EAU · 2026

Renal Colic (Urolithiasis) — Management Guideline

Source: EAU Guidelines on Urolithiasis, European Association of Urology, 2026 edition

✓ Edition checked 3 Oct 2026 — EAU 2026 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Suspected based on acute flank pain radiating to the groin, often with nausea/vomiting and hematuria; confirmed by imaging showing a ureteral or renal stone. Non-contrast CT is the gold standard for diagnosing acute flank pain and has replaced intravenous urography.

⚠ Alarm features (investigate before diagnosing)

Fever or signs of infection (an obstructed, infected kidney is a urological emergency)
Solitary or transplanted kidney with obstruction
Bilateral obstruction or anuria
Uncontrolled pain despite analgesia
Significant deterioration in renal function

Initial workup

Test	When to order
Ultrasound	Primary diagnostic imaging tool (avoids radiation); pain relief or any other emergency measure should not be delayed by imaging.
Immediate imaging	Indicated with fever or a solitary kidney, and when the diagnosis is uncertain.
Non-contrast CT	To confirm the stone diagnosis in patients with acute flank pain following the initial ultrasound assessment.
Urine dipstick (red cells, white cells, nitrites, pH) with microscopy and/or culture	In emergency stone patients; obtain a urine culture or microscopy before any treatment is planned.
Serum creatinine, uric acid, ionised calcium, sodium, potassium, blood count, and CRP	In emergency stone patients; the metabolic risk evaluation follows after the acute episode.
Coagulation tests (PTT and INR)	If an intervention is likely or planned.
Imaging in pregnancy	Ultrasound is preferred; MRI is second-line, and low-dose CT is a last-line option.

✕ Tests the guideline advises against

Kidney-ureter-bladder (KUB) urography when non-contrast CT is being considered: EAU states that KUB should not be performed if non-contrast CT is being considered.

Treatment

Acute pain management

1 NSAID (e.g., diclofenac; ibuprofen or metamizole are alternatives) Strong (Guideline recommendation) — first drug of choice, depending on cardiovascular risk factors and side effects

Dose: Diclofenac sodium 100-150 mg/day (oral or suppository, in divided doses); IM dosing may be used for immediate acute pain relief in the emergency setting
Duration: As needed for the acute episode; 3-10 days for stones expected to pass spontaneously
Evidence level: High
Avoid if: Significant renal impairment, active GI bleeding, cardiovascular disease (diclofenac only after careful consideration in patients with significant cardiovascular risk factors)
If no response ClinicoQ pathway: Add an opioid if pain remains uncontrolled; avoid pethidine specifically if an opioid is needed

2 Paracetamol Guideline-supported option — effective in acute stone colic, with NSAIDs preferred as first drug of choice

Dose: Per product labeling
Duration: As needed for the acute episode
Evidence level: Moderate
Avoid if: Liver disease; known hypersensitivity
If no response ClinicoQ pathway: Add or switch to an NSAID if not contraindicated, or to an opioid

3 Opioid (hydromorphone, pentazocine, or tramadol) or ketamine, as a second choice Weak (Guideline recommendation) — second choice after NSAIDs

Dose: Per product labeling
Duration: Short-term, in the acute setting
Evidence level: Low
Avoid if: Pethidine: guideline advises against it as the opioid (high rate of vomiting and more further analgesia needed)
If no response: Renal decompression (stent or percutaneous nephrostomy) or ureteroscopic stone removal for analgesia-refractory colic

Facilitating stone passage (observation and medical expulsive therapy)

1 Observation with periodic evaluation Strong (Guideline recommendation) — for newly diagnosed small ureteral stones when active removal is not indicated and the patient is informed

Dose: —
Duration: Until passage, or until a complication or an indication for removal arises
Evidence level: Moderate
Avoid if: Infection, refractory pain, or deterioration of renal function
If no response ClinicoQ pathway: Offer an alpha-blocker as medical expulsive therapy for distal ureteral stones larger than 5 mm

2 Alpha-blocker as medical expulsive therapy (e.g., tamsulosin), off-label Strong (Guideline recommendation, 2026) — one of the treatment options for distal ureteral stones larger than 5 mm; off-label indication

Dose: e.g., tamsulosin 0.4 mg once daily
Duration: Until stone passage or until active treatment is chosen
Evidence level: Conflicting overall (some advantage for distal ureteral stones larger than 5 mm)
Avoid if: Symptomatic hypotension; known hypersensitivity
If no response: Active stone removal if pain persists despite analgesia, obstruction persists, renal function is impaired, or spontaneous passage is unlikely

Obstructed infected kidney / anuria (urological emergency)

1 Urgent decompression of the collecting system (percutaneous drainage or ureteral stenting) Strong (Guideline recommendation) — in sepsis with an obstructing stone

Dose: —
Duration: Urgent
Evidence level: High
Avoid if: —
If no response: Start antibiotics immediately (with intensive care if necessary), collect urine for antibiogram after decompression, re-evaluate the antibiotic regimen, and delay definitive stone treatment until sepsis is resolved

Active stone removal for ureteral stones (when indicated)

1 Ureteral stone larger than 10 mm: ureteroscopy first-line, shock wave lithotripsy second Strong (Guideline recommendation) — indications: low likelihood of spontaneous passage, persistent pain despite analgesia, persistent obstruction, or renal insufficiency. Inform patients that ureteroscopy more often achieves stone-free status in a single procedure but has higher complication rates than shock wave lithotripsy; use ureteroscopy first-line in morbid obesity

Dose: —
Duration: Elective, after sepsis and infection are excluded or treated
Evidence level: High
Avoid if: Untreated urinary tract infection; shock wave lithotripsy is contraindicated in pregnancy, uncorrected bleeding disorders, and distal anatomical obstruction

2 Ureteral stone smaller than 10 mm: shock wave lithotripsy or ureteroscopy Guideline treatment algorithm (EAU, proximal and distal ureteral stones)

Dose: —
Duration: Elective
Evidence level: High
Avoid if: Same as above

Pregnancy

1 Conservative management of uncomplicated stones Strong (Guideline recommendation)

Dose: —
Duration: Until passage, unless a clinical indication for intervention arises
Evidence level: Moderate
Avoid if: —
If no response: If intervention is needed, ureteral stent or percutaneous nephrostomy are the readily available primary options; ureteroscopy is a reasonable alternative to avoid long-term drainage

✕ Treatments the guideline advises against

Pethidine (as the opioid of choice): If an opioid is needed, EAU recommends that it not be pethidine — it is associated with a high rate of vomiting compared with NSAIDs and a greater likelihood of further analgesia being needed.

Definitive stone treatment while sepsis from an obstructing stone is unresolved: EAU strongly recommends decompressing first and delaying definitive stone treatment until sepsis is resolved.

Routine antibiotic prophylaxis before shock wave lithotripsy in patients with sterile urine: EAU strongly recommends against it; prescribe prophylaxis only for suspected or diagnosed infected stones or bacteriuria.

Routine ureteral stent after uncomplicated ureteroscopy: EAU strongly recommends not inserting a stent in uncomplicated cases.

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.