Volume 4, Issue 3

Ureteric stones are a common cause of emergency presentation, and most stones in the distal ureter that are smaller than 10 mm can be managed without intervention. Medical expulsive therapy (MET), most often with the α1-adrenoceptor antagonist tamsulosin, aims to increase the likelihood and speed of spontaneous passage by relaxing ureteric smooth muscle. Early small trials suggested large benefits, but subsequent large multicenter placebo-controlled trials reported little or no overall effect, which led to conflicting guideline recommendations. This review summarizes the pharmacological basis of MET, appraises the evidence from randomized trials and meta-analyses, and offers practical recommendations for clinicians. Current evidence indicates that α-blockers have no meaningful benefit for stones smaller than 5 mm, which usually pass spontaneously, but increase the stone passage rate by about 20 percentage points for distal ureteric stones of 5–10 mm, shorten the time to passage and reduce analgesic requirements and the number of colic episodes. Tamsulosin 0.4 mg daily for up to 4 weeks is the best-studied regimen, and silodosin may be at least as effective. Calcium channel blockers and phosphodiesterase type 5 inhibitors are less effective or less well studied. MET is appropriate only for patients with controlled pain, adequate renal function and no signs of infection, and should be accompanied by clear safety-netting advice and follow-up imaging. Patients should be informed that its use for this indication is off-label in many countries and that dizziness and ejaculatory dysfunction may occur.