : tamsulosin, terazosin and
doxazosin, alfuzosin, naftopidil, silodosin
n Pharmacology : Blocks alpha 1a
adrenergic in smooth muscle of prostate,
bladder neck, and relaxing or decrease
resistance of urinary tract
n Side effect : headache, abnormal
ejaculation, decrease libido
n -1

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p. 20

Medical Agent of METS

-1 bloker better than nifedipine in result
n no recommendation for the use of
corticosteroids in combination with -blockers
in MET
n Calcium Channel Blocker : Nifedipine
n Side effect: peripheral edema, dizziness,
headache
n

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p. 20

n = 70/grup

phloroglucinol

Tamsulosin

Nifedipin

Waktu keluar

120 jam

72 jam

120 jam

Ukuran : mm

6.2

7.2

6.2

Keluar

45/70

68/70

54/70

100

97.1

90
80

77.1

70
60
50

64.3

40
30
20
10
0

phloroglucinol

tamsulosin

nifedipin

Meta-analysis of randomized clinical trials 1966 -2005

11 trials (911 participants)
11 trials : Tamsulosin 0,4 mg
1 trials : Terazosin & Doxazosin

Compared :
patients receiving conservative th/ only
Patients receiving conservative th/ + alfa-blockers
were 44% more likely to spontaneously expel the stones
Without or With ESWL

n
n
n

n
n

Meta-analysis of randomized clinical trials 1980 -2007

4.443 publications
Batu < 5mm :
keluar 4 minggu
Jarang Urologist
Batu 5 10 :
Sering konsul Urologist
Batu > 10 : Tidak dianjurkan medical terapi ESWL
Alfa -blocker

Calcium channel blocker

Trials (pasien)

16 (1.235)
13 (Tamsulosin)
3 (Terazosin &Doxazosin)

9 (686)

Lama batu keluar

14 hari

28 hari

Advers effects

4%

15,2%

discontinuation

1 pasien (0.2%)

10 pasien (2,9%)

Follow-up Pasien

Patients should be followed once between 1 and 14 days to

monitor stone position

n BNO

IVP

Sites of normal functional or

anatomic narrowing ureter

Take Home Message

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p. 78.

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p.82.

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology.

2014; p. 87.

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p.91.

Turk C, et al. Guidelines on Urolithiasis. Europian Association of Urology. 2014; p. 93.