Strategies For Managing Stent Discomfort-2-2

STRATEGIES FOR
MANAGING STENT
DISCOMFORT
Dr. Zulfikar Ali, SpU
HISTORY
• Gustav Simon described the first case of ureteral stenting

during open cystostomy in the 1900s
• Yoaquin Albarann (1900)  created the first ureteral
stent
• Zimskind (1967)  silicone rubber ureteral splint
inserted cystocopically
• Finney (1978)  1st DJ stent (solved migration problem)
• Nowadays  overused in practice  2/3 urologist place
a stent more than 50%
Miyaoka R, Monga M. Ureteral stent discomfort: Etiology and management. Indian J Urol 2009;25:455-60.
Pansota MS, Rasool M, Saleem MS, Tabassum SA, Hussain A. Indications and complications of double j ureteral
stenting: our experience. Gomal J Med Sci 2013; 11:8-12.
CURRENT INDIC ATION
Urgent Safety related Relative
• Obstructive • Ureteral edema • Stone burden > 2

pyelonephritis • Ureteral cm, before ESWL
• Intolerable acute perforation • Preggnancy
renal colic • Steintrasse • Long standing
• Renal failure • Previous history impacted stone
secondary to of renal failure • History of UTI or
ureteral • Solitary kidney sepsis
obstruction • Passive dilatation
• Transplant kidney
• Prolonged
endoscopic
operative time
• Patients with
imminent post
operative plants
(2nd look)
IDEAL STENT
Easy to insert
Ability to relieve intra & extra luminal obstruction
Excellent flow characteristic
Resistent to encrustation & infection
Chemically stable in urinary environment
Doesn’t induced symptoms

Tailly T, Denstedt JD. Fundamentals of urinary tract drainage in: Campbell-Walsh Urology. Ed 11 Vol 4. 2016: 119-135
STENT RELATED SYMPTOMS
• Stent-associated symptoms can have a significant impact on patient

quality of life.
• Joshi and colleagues reported quality of life to be influenced in 80% of

stented patients.
• From an economic perspective, 58% of patients had reduced work
capacity because of stent discomfort, and approximately half of the
patients had sought medical professional help for stent-related
symptoms
• prospective cohort study reported that approximately one third of

patients required early removal of ureteral stents because of stent
discomfort (Ringel et al, 2000).
• Sexual dysfunction has been reported in 42% to 82% of male patients

and 30% to 86% of female patients with an indwelling ureteral stent
(Joshi et al, 2003b; Leibovici et al, 2005; Sighinolfi et al, 2007).
SYMPTOMS
Hematuria 25%
“Similar to BPH & OAB”
Suprapubic
pain 30%
Flank pain 19-32%
Incomplete
emptying 76%
Dysuria 40%
Urgency 57-60%
Frequency 50-60%
PATOPHYSIOLOGY 
UNCERTAIN
• Mechanical stimulus
Urgency • Usually at the end of
Flank Pain
from bladder coil voiding
• Relates to physical • Direct results of the • Secondary to trigonal • Results of urine reflux
activities presence of stent irritation by the distal  ↑ Intrapelvic
• May exacerbate end of stent pressure
• Awareness of
stimulation preexisting detrusor
overactivity
Frequency Dysuria
PATOPHYSIOLOGY
Hematuria
• Local bladder • Stent migration:
irritation by distal bladder neck 
coil • Surgical procedure proximal urethra
• 2nd sign of • Stent placement
complication
Suprapubic
Incontinence
pain
ASSESSMENT TOOLS
USSQ
VAS
QoL IPSS
IPSS
Zhou L, Cai X, Li H, Wang KJ. Effects of a-Blockers, Antimuscarinics, or Combination Therapy in Relieving Ureteral Stent-Related
Symptoms: A Meta-Analysis . J Endourol 2015; 29(6): 650-6.
Maldonado-Avila M, Garduno-Artega L, Jungfermann-Guzman R, Manzanila-Garcia HA, Rosas-Nava E, Procuna-Hernandez N, Vela-
Mollinedo A, Almazan-Trevino L, Guzman-Esquivel J. Efficacy of Tamsulosin, Oxybutynin, and their combination in the control of double-
j stent-related lower urinary tract symptoms. Int Braz J Urol 2016; 42: 487-93
ASSESSMENT TOOLS
• The objective evaluation of stent-related symptoms through

the visual analog scale (VAS) and the International Prostate
Symptom Score (IPSS) is complex and nonspecific
• Joshi et al. developed the ureteral stent symptoms ques-
tionnaire (USSQ) , which is a validated and safe psychometric
instrument for evaluating the impact of ureteral stents on
symptoms and quality of life.
• This questionnaire explores 6 areas that include urinary
symptoms, body pain, general health status, work
performance, sexual matters, and other additional problems
• It has been utilized in numerous clinical trials and translated
into different languages, including Spanish
Maldonado-Avila M, Garduno-Artega L, Jungfermann-Guzman R, Manzanila-Garcia HA, Rosas-Nava E, Procuna-Hernandez N, Vela-

Mollinedo A, Almazan-Trevino L, Guzman-Esquivel J. Efficacy of Tamsulosin, Oxybutynin, and their combination in the control of
double-j stent-related lower urinary tract symptoms. Int Braz J Urol 2016; 42: 487-93
ASSESSMENT TOOLS
• USSQ index, total IPSS, QoL score of IPSS,Visual Analogue

Pain Scale (VAPS) were used for quantitative analysis:
• The USSQ is divided into six index areas: Urinary symptoms (11
questions), body pain (six questions), general health (six
questions), work performance (seven questions), and sexual
performance (four questions). Each question has a score giving a
total score for each index.
• The IPSS was divided into the total score, obstructive symptom
score, and storage symptom score.
• The VAPS grade from 1 (minimal or no symptoms) to 10
(symptoms of maximal severity)
Symptoms: A Meta-Analysis . J Endourol 2015; 29(6): 650-6.
STRATEGIES
Prevention
• Precise indication
• Minimize stenting dwelling time
• Prestenting maneuvers
• Stent length & size
• Position
• Stent coating
Management
• Pharmacology
PRECISE INDIC ATION
• “preventing as the best treatment”
• If you had to placed ureteral stent, make sure to:
MINIMIZE THE DWELLING TIME
PRESTENTING MANEUVERS
• Periureteral anesthetic injection

• Single blinded, 22 patients, 50 mg ropivacaine  no significant
changes in postoperative pain, voiding symptoms, narcotics
requirement
POSITION
• Crossing midline
• Italian study  urinary symptoms, body pain, general health, work
performance, sexual matters worsened at 1 & 4 weeks
• Multivariate analysis  crossing the midline of the distal end
were significantly associated with stent-related symptoms after
URSL
• Proximal loop positioning not correlated with pain
Ho CH, Tai HC, Chang HC, Hu FC, Chen SC, Lee YJ, Chen J, Huang KH. Predictive Factors for Ureteral Double-J-Stent-Related
Symptoms: A Prospective, Multivariate Analysis. J Formos Med Assoc 2010;109(11):848–856
Walker NAF, Bultitude MF, Brislane K, Thomas K, Glass JM. Management of stent symptoms: what a pain. BJU Int 2014; 116 : 797-8
STENT LENGTH
• Length of stent correlate to position of ureteral stent  whether

crossing the midline or not  so it also effect the symptoms
• Several study try to find how to measure the ureteral length:
Author Formula
Ho, et al 22-cm stent for patients 149.5-178.5 cm
Hao, et al Length = 0.125 x body height + 0.5 cm
Vertical distance: 2nd lumbar to pubic symphysis minus 2 cm
Palmer, et al Pediatric  (stent length = patient ages [years] + 10)
Hruby, et al Xyphoid process to pubic symphysis distance or
Acromium process to head of ulna
Ho CH, Tai HC, Chang HC, Hu FC, Chen SC, Lee YJ, Chen J, Huang KH. Predictive Factors for Ureteral Double-J-Stent-Related
Symptoms: A Prospective, Multivariate Analysis. J Formos Med Assoc 2010;109(11):848–856
METHODS TO MEASURE
URETERAL LENGHT
Patient height:
• shorter than 5
feet 10 inches
 22-cm stent;
Using ureteral • 5 feet 10 inches Intravenous
to 6 feet 4 CT scan
cateter (5Fr) inches  24-cm pyelography
stent;
• taller than 6 feet
4 inches, 26-cm
stent
STENT SIZE
• Erturk et al
• compared 4,7 Fr & 6 Fr
• no significant difference on symptoms
• smaller one are more likely to migrate & dislodge
Erturk E, Sessions A, Joseph JV. Impact of Ureteral Stent Diameter on Symptoms and Tolerability. J Endourol 2003; 17(2): 59-63
STENT COATING
• Decrease bacterial growth of artificially

Triclosan loaded infected urine with proteus mirabilis
• Preventing adherence to biofilm
Oxalate • Watterson Study in rabbit  21% &

degrading 40% reduction in dry weight & calcium
enzyme of encrustation
• Riedl study  during 6 week, effective
inhibition of biofilm & encrustation
Heparin
STENT COATING
Silver nitrate • Multanen, et al  less tissue reaction and prevent

+ ofloxacine biofilm & encrustation formation
Hydrophilic • Coated at distal loop  decrease coefficients of

friction
hydrogel • Joshi, et al  no difference between hard and soft

stent
Ketorolac • Less painkillers in younger patients on days 3-4
PHARMACOLOGY
• Beiko, et al  Trial on 42
patients receive ketorolac,
Intravesical alkalinized lidocaine, or

oxybutynin
•  Ketorolac decrease in
Instillation irritative symptoms 1 hour after
intervention
ALPHA BLOCKER
• Alpha-blockers reduce the morbidity of ureteral stents and

increase tolerability
• An alpha blocker can reduce stent related symptoms and

colic episodes ( LE 1b)
EAU Guidelines 2017

ALPHA BLOCKER - ALFUZOSIN
Deliviolities, et al Beddingfield, et al Park, et al.
• RCT using QOL & • RCT in 55 patients • Compare alfuzosin

USSQ  patients compare with with 4 mg
underwent stenting placebo  improve tolterodine ER &
due to stone related sleep interrupted by placebo  Both
hydronephrosis given pain frequency of alfuzosin &
1 x 10 mg for 4 painkilller, pain tolterodine improve
weeks  decrease interfering with life, pain & urinary
in mean urinary flank pain associated symptom
symptom (p<0,001), micturition
frequency related
pain (p= 0,027),
improve general
health (p <0,001)
ALPHA BLOCKER - TAMSULOSIN
Damiano, et, al
• decrease flank pain & urinary
symptoms at 1 week &
increase general health index
ANTICHOLINERGIC -
TOLTERODINE
Park et al.
• Tolterodine showed improvement in
urinary symptoms and pain compared
with placebo. When compared to
alfuzosin, no significant difference,
Neither drug have effect on general
health, work or sexual performance
COMBINATION
• Abdelkader et al:
• Combination Tamsulosin + tolterodine significantly improve
post-URS lower urinary tract symptoms secondary to ureteral
stents compared to either agent alone
• Zhou, et al:
• Meta analysis study show combination therapy of a-blocker
(Tamsulosin/alfuzosin) and antimuscarinic (tolterodine) have
significant advantages compared with a-blocker monotherapy
• Combination therapy improve voiding & storage
symptoms
Abdelkader O, Mohyeldenb K , Sherif MH, Metwalya AH, Aldaqadossi H, Shelbayac A, Khairy H, Elnashar A.. Impact of
Tamsulosin, Tolterodine and drug-combination on the outcomes of lower urinary tract symptoms secondary to post
ureteroscopy ureteral stent: A prospective randomized controlled clinical study. Afr J Urol 2017; 23: 28–32
Symptoms: A Meta-Analysis. J Endorurol 2015: 29 (6): 650-6
PHENAZOPYRIDINE
Norris et al
• compare with ER
oxybutynin & placebo in 60
patients  no significant
different of symptoms score
Norris RD, Sur RL, Springhart WP, Marguet CG, Mathias BJ, Pietrow PK, Albala DM, Preminger GM. A prospective,
randomized, double-blinded placebo-controlled comparison of extended release oxybutynin versus phenazopyridine for
the management of postoperative ureteral stent discomfort. J Urol 2008; 71:792-5
MATERIAL AND METHODS
o Prospective, Single blind

Randomized clinical trial 39 patients assessed for
eligibility
o From July 2016 to October 2016 in
Kardinah Hospital, Tegal, Central Java
8 patients were
o The exclusion criteria included : excluded
1 patient declined to
participate
 History of pelvic or gynecologic surgery
 History transurethral resection of the
prostate or a bladder tumor 10 patients 10 patients for
assigned to 10 patients control
 Chronic consumption of alpha-blocker receive
Tamsulosin 1 x assigned to receive
and/or anticholinergic 0,2mg Propiverine HCL 1
x 15mg
 Recent or recurrent urinary tract
infection
 Benign prostate hyperplasia, prostatitis, 10 patients 10 patients 10 patients
analyzed analyzed analyzed
prostate cancer, bladder outlet
obstruction.
 Diabetes and pregnancy.
RESULTS
Table 1 - Basic and clinical characteristics of the study.
Group 1 Group 2 Group 3 P
Age 49,90 ± 5,48 46,11 ± 11,30 53,12 ± 11,71 0,305
Male 5 (16,7%) 3 (10%) 8 (26,7%) 0,079
Stone place 0,185
 Pyelum 5 (16,7%) 6 (20%) 2 (6,7%)

 Upper ureter 4 (13,3%) 1 (3,3% 2 (6,7%)
 Lower ureter 1 (3.3%) 3 (10%) 6 (20%)
Surgery type 0,386

 Pyelolitotomy 5 (16,7%) 5 (16,7%) 2 (6,7%)
 Ureterolitotomy 2 (6,7%) 3 (10%) 2 (6,7%)
 URS 3 (10%) 2 (6,7 %) 6 (20%)
TABL E -
URINARY
SYMPTOMS, PAIN Group 1 Group 2 Group 3 P
AND QOL AMONG Total IPSS score
THE GROUPS. Baseline 6,30 ± 0,95 5,50 ± 0,97 6,10 ± 1,20 0,223
Removal time 3,70 ± 0,82 3,80 ± 1,34 5,00 ± 1,25 0,046
Irritative subscore
Baseline 4,30 ± 0,78 3,90 ± 0,32 4,10 ± 0,99 0,321
Removal time 2,40 ± 0,48 2,80 ± 0,92 3,20 ± 1,40 0,042
Flank pain
Baseline 3,40 ± 0,97 3,90 ± 0,32 3,60 ± 0,84 0,351
Removal time 1,30 ± 0,48 1,50 ± 0,71 2,20 ± 0,92 0,062
Suprapubic pain
Baseline 2,70 ± 0,39 2,80 ± 0,42 2,90 ± 0,97 0,556

Removal time 1,80 ± 0,31 1,70 ± 0,42 1,90 ± 0,74 0,017
Voiding pain
Baseline 2,60 ± 0,42 2,50 ± 0,53 2,80 ± 0,42 0,259
Removal time 1,30 ± 0,32 1,10 ± 0,35 2,50 ± 0,85 0,014
Quality of life
Baseline 3,10 ± 0,32 3,20 ± 0,42 3,60 ± 0,70 0,083
Removal time 1,70 ± 0,52 1,82 ± 0,63 2,70 ± 0,74 0,013
RESULTS
IPSS among the groups

IPSS
10 1,2
9
Mean difference
1
8
2,6 ± 0,13
7
1,7 ± 0,37 0,8
6
1,1 ± 0,05
5 0,6
4
P = 0,046 0,4
3
2
0,2
1
0 0
Alpha blocker Anti muskarinik Kontrol
Baseline Removal time
• Precise indication in order to
prevent unnecessary ureteral
stent
• If you had to placed, make sure
TAKE HOME NOTE to minimize the indwelling time
• Choose the appropriate length
of stent so the distal loop won’t
crossed the midline
• If the voiding symptoms  give
alpha blocker
• If the voiding & storage 
combination with anticholinergic

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STRATEGIES FOR

• Gustav Simon described the first case of ureteral stenting

Urgent Safety related Relative

• Obstructive • Ureteral edema • Stone burden > 2

Ability to relieve intra & extra luminal obstruction

Excellent flow characteristic

Resistent to encrustation & infection

Chemically stable in urinary environment

Doesn’t induced symptoms

• Stent-associated symptoms can have a significant impact on patient

• Joshi and colleagues reported quality of life to be influenced in 80% of

• prospective cohort study reported that approximately one third of

• Sexual dysfunction has been reported in 42% to 82% of male patients

Flank pain 19-32%

• The objective evaluation of stent-related symptoms through

Maldonado-Avila M, Garduno-Artega L, Jungfermann-Guzman R, Manzanila-Garcia HA, Rosas-Nava E, Procuna-Hernandez N, Vela-

• USSQ index, total IPSS, QoL score of IPSS,Visual Analogue

• “preventing as the best treatment”

• If you had to placed ureteral stent, make sure to:

MINIMIZE THE DWELLING TIME

• Periureteral anesthetic injection

• Length of stent correlate to position of ureteral stent  whether

• Several study try to find how to measure the ureteral length:

• Decrease bacterial growth of artificially

Oxalate • Watterson Study in rabbit  21% &

Silver nitrate • Multanen, et al  less tissue reaction and prevent

Hydrophilic • Coated at distal loop  decrease coefficients of

hydrogel • Joshi, et al  no difference between hard and soft

Ketorolac • Less painkillers in younger patients on days 3-4

Intravesical alkalinized lidocaine, or

• Alpha-blockers reduce the morbidity of ureteral stents and

• An alpha blocker can reduce stent related symptoms and

EAU Guidelines 2017

Deliviolities, et al Beddingfield, et al Park, et al.

• RCT using QOL & • RCT in 55 patients • Compare alfuzosin

o Prospective, Single blind

Group 1 Group 2 Group 3 P

Age 49,90 ± 5,48 46,11 ± 11,30 53,12 ± 11,71 0,305

Male 5 (16,7%) 3 (10%) 8 (26,7%) 0,079

Stone place 0,185

 Pyelum 5 (16,7%) 6 (20%) 2 (6,7%)

Surgery type 0,386

Baseline 2,70 ± 0,39 2,80 ± 0,42 2,90 ± 0,97 0,556

IPSS among the groups

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