Medical management of acute urolithiasis in one American academic emergency room

OBJECTIVE To determine the implementation of medical expulsive therapy (MET) for ureterolithiasis in one tertiary-care emergency room (ER); referral patterns in the surgical and metabolic follow-up of ureterolithiasis were also assessed. PATIENTS AND METHODS In this retrospective review we identified 556 patients with ureterolithiasis in the ER at our centre between 2005 and 2007. Of these, 131 patients met inclusion criteria, including first-time stone formers and no urological visit within the previous 5 years. ER records were reviewed and telephone interviews conducted to determine if MET was used, if the patient was referred to a urologist, if surgery was ultimately required, and if there was ultimately a metabolic evaluation. RESULTS The mean (range) stone size was 4.2 (2-10) mm. Ten patients were admitted directly from the ER and 121 were discharged home. Of the 121 discharged patients, 48 (40%) were prescribed MET. In all, 46 patients received tamsulosin 0.4 mg and two received doxazosin 2 mg; no patient was prescribed steroids. The mean size of passed stones was statistically significantly lower than that of stones that did not pass (P < 0.05). Patients prescribed MET had a 23% chance of needing surgery, vs 32% in those not prescribed MET (P < 0.05). Seventy-one (61%) patients were followed up by a urologist, 27 (23%) by a primary-care physician, and eight (7%) had no further follow-up. Ultimately, 31 (23%) patients had a metabolic evaluation and it was abnormal in 29 (95%). CONCLUSIONS In this single-institution ER experience, 40% of patients with symptomatic ureterolithiasis were treated with MET on discharge from the ER. Our data also show that only patients referred to a urologist received a metabolic evaluation. This is notable given that the vast majority of those evaluated were found to have a correctable abnormality.