## Clinical Context This patient presents with classic acute ureteric colic: flank pain, hematuria, and imaging confirmation of a small ureteric stone with proximal obstruction. The stone is 6 mm, which is below the threshold for spontaneous passage difficulty. ## Management Algorithm for Ureteric Stones ```mermaid flowchart TD A[Ureteric stone on NCCT]:::outcome --> B{Stone size?}:::decision B -->|< 6 mm| C[Expectant management]:::action B -->|6-10 mm| D[Observe vs ESWL]:::action B -->|> 10 mm| E[ESWL or URS]:::action C --> F[Analgesics, hydration, strain urine]:::action F --> G[Repeat imaging at 4-6 weeks]:::action G -->|Passed| H[Success]:::outcome G -->|Persisted| I[Consider ESWL/URS]:::action D --> J{Symptoms controlled?}:::decision J -->|Yes| K[Observe with follow-up]:::action J -->|No| L[ESWL or URS]:::action ``` ## Key Point: **Stones < 6 mm have ~90% spontaneous passage rate within 4–6 weeks.** Conservative management with hydration, analgesia, and follow-up imaging is the standard of care for uncomplicated cases with normal renal function and no signs of infection. ## High-Yield: The decision to intervene (ESWL/URS) is based on: - Stone size > 6–10 mm - Uncontrolled pain - Recurrent obstruction - Infection (pyonephrosis) - Solitary kidney - Pregnancy This patient has normal renal function, controlled symptoms on analgesics, and a small stone—all favoring expectant management. ## Clinical Pearl: **NCCT (non-contrast CT) is the gold standard for diagnosis** because it detects radiolucent stones missed on plain radiography and provides stone size, location, and degree of obstruction—all critical for triage. ## Warning: **Do NOT rush to intervention for small stones in uncomplicated cases.** Unnecessary ESWL or URS increases morbidity (ureteric stricture, residual fragments, infection) without improving outcomes for stones likely to pass spontaneously. [cite:Harrison 21e Ch 282] 
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