Official reprint from UpToDate

www.uptodate.com 2017 UpToDate

Acute management of nephrolithiasis in children

Authors: Thomas S Lendvay, MD, FACS, Jodi Smith, MD, MPH, F Bruder Stapleton, MD
Section Editor: Laurence S Baskin, MD, FAAP
Deputy Editor: Melanie S Kim, MD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2017. | This topic last updated: Aug 08, 2016.

INTRODUCTION The management of pediatric nephrolithiasis is divided into two parts.

Acute episode During the acute phase when the stone is being passed, management is directed
towards pain control, and facilitating passage or removal of the stone(s).

Prevention of recurrent disease After the acute episode, management is directed towards
prevention of recurrent stone disease. This includes an evaluation to identify any underlying cause or
risk factors for stone formation. Based upon this assessment, interventions are tailored to reduce the
risk of recurrent stone formation.

The acute management of childhood nephrolithiasis will be reviewed here. The prevention of recurrent
disease, epidemiology, risk factors, clinical manifestations, and diagnosis of nephrolithiasis in children are
discussed separately. (See "Prevention of recurrent nephrolithiasis in children" and "Epidemiology of and
risk factors for nephrolithiasis in children" and "Clinical features and diagnosis of nephrolithiasis in
children".)

OVERVIEW The acute management of nephrolithiasis depends upon the severity of the pain, and the
presence of obstruction or infection. In some patients, outpatient medical management with oral
analgesics and hydration is possible. However, in others, especially those with nausea, vomiting, and
severe pain, hospitalization is required for parenteral fluid and pain medication. Other indications for
hospitalization include urinary obstruction, solitary kidney, and infection.

Urologic removal of stones may be required in patients with unremitting severe pain that is refractory to
analgesic therapy, or in those with obstruction or infection. (See 'Indications' below.)

MEDICAL MANAGEMENT

Supportive care Supportive management includes symptomatic treatment and aggressive hydration.
In our center, we start intravenous hydration at 1.5 to 2 times the maintenance rate as quickly as possible.
Nausea and vomiting should be treated with intravenous antiemetics. Pain associated with renal colic is
best treated with narcotic analgesics combined with nonsteroidal antiinflammatory medications.

Pain control Both nonsteroidal antiinflammatory drugs (NSAIDs) and opioid therapy are used to
control pain associated with nephrolithiasis. In studies of adult patients, both classes of analgesics are
effective in pain relief. Combination therapy of the two has also been reported to be effective and in some
cases superior to either agent alone. In adults, the combination of morphine and ketorolac has been
shown to be an effective combination to control pain in patients with renal colic. (See "Diagnosis and
acute management of suspected nephrolithiasis in adults", section on 'Pain control' and "Pharmacologic
agents for pediatric procedural sedation outside of the operating room", section on 'Analgesic agents' and
"Selection of medications for pediatric procedural sedation outside of the operating room", section on
'Approach'.)
At our institution, in patients with less severe disease who can be managed as an outpatient, we initiate
pain relief with NSAIDs if renal function is not impaired. If pain relief is not achieved, the patient may
require hospitalization for more aggressive therapy. In the hospitalized patient, we use hydration,
intravenous ketorolac, and opioid therapy as follows:

Morphine For children >6 months of age and 50 kg, intravenous morphine is given as 0.05 to 0.1
mg/kg per dose every two to four hours as needed.

Ketorolac For children >2 years of age, intravenous ketorolac is given as 0.5 mg/kg per dose every
six hours with a maximum dose of 30 mg. Kerorolac is automatically discontinued after 72 hours of
intravenous administration.

The use of NSAIDs should be stopped three days before a urologic intervention, if possible, to minimize
the risk of bleeding. (See "Diagnosis and acute management of suspected nephrolithiasis in adults",
section on 'Pain control'.)

Urine culture Because urinary tract infection (UTI) is often present in children with nephrolithiasis, a
urine culture should be obtained. If a UTI is diagnosed, appropriate antibiotic therapy should be initiated.
(See "Epidemiology of and risk factors for nephrolithiasis in children", section on 'Infection' and "Urinary
tract infections in infants older than one month and young children: Acute management, imaging, and
prognosis", section on 'Antibiotic therapy'.)

Stone passage The majority of stones less than 5 mm in diameter will pass spontaneously, even in
small children [1,2]. Hydration increases urinary flow and is thought to facilitate stone passage. In children,
ultrasonography and a single kidney-ureter-bladder (KUB) radiograph (if the stone is radiopaque) are
generally used to monitor stone passage because noncontrast helical computed tomography (CT) is more
costly and is associated with higher radiation exposure. CT, however, is the most sensitive imaging
modality in the detection of renal or urinary tract stones and is used in the diagnosis of nephrolithiasis,
especially when true stone burden and exact stone location are required for surgical management.
Imaging is typically performed after a two-week period of observation to confirm stone passage. (See
"Clinical features and diagnosis of nephrolithiasis in children", section on 'Imaging'.)

In adults, several medical interventions have been used to increase the passage rate of ureteral stones,
including antispasmodic agents, calcium channel blockers, and alpha blockers. Data are limited on the
use of these agents in children.

In one small clinical trial of 39 patients, children with distal ureteral stones that were smaller than 10
mm were randomly assigned to either doxazosin (an alpha blocker) at a daily dose of about 0.03
mg/kg or ibuprofen [3]. There were no differences between the doxazosin and ibuprofen groups in the
rate of stone passage (84 versus 70 percent) or in the mean time for stone expulsion (5.9 versus 6.1
days).

In contrast, another trial of 45 children (ages 3 to 15 years) reported increased expulsion rates for
patients with distal ureteral stones who received both doxazosin and ibuprofen compared with those
who only received ibuprofen (71 versus 29 percent) [4].

Tamsulosin, an alpha blocker, was studied in a prospective controlled trial in 61 children with distal
ureteral stones <12 mm in diameter. In this small study, children who received tamsulosin and
standard analgesia, compared with those treated with placebo and standard analgesia, had a higher
stone-free rate at the end of the four-week trial (88 versus 64 percent) and a shorter mean stone
expulsion time (8.2 versus 14.5 days) [5]. These findings were confirmed by a retrospective study of
274 children that showed a greater likelihood of stone passage in patients who received tamsulosin (n
= 99) versus those who only received analgesics (n = 175) [6].
In our practice, we have used alpha blockers to facilitate stone passage in children with distal ureteral
stones. Although the US Food and Drug Administration has not approved the use of alpha blockers in
children, based on the above data, we will use tamsulosin in children older than five years of age with
symptomatic ureterovesical stones. We use a dose of 0.4 mg of tamsulosin given in the evening before
bedtime. If there has been no spontaneous passage by one or two weeks, we will intervene surgically.
These medications have been well tolerated, and we have not seen orthostatic hypotension, even though
this is a potential side effect of alpha blockers. (See "Diagnosis and acute management of suspected
nephrolithiasis in adults", section on 'Facilitating stone passage' and 'Urologic intervention' below.)

Stone retrieval The family/patient should be instructed to strain the child's urine for several days, in
order to retrieve the stone. If the stone or any fragment is recovered, it should be sent for stone analysis.
The known composition of the stone can guide further evaluation and preventive measures to prevent
recurrent stones.

Urinary strainers are available from medical supply companies. If a urinary strainer cannot be obtained, a
receptacle covered by a cheese cloth or fine mesh sheet can be used. A fish net used for home
aquariums is also a good alternative. (See "Prevention of recurrent nephrolithiasis in children", section on
'Evaluation for underlying risk factors'.)

UROLOGIC INTERVENTION

Indications Indications for urologic intervention are based upon observational evidence that is
primarily from adult studies. Although similar data are not available for children, we believe this indirect
evidence is applicable to children with nephrolithiasis. In our practice, urologic intervention is performed
versus continued observation with medical management in the following settings:

Unremitting severe pain Severe pain despite adequate analgesia is most often due to a uretero-
vesical (UVJ) or uretero-pelvic junction (UPJ) stone, which is usually accompanied by obstruction. In
these patients, pain is relieved with a temporizing ureteral stent and subsequent stone removal,
regardless of the size of the stone.

Urinary obstruction Obstruction from renal calculi can result in renal parenchymal injury and a
decrease in renal function [7]. Intervention in patients with mild renal insufficiency demonstrates both
an initial improvement in renal function due to the relief of the obstruction and subsequent
improvement thought to be due to recovery of injured renal tissue [8,9]. Without relief, persistent
obstruction can result in permanent scarring and loss of renal tissue [7].

Nevertheless, because of the high spontaneous stone passage rates for smaller calculi, as well as the
cost and potential complications from urologic procedures, it is generally accepted that an observation
period with adequate pain control should be given. The optimal length of time for observation prior to
intervention remains uncertain; however, in our practice, an observation period of up to two weeks is
employed. The goal of management is to minimize renal injury, which requires balancing the risk of a
urologic procedure (ie, urinary drainage or stone removal) versus potential chronic renal injury from
continued obstruction.

In our practice, surgical intervention is considered in the following settings:

Surgical removal If there are signs of infection, complete obstruction, partial obstruction by a stone
in a solitary kidney, or renal insufficiency, or if the stone is greater than 5 mm in diameter, as it is
unlikely to pass spontaneously. These above criteria are absolute indications and lead us to intervene
without a trial of medical observation and treatment, as we feel these situations can lead to
significant morbidity.

Struvite stones (magnesium ammonium phosphate and calcium carbonate-apatite) are often
 associated with an underling UTI, and tend to branch and enlarge resulting in a filling of the renal
calyces producing a "staghorn" appearance (image 1 and image 2). Urologic removal of struvite
calculi is generally required to eradicate the underlying infection [10]. Persistent infection, usually
due to a urease-producing bacteria (eg, Proteus or Klebsiella), is a risk factor for recurrent stone
formation. (See "Epidemiology of and risk factors for nephrolithiasis in children", section on
'Infection' and "Pathogenesis and clinical manifestations of struvite stones" and "Management of
struvite or staghorn calculi".)

Symptomatic stones that fail to pass after a trial of conservative therapy Surgical intervention is
performed if there is no improvement after a trial of medical therapy after two weeks for symptomatic
patients without an underlying UTI, and for those with evidence of radiographically-confirmed
obstruction or who have mild proximal urinary tract dilation that is managed with oral analgesics that
do not impair daily activities.

Asymptomatic patients We offer urologic intervention to asymptomatic children with stones that do
not spontaneously pass after two weeks of medical therapy and observation. These stones are often
located in the kidney and generally do not result in symptoms. However, their removal could prevent a
potential acute episode of renal colic due to obstruction of the urinary tract. Alternatively, patients can
be treated conservatively with hydration and pain control as needed. In patients with uric acid stones,
urine alkalinization increases the solubility of uric acid and may result in a decrease in stone size with
subsequent passage. (See "Prevention of recurrent nephrolithiasis in children", section on
'Hyperuricosuria'.)

Urosepsis Although not commonly seen in children, urosepsis is a serious and life-threatening
complication of nephrolithiasis. In adult patients, urinary drainage is used to lower the intrarenal pelvic
pressure due to stone-induced obstruction, which is thought to improve delivery of antibiotics to the
infected kidney [11]. Because we feel the risk of a lower UTI expanding to urosepsis is significant in
the setting of static urine from partially or completely obstructive stones, we recommend surgical
intervention for stones in the face of concomitant lower UTI as well. Furthermore, clearance of UTIs
with only antibiotic therapy is difficult in patients with symptomatic stones.

Procedures Over the past two decades, the following new urologic procedures for stone removal have
been developed and adapted to children [12-15]. These procedures have generally replaced open surgical
repair and can be used in children of all ages, including small children and infants. However, the
experience and comfort of the surgeon as well as the equipment available should be considered in the
decision of which intervention to use. Many of these interventions are limited by the size of the
instruments available. Our group has used each of the three modalities below to treat children as little as
infants, but other medical centers may be constrained by their pediatric-sized resources.

Extracorporeal shock wave lithotripsy (ESWL)

Percutaneous nephrostolithotomy (PCNL)
Ureteroscopy

Extracorporeal shock wave lithotripsy Extracorporeal shock wave lithotripsy (ESWL) employs
high energy shock waves produced by an electrical discharge. Historically, the child was placed in a water
bath and the shock waves were transmitted through the water and directly focused onto the stone with the
aid of biplanar fluoroscopy. Second and third generation lithotriptors do not require the water bath, but
utilize a contained fluid interface with the patient to transmit the shockwaves. The change in tissue density
between the soft renal tissue and the hard stone causes a release of energy at the stone surface, which
fragments the stone.

For stones that are less than 2 cm in diameter, the resulting fragments are usually passed without
difficulty. Stents can be placed when the stone is greater than 2 cm to reduce the risk of obstruction [16].
However, in children, the placement and removal of the stent generally requires conscious sedation or
general anesthesia. In one case series of 24 children (age range 2 to 14 years), stones between 2.5 and
3.5 cm (mean 3.1 cm) were treated by ESWL without the use of stents [17]. At the end of therapy, the
overall stone-free rate was 83 percent, and complications occurred in six patients, including ureter
obstruction by stone fragments, also referred to as steinstrasse (n = 4), and renal colic (n = 2). Of the four
with steinstrasse, one patient required ureteroscopy to relieve the obstruction, and spontaneous stone
passage occurred in the other three patients. However, because of the increased morbidity associated
with steinstrasse, we continue not to recommend stentless ESWL for stones greater than 2 cm in
diameter.

We use general anesthesia for ESWL due to the requirements of a completely stationary patient during
the procedure and the minimal skin sensation, which an awake child would perceive at the entrance site of
the shock wave.

ESWL has been shown to be an effective and safe procedure for removing stones in children [12,18,19],
including small children and infants [13,20-22]. However, modifications to ensure proper positioning of the
child and appropriate dose of electrical discharge to the size of the patient are required to reduce the
likelihood of complications such as hematomas or lung contusions [16]. Typically, the shock waves are
delivered in a synchronized manner with the electrocardiogram (gated). However, in a small clinical trial
using ungated ESWL, slowing the shock wave rate from 120 to 80 waves per minute improved stone
clearance in children with stones that were less than 20 mm in diameter after one session (26 versus 60
percent) [23]. However, the time of general anesthesia was longer in the group of patients who received
ESWL using a slower wave frequency. Further research in larger cohort studies is needed to determine
the optimal delivery and rate of shock waves for lithotripsy in children.

In a large case series, 344 Turkish children (age range 6 months to 14 years) were treated with ESWL
over a 12-year period [12]. ESWL was performed as an outpatient procedure with administration of
conscious sedation, general anesthesia, and no anesthesia in 40, 38, and 22 percent of children,
respectively. The following findings were noted at three month follow-up:

After ESWL, the overall stone-free rate was 73 percent. Stone-free rates varied depending upon the
size of the stones and were 92, 68, and 50 percent for stones with diameters smaller than 1 cm,
between 1 and 2 cm, and greater than 2 cm in diameter, respectively.

The overall stone-free rate for calyceal stones was 56 percent. A higher rate of 63 percent was
associated with small stones less than 1 cm and a lower rate of 40 percent with stones with diameters
equal to or greater than 1 cm in diameter. ESWL was more likely to fail when stones were located in
the lower versus upper pole calyx.

Stone-free rates were greater than 90 percent for ureteral and bladder stones regardless of their size.

The average number of ESWL sessions per patient was 1.9.

Complications were observed in 10 percent of cases (n = 33). Steinstrasse (obstruction by stone

fragments) occurred in 13 of 167 children treated for renal pelvic stones. Of the 13 patients with
obstruction, 9 had stones greater than 2 cm, and 4 had stones between 1 and 2 cm in diameter.
Other complications included stenting for hydronephrosis and UTIs. There were no episodes of
perirenal hematoma or dermal ecchymosis.

In another study, a nomogram was developed to predict stone-free rates after ESWL in 412 children. The
results show that the overall stone-free rate was 76.7 percent following the first ESWL. Multivariate
analysis showed that a prior history of ipsilateral renal stone treatment or increased stone burden was
associated with lower stone-free rates [24].
Although a stone-free status is the preferred outcome after ESWL, some patients will have residual
fragments after the procedure. In some cases, these fragments (usually less than 4 mm in diameter) will
pass without symptoms, sometimes taking several months to clear. However, in other cases, residual
fragments may grow in size and be associated with an increased risk of recurrent symptomatic episodes
[25]. (See "Clinical significance of residual stone fragments following stone removal".)

Complications In children, limited data suggest there are few short-term and no long-term
adverse effects of ESWL upon renal function as demonstrated by the following studies:

In a retrospective review of 128 children treated with ESWL, 22 patients (18 percent) had
complications in the postoperative week including 5 with steinstrasse, 14 with decreased oral intake
requiring intravenous hydration, 7 with side pain/renal colic requiring parenteral analgesics, 12 with
gross hematuria, and 3 with fever [26].

In a prospective study of 50 children, renal ultrasonography performed after ESWL in 40 patients

demonstrated perirenal hematomas in three patients, intrarenal hematoma in two, and subcapsular
hematoma in one patient. All hematomas resolved spontaneously [19]. Glomerular filtration rate
measured before and after ESWL by 99mTc-diethylenetriamine pentaacetic acid renal scan (DTPA)
remained unchanged.

In a retrospective study, 99mTcdimercaptosuccinic acid (DMSA) renal scans performed in 94 of 182

children before and six months after ESWL detected no new scar formation on post-DMSA scans
[27]. Relative renal function of the treated side remained normal in 66 patients, was reduced pre-
ESWL and remained unchanged in 18 patients, showed improvement after ESWL in 7 patients, and
deteriorated in 2 patients.

In a prospective study of 100 children with a mean age of 8 years (range 3 to 14 years) treated from
2005 to 2008, DMSA renal scans performed before and six months after ESWL detected no new scar
formation [28]. There was also no decrease in the split kidney function as measured by DTPA scan
after ESWL with mean GFR values of 113 mL/min per 1.73 m2 both before and after the last ESWL
session. The average number of ESWL sessions was 1.53 and the overall stone-free rate was 88
percent. There were complications in 11 patients due to stone passage including renal colic (n = 8),
and lower tract obstruction requiring ureteroscopy for stone removal (n = 3).

In a retrospective review of 341 renal units, steinstrasse (ureteral obstruction by stone fragments)
occurred in 26 renal units (8 percent). Logistic regression analysis showed that the initial stone
burden was associated with steinstrasse. Successful interventions included repeat ESWL in 17 renal
units, ureteroscopy after failure of ESWL in four renal units and without ESWL in 1 renal unit, and
conservative management in the remaining four units.

Renal growth Follow-up studies have shown no adverse effect on subsequent renal growth.

In 74 children treated at a mean age of nine years (range 9 months to 14 years) with ESWL at a
tertiary center in the United States, evaluation of renal growth was performed by measuring renal
length by ultrasonography at the time of diagnosis and follow-up [29]. There was no difference in the
rate of renal growth between the treated and untreated kidneys at a mean follow-up of 6.2 years
(range 1.3 to 13.1 years).

In a prospective Egyptian study of 150 children who underwent ESWL between 2005 and 2010, there
was no difference in renal growth based on renal ultrasound assessments between patients 12
months after ESWL and controls [30].

Percutaneous nephrostolithotomy Although percutaneous techniques for stone removal were

initially introduced in the late 1970s, it was not until the 1990s that instrumentation was adapted to
pediatric patients [31]. Percutaneous nephrostolithotomy (PCNL) entails obtaining percutaneous access to
the collecting system, dilating the tract with a balloon dilator, and extracting the stone with grasping
forceps or fragmenting the stone with a LASER, ultrasonic, pneumatic, hydraulic, or combined lithotripsy
probe. PCNL can be performed in conjunction with ESWL.

Stone-free rates of 70 to 90 percent have been reported. Rates vary depending upon the experience of
the clinician, the complexity of the stones, and the presence of an underlying structural abnormality
[14,32,33]. In one retrospective Egyptian study of children with renal stones between 1 and 2 cm in
diameter, the stone-free rates between a single PCNL and one ESWL session were comparable (87
versus 85 percent, respectively) at a mean follow-up of 31 months (range 6 to 84 months) [14].

In children, data on complication rates are limited. Serious adverse events appear to be similar to those
reported in adults (who have a complication rate of 4 to 5 percent) and include urosepsis, bleeding
(sometimes requiring red blood cell transfusions), renal pelvic perforation, and injury to adjacent organs
(eg, hydrothorax and colon perforation) [14,16,32].

Follow-up data regarding renal function are also lacking. One study using 9mTc-dimercaptosuccinic acid
(DMSA) and DTPA renal scans reported no evidence of postoperative scarring after PCNL or impairment
of glomerular filtration rate when evaluated six months after the procedure [33].

Ureteroscopy Ureteroscopic instrumentation has been adapted for use in pediatric patients of all
ages as first line therapy and is useful for the management of children with calculi who have failed ESWL,
especially those with ureteral stones [34,35]. Once the stone is visualized, it is extracted with grasping
forceps or basket, or fragmented with LASER, ultrasonic, or electrohydraulic lithotripsy. (See "Options in
the management of renal and ureteral stones in adults", section on 'Ureteroscopy'.)

Although data are limited regarding stone-free rates in children, a systematic review of the literature
reported stone-free rates around 90 percent in children with a mean age of 7.8 years [34]. In this review,
the mean stone size was 9.8 mm and the majority of the stones were in the ureter (83 percent). The
success rate was lower in children less than six years of age.

Ureteroscopy is not as successful in the removal of staghorn calculi. This was illustrated in a case series
of 19 children with 23 renal calculi that demonstrated clearance of renal pelvic stones in six of eight
children (mean number of sessions 1.5), successful clearance of stones in all four children with polar
stones after multiple sessions, and clearance in only one of seven children with staghorn calculi [36].
These results suggest that ureteroscopy does not have a role in treating children with staghorn calculi.
(See "Management of struvite or staghorn calculi".)

Stenting The need for stenting in children who undergo ESWL or ureteroscopy is controversial [16].
Stents are used to prevent ureteric obstruction either from edema due to ureteral injury or residual
fragments in ESWL. Studies in adults have demonstrated that patients with stents versus those without
stents were more likely to have lower urinary tract symptoms (dysuria, frequency, or urgency), while there
was no difference in stone-free rate, and the rates of UTIs, ureteric structures, and analgesic
administration. Similar data in children are lacking. In practice, most pediatric urologists do not place a
stent in simple, uncomplicated cases of ureteroscopy or in a patient with a stone less than 1.5 to 2 cm in
diameter who is treated with ESWL [16].

However, pre-stenting (the practice of placing a stent a week or two prior to the ureteroscopic procedure
to facilitate ease of passage of the ureteroscopes) has been employed for passive dilation of the ureter.
This does place the child at a higher risk for lower urinary tract symptoms and possible infection, but
minimizes the need for ureteral dilation at the time of ureteroscopy.

Choice of procedure Choice of treatment is dictated by the experience of the clinician and the
availability of instrumentation adapted for pediatric cases. In centers where the different procedures are
available, treatment choices are based upon the stone size and location, presence of an anatomical
abnormality, and, if known, stone composition as follows [14,16]:

Size ESWL is the preferred procedure when stones are radiopaque and small (less than 1 cm in
diameter) in the renal pelvis, but not distal ureteral stones in girls because of the position of the
ovaries. It is the least invasive procedure with fewer serious complications.

For patients with stones greater than 2 cm in diameter in the kidney, PCNL is the preferred
modality for successful stone removal because of the low stone-free rates and difficulty of high
stone burden passage produced by ESWL.

In patients with stones between 1 and 2 cm in diameter, it is uncertain which is the best modality.
As discussed previously, a retrospective study reported comparable stone-free rates for ESWL
and PCNL in children with stones between 1 and 2 cm in diameter [14]. If clearance with ESWL
is impaired, such as in a child with calyceal diverticulum, PCNL may be preferred. Otherwise,
ESWL as an initial therapy is suggested because it is less invasive and has a lower rate of
significant complications.

Location Poorer clearance of renal stone fragments from the lower pole compared with other
locations has been reported in adults after ESWL. Similar results have been noted in several case
series in children [12,37]. In contrast, a single report of 126 children from a tertiary center in Egypt
demonstrated similar clearance rates regardless of the stone location within the kidney [38].

Structural abnormality Children with underlying structural abnormalities, such as ureteropelvic (UPJ)
obstruction and calyceal diverticulum, are at increased risk for developing renal stones. In addition,
the underlying anatomical defect prevents effective passage of stone fragments with ESWL. In most
centers, PCNL is the preferred procedure for patients with calyceal diverticulum, and in children with
UPJ obstruction, either PCNL or ureteroscopy is used for stone removal. Additionally, calyceal
diverticular stones may be accessed from a laparoscopic approach with an incision being made over
the dilated stone-laden calyx and directly extracting the stones.

Composition of stone Stones of harder composition, such as cystine and calcium oxalate
monohydrate stones, are less amenable to fractionating with ESWL. As an example, in patients with
cystine stones, the stone-free success rate is only 50 percent with ESWL, even after four sessions
[39]. As a result, PCNL or ureteroscopy and LASER lithotripsy are the preferred procedure in these
patients. In contrast, struvite, calcium oxalate dihydrate, and uric acid stones break more readily with
ESWL and have a high stone-free success rate with ESWL [40].

Open surgical repair is rarely, if ever, performed today and is reserved for children who have failed
other urologic procedures or those with complex renal or ureteral anatomic abnormalities.

Recommended approach In institutions where different treatment options are available, therapy
can be individualized based upon the factors discussed in the previous section as follows:

In patients with stones up to 2 cm in diameter, ESWL or ureteroscopy with lithotripsy are both
reasonable options for stone removal.

In patients with stones greater than 2 cm in diameter, we suggest ureteroscopy with lithotripsy, or
PCNL. If the stone is in the lower pole calyces, these interventions have a greater success rate than
ESWL.

In patients with an underlying structural abnormality, the choice of therapy is individualized based
upon the anatomy, and the size and location of the stone.

SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: Kidney
stones" and "Society guideline links: Pediatric nephrolithiasis".)

INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, "The
Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the
5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a
given condition. These articles are best for patients who want a general overview and who prefer short,
easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients
who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Kidney stones in children (The Basics)")

Beyond the Basics topics (see "Patient education: Kidney stones in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS The acute management of nephrolithiasis in children is

directed towards pain control and facilitating passage or removal of the stone(s). Therapeutic choices are
dependent upon the severity of pain, the presence of obstruction or infection, and the size and location of
the stone.

Indications for hospitalization include urinary obstruction, infection, solitary kidney, the need for
parenteral fluid and pain medications because of severe pain, or inability to take oral analgesics or
fluids (eg, vomiting). (See 'Overview' above.)

One of the main goals of medical management is to provide adequate pain control. The choice of
analgesic agent is dependent upon the severity of pain and the ability of the child to take oral
medications. Both nonsteroidal antiinflammatory drugs (NSAIDs) and opioids are used in controlling
pain in children with nephrolithiasis. In our practice, we generally use NSAIDs in patients who are
managed as an outpatient. In hospitalized patients, toradol and opioid therapy are used for pain
management. NSAIDs should be stopped three days before anticipated urologic intervention to
minimize the risk of bleeding. (See 'Pain control' above and "Diagnosis and acute management of
suspected nephrolithiasis in adults", section on 'Pain control'.)

We suggest observation with pain control in patients with stones less than 5 mm in diameter versus
urologic intervention (Grade 2C). Renal ultrasonography is used to monitor stone movement and
passage. (See 'Stone passage' above.)

During this period of observation, the patient is instructed to strain his/her urine for stone retrieval. If
the stone is retrieved, stone composition is determined by laboratory analysis. (See 'Stone retrieval'
above.)

Children with severe debilitating pain refractory to parenteral analgesic therapy require urologic stone
removal for pain relief. (See 'Indications' above.)

Other indications for urologic intervention versus observation with medical management for pediatric
nephrolithiasis include the following:

In children with significant urinary obstruction, we suggest immediate urologic stone removal
(Grade 2C).

In children with struvite stones, we recommend urologic stone removal (Grade 1B). (See
 "Management of struvite or staghorn calculi", section on 'Treatment options'.)

In symptomatic children who fail to pass a stone after two weeks, we suggest stone removal
(Grade 2C). (See 'Indications' above.)

In children with a solitary kidney with partial or total obstruction, we suggest stone removal
(Grade 2C).

The choice of urologic procedure is determined by the experience of the clinician and the availability
of instrumentation adapted for pediatric cases. Surgical options include extracorporeal shock wave
lithotripsy (ESWL), percutaneous nephrostolithotomy (PCNL), and ureteroscopy. These procedures
have generally replaced open surgical repair and can be used in children of all ages, including small
children and infants. (See 'Procedures' above.)

In centers that have different urologic procedures available for stone removal in children, the choice of
the procedure is generally based on the size, location, presence of an anatomical abnormality, and, if
known, stone composition. (See 'Choice of procedure' above.)

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Topic 6114 Version 32.0

GRAPHICS

Abdominal radiograph of renal stones

Nephrolithiasis. Abdominal radiograph anteroposterior projection shows a staghorn calculus in

the right renal pelvis and smaller stones (arrows) in the left kidney.

Graphic 62009 Version 5.0

CT of renal stone

Nephrolithiasis. Image of abdomen from a noncontrast CT shows a stone

(arrow) in the right renal pelvis.

CT: computed tomography.

Courtesy of Mark D Aronson, MD.

Graphic 72669 Version 8.0

Contributor Disclosures
Thomas S Lendvay, MD, FACS Nothing to disclose Jodi Smith, MD, MPH Nothing to disclose F
Bruder Stapleton, MD Nothing to disclose Laurence S Baskin, MD, FAAP Nothing to disclose Melanie
S Kim, MD Nothing to disclose

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