A 32-year-old man from Delhi presents to the emergency department with acute left flank pain radiating to the groin and haematuria. Non-contrast CT (NCCT) abdomen shows a 6 mm stone in the left ureter at the level of the pelvic brim. Renal function is normal, and there is no fever. What is the most appropriate immediate management?

Explanation

## Clinical Context This patient presents with acute ureteric colic secondary to a small ureteric stone (6 mm) with preserved renal function and no signs of infection or obstruction-related complications. ## Management Principles for Ureteric Stones **Key Point:** Small ureteric stones (<6 mm) have a high spontaneous passage rate (80–90% within 4–6 weeks), especially when located in the distal ureter at the pelvic brim. **High-Yield:** The decision to intervene surgically or endoscopically depends on: - Stone size (< 6 mm vs 6–10 mm vs > 10 mm) - Stone location (proximal, mid, distal ureter) - Presence of infection, renal impairment, or uncontrolled pain - Duration of obstruction ## Recommended Approach | Factor | Finding | Implication | |--------|---------|-------------| | Stone size | 6 mm | High spontaneous passage rate | | Location | Pelvic brim (distal) | Favours spontaneous passage | | Renal function | Normal | No urgent decompression needed | | Fever/sepsis | Absent | No obstructive uropathy | | Pain control | Manageable | Allows conservative approach | **Clinical Pearl:** Distal ureteric stones have a better prognosis for spontaneous passage than proximal stones because the distal ureter is wider and less muscular. **Tip:** Conservative management (watchful waiting) is the standard of care for uncomplicated small ureteric stones. Intervention is reserved for: - Uncontrolled pain despite analgesia - Fever with obstruction (obstructive uropathy) - Renal impairment (creatinine rise) - Failure to pass after 4–6 weeks - Solitary kidney ## Why Conservative Management Is Correct 1. **Stone size and location favour passage:** 6 mm stone at pelvic brim has >80% chance of spontaneous passage. 2. **No complications present:** No fever, no renal dysfunction, pain is manageable. 3. **Cost-effective and safe:** Avoids unnecessary intervention and procedural morbidity. 4. **Standard guideline recommendation:** EAU, AUA, and Indian guidelines recommend conservative management for uncomplicated small stones. **Mnemonic: WAIT (When to Avoid Intervention in Stones)** — Uncomplicated, small, distal, no renal impairment, no fever → Wait and observe.