Severe pain that starts in the flank and spreads to the groin, testicle or genital area is often the first clear sign of a ureteral stone. But pain is not the only issue: when a stone blocks the ureter, which carries urine from the kidney to the bladder, it can cause urine to build up in the kidney and increase pressure within it. For this reason, treatment for an obstructing ureteral stone aims not just to suppress pain, but to protect kidney function and safely manage the risk of infection.
Not every stone behaves the same way. Some small stones can pass on their own under appropriate follow-up, while others, even if small, can lodge in a narrow part of the ureter and cause severe pain, repeated emergency visits or dilation of the kidney. The treatment decision should not be based on a single imaging result; it should be made by looking at the stone's characteristics, the patient's clinical condition and the degree to which the kidney is affected, all together.
Why does ureteral stone obstruction matter?
The ureter is a thin channel through which urine from the kidney reaches the bladder. When a stone partially or completely blocks this channel, pressure inside the kidney rises. Kidney dilation, described on imaging as hydronephrosis, may develop. If the obstruction lasts a long time, the risk of loss of function may increase, especially in people with existing kidney disease.
The most critical situation is when obstruction is accompanied by infection. If there are signs such as fever, chills, weakness, nausea and vomiting, and burning during urination, the possibility of an infected, obstructed kidney must be assessed promptly. This condition should not be monitored at home simply in the hope that the stone will pass; an infection that spreads to the bloodstream can have serious consequences.
The approach also becomes more urgent in patients with a single kidney, when obstruction is found in both ureters or when kidney function tests show deterioration. Pain that cannot be controlled with medication and inability to keep fluids down because of persistent vomiting may also require early intervention.
What diagnostic information changes the treatment?
In a patient with a suspected ureteral stone, examination, urinalysis, kidney function tests and imaging are evaluated together. Urinalysis may show signs of bleeding or infection. When necessary, a urine culture is taken to identify the cause of infection.
In stone disease, non-contrast computed tomography usually shows the size of the stone, its level and the degree of obstruction in detail. Ultrasound is a valuable method for assessing kidney dilation and for follow-up. The same imaging approach is not used for every patient; pregnancy, kidney function, previous tests and clinical need are taken into account.
The details that most affect treatment are the stone's size in millimeters, its location in the upper, middle or lower ureter, stone density, dilation of the kidney and the patient's pain and infection status. For example, the likelihood of a small stone in the lower ureter passing is not the same as that of a larger stone in the upper ureter. That is why deciding based only on the question “how many millimeters is the stone?” is not enough.
Treatment options for an obstructing ureteral stone
Observation and medical therapy in suitable patients
For stones that are small, uninfected, do not threaten kidney function and cause pain that is under control, a period of observation may be planned. During this time, pain treatment, a fluid regimen suited to the patient and, in some cases, medications intended to help the stone move along may be used. The choice of medication should be made by the doctor, taking into account blood pressure, cardiovascular disease, other medications and the risk of side effects.
Observation does not mean “just waiting.” The frequency of pain attacks, development of fever, urine output, kidney function and follow-up imaging are assessed regularly. If the stone is not moving, the obstruction persists or quality of life is significantly affected, the treatment plan is changed.
The popular belief that drinking large amounts of water will flush out any stone is not correct. Especially when there is complete obstruction and severe pain, uncontrolled fluid intake can increase the pain. Fluid intake should be evaluated together with the patient's vomiting and the degree of obstruction.
Emergency drainage: securing the kidney first
If there is obstruction with febrile infection, a rapid decline in kidney function or uncontrollable pain, the priority may not be to break up the stone in the same session. The first goal is to drain the urine that has built up in the kidney, reduce the pressure and bring the infection under control.
For this purpose, a double-J stent may be placed in the ureter, or in some cases a nephrostomy catheter running from the skin to the kidney may be used. Which method is chosen depends on the stone's location, the severity of the infection, anatomical conditions and the patient's general condition. Once the infection is under control, definitive treatment of the stone is planned.
A double-J stent does not free the patient from stone disease altogether; it is a temporary solution that provides drainage of the kidney. While the stent is in place, frequent urination, burning on urination, flank and groin pain with movement or mild blood in the urine may occur. These complaints are manageable in most patients, but the date for stent removal must always be tracked.
Minimally invasive laser ureteral stone surgery: URS
Ureteroscopy (URS) allows the stone to be seen directly by entering the ureter with thin endoscopic instruments through the urethra and bladder. In this method, performed without a skin incision, the stone can be broken into small fragments with laser energy and suitable fragments can be removed. It is an effective option, particularly for ureteral stones that are unlikely to pass and are causing pain or obstruction.
During URS, the aim is not to remove every stone in one piece. The stone's hardness, its position, the structure of the ureter and the conditions for safe advancement determine the strategy of the procedure. In some patients, using a temporary stent at the end of the procedure helps reduce swelling in the ureter and maintain urine flow.
Important advantages of minimally invasive laser surgery are that it does not require an open surgical incision and that, in most patients, it allows a quicker return to daily life. However, as with any surgical procedure, there are risks such as infection, bleeding, stent-related complaints, residual stone fragments or, rarely, injury to the ureter. These risks should be discussed openly before the procedure, and the patient should be given realistic expectations.
Other methods depending on the stone's location
Shock wave lithotripsy (ESWL) aims to break up the stone in some selected ureteral stones using sound waves applied from outside the body. The stone's density, size and location, as well as the patient's body build, affect the likelihood of success with this method. Some stones may require more than one session, and the fragments are expected to pass afterwards.
When the stone extends into the kidney, when there are large accompanying kidney stones or in complex anatomical situations, advanced minimally invasive stone surgery techniques such as RIRS or PCNL may be considered. The right method is not the routine use of the newest technology, but the choice of the approach that is safest and has the highest likelihood of success for that particular patient.
What should be considered after surgery?
After laser ureteral stone surgery, short-term burning, frequent urination and a slightly pink color of the urine may occur. If a stent is in place, these complaints may be more noticeable. It is important to take the medications your doctor recommends regularly, not to miss the planned check-up and to keep track of the stent removal date.
If fever of 38 degrees or higher, chills, increasingly severe pain, inability to urinate, heavy bleeding or persistent vomiting develops, seek medical care without delay. Unlike ordinary postoperative discomfort, these symptoms may suggest infection or a drainage problem.
The process is not over once the stone has been removed. In recurrent stone disease, stone analysis, blood and urine tests and a metabolic evaluation may be performed. Insufficient fluid intake, high salt consumption, high animal protein intake, certain metabolic diseases and family predisposition can affect stone formation. A preventive plan should be tailored to the stone type and the person's lifestyle.
Why does personalized planning make a difference?
In ureteral stone treatment, the goal is not only to make the stone disappear on imaging. Protecting the kidney, managing pain safely, not missing an infection, avoiding unnecessary intervention and taking measures to reduce stone recurrence are all parts of the same plan.
In the approach of Assoc. Prof. Dr. Uygar Miçooğulları, minimally invasive and laser stone surgery options are planned individually after a detailed assessment; preoperative counseling and close postoperative follow-up are seen as a continuation of treatment. If flank and groin pain is accompanied by fever, vomiting or a marked decrease in urination, getting a timely urology assessment rather than waiting for the stone to pass on its own may be the right step to protect your kidney.
