Ureteroscopy pp 351-359 | Cite as

Medical Therapy for Stent Discomfort

  • Zachariah G. Goldsmith
  • Michael E. Lipkin
  • Glenn M. PremingerEmail author
Part of the Current Clinical Urology book series (CCU)


Indwelling ureteral stents are associated with high rates of morbidity, including urinary frequency, urgency, and flank pain. These symptoms have been associated with increased narcotic requirement, decreased quality of life, and decreased attendance in the workplace. Methods to ameliorate stent-related morbidity are needed to provide comprehensive care following ureteroscopy with stent placement. The pathophysiology of stent discomfort is likely related to trigonal irritation, ureteral spasm, changes in stent position with ambulation, and vesicoureteral reflux. Ureteral contraction is mediated by intracellular calcium influx, and this process is regulated by alpha-stimulatory and beta-inhibitory adrenergic signaling. This system has served as the primary target for pharmacologic agents to reduce stent pain.

Alpha blockers (tamsulosin 0.4 mg daily) and alfuzosin (10 mg daily) have demonstrated efficacy in reducing stent morbidity in multiple randomized clinical trials as well as recent meta-analyses. Anticholinergic therapy (tolterodine ER 4 mg daily) has also been demonstrated to reduce stent-related morbidity in a randomized trial. Calcium channel blockers, phosphodiesterase inhibitors, and anti-inflammatories have shown promising effects in preclinical studies and other settings. Innovations in stent design (including drug-eluting ureteral stents) and intravesical therapies are likely to lead to improvements in stent-related morbidities.


Stent Placement International Prostate Symptom Score Ureteral Stone Ureteral Stents Alpha Blocker 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Joshi HB, et al. Characterization of urinary symptoms in patients with ureteral stents. Urology. 2002;59(4):511–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Joshi HB, et al. Indwelling ureteral stents: evaluation of symptoms, quality of life and utility. J Urol. 2003;169(3):1065–9. discussion 1069.PubMedCrossRefGoogle Scholar
  3. 3.
    Hao P, et al. Clinical evaluation of double-pigtail stent in patients with upper urinary tract diseases: report of 2685 cases. J Endourol. 2008;22(1):65–70.PubMedCrossRefGoogle Scholar
  4. 4.
    Borboroglu PG, et al. Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications. J Urol. 2001;166(5):1651–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Thomas R. Indwelling ureteral stents: impact of material and shape on patient comfort. J Endourol. 1993;7(2):137–40.PubMedCrossRefGoogle Scholar
  6. 6.
    Rane A, et al. Have stent-related symptoms anything to do with placement technique? J Endourol. 2001;15(7):741–5.PubMedCrossRefGoogle Scholar
  7. 7.
    Miyaoka R, Monga M. Ureteral stent discomfort: Etiology and management. Indian J Urol. 2009;25(4):455–60.PubMedCrossRefGoogle Scholar
  8. 8.
    Chew BH, et al. Pilot study of ureteral movement in stented patients: first step in understanding dynamic ureteral anatomy to improve stent comfort. J Endourol. 2007;21(9):1069–75.PubMedCrossRefGoogle Scholar
  9. 9.
    Mosli HA, et al. Vesicoureteral reflux in patients with double pigtail stents. J Urol. 1991;146(4):966–9.PubMedGoogle Scholar
  10. 10.
    Yossepowitch O, et al. Assessment of vesicoureteral reflux in patients with self-retaining ureteral stents: implications for upper urinary tract instillation. J Urol. 2005;173(3):890–3.PubMedCrossRefGoogle Scholar
  11. 11.
    El-Nahas AR, et al. Self-retaining ureteral stents: analysis of factors responsible for patients’ discomfort. J Endourol. 2006;20(1):33–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Weiss RM. Uretral function. Urology. 1978;12(2):114–33.PubMedCrossRefGoogle Scholar
  13. 13.
    Dixon JS, Gosling JA. The fine structure of pacemaker cells in the pig renal calices. Anat Rec. 1973;175(2):139–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Malin Jr JM, Deane RF, Boyarsky S. Characterisation of adrenergic receptors in human ureter. Br J Urol. 1970;42(2):171–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Mastrangelo D, Iselin CE. Urothelium dependent inhibition of rat ureter contractile activity. J Urol. 2007;178(2):702–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Lipkin M, Shah O. The use of alpha-blockers for the treatment of nephrolithiasis. Rev Urol. 2006;8 Suppl 4:S35–42.PubMedGoogle Scholar
  17. 17.
    Sigala S, et al. Evidence for the presence of alpha1 adrenoceptor subtypes in the human ureter. Neurourol Urodyn. 2005;24(2):142–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Weiss RM, Bassett AL, Hoffman BF. Adrenergic innervation of the ureter. Invest Urol. 1978;16(2):123–7.PubMedGoogle Scholar
  19. 19.
    Joshi HB, et al. Ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. J Urol. 2003;169(3):1060–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Damiano R, et al. Effect of tamsulosin in preventing ureteral stent-related morbidity: a prospective study. J Endourol. 2008;22(4):651–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Wang CJ, Huang SW, Chang CH. Effects of specific alpha-1A/1D blocker on lower urinary tract symptoms due to double-J stent: a prospectively randomized study. Urol Res. 2009;37(3):147–52.PubMedCrossRefGoogle Scholar
  22. 22.
    Deliveliotis C, et al. Is there a role for alpha1-blockers in treating double-J stent-related symptoms? Urology. 2006;67(1):35–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Beddingfield R, et al. Alfuzosin to relieve ureteral stent discomfort: a prospective, randomized, placebo controlled study. J Urol. 2009;181(1):170–6.PubMedCrossRefGoogle Scholar
  24. 24.
    Lingeman JE, et al. Assessing the impact of ureteral stent design on patient comfort. J Urol. 2009;181(6):2581–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Giannarini G, et al. Predictors of morbidity in patients with indwelling ureteric stents: results of a prospective study using the validated Ureteric Stent Symptoms Questionnaire. BJU Int. 2011;107(4):648–54.PubMedCrossRefGoogle Scholar
  26. 26.
    Barry MJ, et al. The American Urological Association symptom index for benign prostatic hyperplasia. The Measurement Committee of the American Urological Association. J Urol. 1992;148(5):1549–57. discussion 1564.PubMedGoogle Scholar
  27. 27.
    Navanimitkul N, Lojanapiwat B. Efficacy of tamsulosin 0.4 mg/day in relieving double-J stent-related symptoms: a randomized controlled study. J Int Med Res. 2010;38(4):1436–41.PubMedGoogle Scholar
  28. 28.
    Lee SJ, et al. Stent position is more important than alpha-blockers or anticholinergics for stent-related lower urinary tract symptoms after ureteroscopic ureterolithotomy: a prospective randomized study. Korean J Urol. 2010;51(9):636–41.PubMedCrossRefGoogle Scholar
  29. 29.
    Erturk E, Sessions A, Joseph JV. Impact of ureteral stent diameter on symptoms and tolerability. J Endourol. 2003;17(2):59–62.PubMedCrossRefGoogle Scholar
  30. 30.
    Sur RL, et al. Efficacy of intravesical ropivacaine injection on urinary symptoms following ureteral stenting: a randomized, controlled study. J Endourol. 2008;22(3):473–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Chew BH, Lange D. Ureteral stent symptoms and associated infections: a biomaterials perspective. Nat Rev Urol. 2009;6(8):440–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Haleblian G, et al. Ureteral stenting and urinary stone management: a systematic review. J Urol. 2008;179(2):424–30.PubMedCrossRefGoogle Scholar
  33. 33.
    Dellis A, et al. Relief of stent related symptoms: review of engineering and pharmacological solutions. J Urol. 2010;184(4):1267–72.PubMedCrossRefGoogle Scholar
  34. 34.
    Candela JV, Bellman GC. Ureteral stents: impact of diameter and composition on patient symptoms. J Endourol. 1997;11(1):45–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Damiano R, et al. Does the size of ureteral stent impact urinary symptoms and quality of life? A prospective randomized study. Eur Urol. 2005;48(4):673–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Joshi HB, et al. A prospective randomized single-blind comparison of ureteral stents composed of firm and soft polymer. J Urol. 2005;174(6):2303–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Lee C, et al. Randomized evaluation of Ureteral Stents using validated Symptom Questionnaire. J Endourol. 2005;19(8):990–3.PubMedCrossRefGoogle Scholar
  38. 38.
    Al-Kandari AM, et al. Effects of proximal and distal ends of double-J ureteral stent position on postprocedural symptoms and quality of life: a randomized clinical trial. J Endourol. 2007;21(7):698–702.PubMedCrossRefGoogle Scholar
  39. 39.
    Ho CH, et al. Determining the appropriate length of a double-pigtail ureteral stent by both stent configurations and related symptoms. J Endourol. 2008;22(7):1427–31.PubMedCrossRefGoogle Scholar
  40. 40.
    Beiko DT, et al. Double-blind randomized controlled trial assessing the safety and efficacy of intravesical agents for ureteral stent symptoms after extracorporeal shockwave lithotripsy. J Endourol. 2004;18(8):723–30.PubMedGoogle Scholar
  41. 41.
    Gupta M, et al. Prospective randomized evaluation of periureteral botulinum toxin type A injection for ureteral stent pain reduction. J Urol. 2010;183(2):598–602.PubMedCrossRefGoogle Scholar
  42. 42.
    Chew BH, Denstedt JD. Technology insight: Novel ureteral stent materials and designs. Nat Clin Pract Urol. 2004;1(1):44–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Cadieux PA, et al. Triclosan loaded ureteral stents decrease proteus mirabilis 296 infection in a rabbit urinary tract infection model. J Urol. 2006;175(6):2331–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Liatsikos EN, et al. Application of paclitaxel-eluting metal mesh stents within the pig ureter: an experimental study. Eur Urol. 2007;51(1):217–23.PubMedCrossRefGoogle Scholar
  45. 45.
    Caine M, Raz S. Some clinical implications of adrenergic receptors in the urinary tract. Arch Surg. 1975;110(3):247–50.PubMedCrossRefGoogle Scholar
  46. 46.
    Nakada SY, et al. Doxazosin relaxes ureteral smooth muscle and inhibits epinephrine-induced ureteral contractility in vitro. Urology. 2007;70(4):817–21.PubMedCrossRefGoogle Scholar
  47. 47.
    Danuser H, et al. Systemic and topical drug administration in the pig ureter: effect of phosphodiesterase inhibitors alpha1, beta and beta2-adrenergic receptor agonists and antagonists on the frequency and amplitude of ureteral contractions. J Urol. 2001;166(2):714–20.PubMedCrossRefGoogle Scholar
  48. 48.
    Davenport K, Timoney AG, Keeley Jr FX. Effect of smooth muscle relaxant drugs on proximal human ureteric activity in vivo: a pilot study. Urol Res. 2007;35(4):207–13.PubMedCrossRefGoogle Scholar
  49. 49.
    Kubacz GJ, Catchpole BN. The role of adrenergic blockade in the treatment of ureteral colic. J Urol. 1972;107(6):949–51.PubMedGoogle Scholar
  50. 50.
    Park SC, et al. The effects of tolterodine extended release and alfuzosin for the treatment of double-j stent-related symptoms. J Endourol. 2009;23(11):1913–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Yakoubi R, et al. Is there a role for alpha-blockers in ureteral stent related symptoms? A systematic review and meta-analysis. J Urol. 2011;186(3):928–34.PubMedCrossRefGoogle Scholar
  52. 52.
    Lamb AD, Vowler SL, Johnston R, Dunn N, Wiseman OJ. Meta-analysis showing the beneficial effect of α-blockers on ureteric stent discomfort. BJUI. 2011;108:1894–902.CrossRefGoogle Scholar
  53. 53.
    Tseng TY, et al. How to use a systematic literature review and meta-analysis. J Urol. 2008;180(4):1249–56.PubMedCrossRefGoogle Scholar
  54. 54.
    Norris RD, et al. A prospective, randomized, double-blinded placebo-controlled comparison of extended release oxybutynin versus phenazopyridine for the management of postoperative ureteral stent discomfort. Urology. 2008;71(5):792–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Forman A, et al. Effects of nifedipine on the smooth muscle of the human urinary tract in vitro and in vivo. Acta Pharmacol Toxicol (Copenh). 1978;43(2):111–8.CrossRefGoogle Scholar
  56. 56.
    Troxel SA, et al. Physiologic effect of nifedipine and tamsulosin on contractility of distal ureter. J Endourol. 2006;20(8):565–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Ames CD, et al. Pharmacologic manipulation of the porcine ureter: Acute impact of topical drugs on ureteral diameter and peristaltic activity. J Endourol. 2006;20(11):943–8.PubMedCrossRefGoogle Scholar
  58. 58.
    Borghi L, et al. Nifedipine and methylprednisolone in facilitating ureteral stone passage: a randomized, double-blind, placebo-controlled study. J Urol. 1994;152(4):1095–8.PubMedGoogle Scholar
  59. 59.
    Porpiglia F, et al. Corticosteroids and tamsulosin in the medical expulsive therapy for symptomatic distal ureter stones: single drug or association? Eur Urol. 2006;50(2):339–44.PubMedCrossRefGoogle Scholar
  60. 60.
    Becker AJ, et al. The effect of the specific phosphodiesterase-IV-inhibitor rolipram on the ureteral peristalsis of the rabbit in vitro and in vivo. J Urol. 1998;160(3 Pt 1):920–5.PubMedGoogle Scholar
  61. 61.
    Gratzke C, et al. In vitro effects of PDE5 inhibitors sildenafil, vardenafil and tadalafil on isolated human ureteral smooth muscle: a basic research approach. Urol Res. 2007;35(1):49–54.PubMedCrossRefGoogle Scholar
  62. 62.
    Bandi G, et al. Third prize: Effect of hydrocortisone on porcine ureteral contractility in vitro. J Endourol. 2008;22(6):1169–73.PubMedCrossRefGoogle Scholar
  63. 63.
    Nakada SY, et al. Selective cyclooxygenase-2 ­inhibitors reduce ureteral contraction in vitro: a better alternative for renal colic? J Urol. 2000;163(2):607–12.PubMedCrossRefGoogle Scholar
  64. 64.
    Wen CC, et al. Ketorolac effectively inhibits ureteral contractility in vitro. J Endourol. 2008;22(4):739–42.PubMedCrossRefGoogle Scholar
  65. 65.
    Chaignat V, et al. Effects of a non-selective COX inhibitor and selective COX-2 inhibitors on contractility of human and porcine ureters in vitro and in vivo. Br J Pharmacol. 2008;154(6):1297–307.PubMedCrossRefGoogle Scholar
  66. 66.
    Lee SY, et al. NS-398 (a selective cyclooxygenase-2 inhibitor) decreases agonist-induced contraction of the human ureter via calcium channel inhibition. J Endourol. 2010;24(11):1863–8.PubMedCrossRefGoogle Scholar
  67. 67.
    Krambeck AE, et al. A novel drug eluting ureteral stent: a prospective, randomized, multicenter clinical trial to evaluate the safety and effectiveness of a ketorolac loaded ureteral stent. J Urol. 2010;183(3):1037–42.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Zachariah G. Goldsmith
    • 1
  • Michael E. Lipkin
    • 1
  • Glenn M. Preminger
    • 1
    Email author
  1. 1.Division of Urologic Surgery, Surgery DepartmentDuke University Medical CenterDurhamUSA

Personalised recommendations