The purpose of this article is to review the effects of different types of pharmacotherapy on symptoms that affect the quality of a patient's life after stent insertion. A thorough Medline/PubMed nonsystematic review was conducted from 1987 to January 2023, using the terms: “pigtail” OR “ureteral stents” AND “lower urinary tracts symptoms” OR “LUTS” AND “pharmacotherapy” OR “drugs”. Relevant studies conducted in humans and reported in English language were included. The available reviews and articles associating the use of drugs with stent-related symptoms (SRS) provide conflicting results. Most of them show a clear benefit of alpha blockers, particularly alfuzosin, on treating urinary SRS, and hence there is a strong recommendation for the use of alpha blockers for the treatment of SRS in the guidelines of the European Association of Urology. Anticholinergics and mirabegron have shown a significant benefit in dealing with irritative bladder symptoms. In contrast, the findings for combination therapies are contradictory, with some studies showing that combination therapy is no superior to monotherapy with regards to most of the subsets of the Ureteral Stent Symptom Questionnaire (USSQ), whereas others present a clear benefit of combination therapies, specifically silodosin and solifenacin, in treating stent-associated lower urinary tract symptoms (LUTS), in comparison with any other type of monotherapy or combination therapy. Many studies suggest that some categories of pharmacotherapy, such as alpha blockers, can alleviate SRS. However, there is conflicting evidence concerning most other types of medical treatment. Randomized trials with the largest number of patients are needed to investigate the effectiveness of novel approaches on SRS.

Ureteral stents have become an important part of urologic practice since Finney et al and Hepperlen et al first described the double-J stent and single-pigtail stent, respectively.^1-3 Ureteral stenting is used to prevent the obstruction of the kidney by residual stone fragments, edema, and hematoma, to avoid urine extravasation, and to relieve pain.^{4, 5}

Joshi et al report that 80% of patients with single-pigtail stents experience at least 1 bothersome urinary tract symptom.⁶ There is evidence that medical treatment can successfully deal with the symptoms related to pigtail stents. The scope of this article is to review the effectiveness of the available categories of medication on the treatment of stent-related symptoms (SRS).

Methods

In this non-systematic review, PubMed and MEDLINE databases were thoroughly searched from 1987 to January 2023, using the terms: “pigtail” OR “ureteral stents” AND “lower urinary tracts symptoms” OR “LUTS” AND “pharmacotherapy” OR “drugs”, and were screened independently by 1 author and rechecked by another 2 authors. Any disputes were solved by a fourth author.

From the studies screened, the original studies listed in Table 1 were used to conduct this review concerning the association between pharmacotherapy and SRS. Studies concerning animal models were excluded.

Table 1. Original Articles

Study/year	Type	Total sample	Stent characteristics	Questionnaire	Intervention	Results	Conclusions
Liu et al, 2016⁵	RCT	100	Bard Inlay, 4.7 Fr./26 cm	USSQ	After stent insertion, randomized into 4 groups receiving: (1) placebo (2) solifenacin (3) tamsulosin (4) combination	Superiority in all domains of combination therapy before day 4, but after that similar effect	Combination therapy takes effect faster but has no superiority
Joshi et al, 2002⁶	Prospective	48	Not mentioned	- 50% IPSS with questions on hematuria, dysuria, and loin pain - 50% ICS with frequency volume charts and uroflowmetry	Divided into 2 groups after pigtail placement and given questionnaire after insertion and 6 weeks after removal	80% reported urinary symptoms. ICS analysis showed storage symptoms, incontinence (60%), and bladder pain (80%)	Storage symptoms, bladder pain, and hematuria are the most bothersome symptoms. Development of USSQ
Deliveliotis et al, 2006⁷	RCT	100	Polyurethane, 5/26 or 5/28	USSQ	Patients with pigtails divided into 2 groups receiving: (1) 10 mg alfuzosin (2) placebo	Stent-related pain 44% in group 1 versus 66% in group 2. General health and sexual function better in group 1	Alfuzosin improves a subset of urinary symptoms and pain
Nazim et al, 2012⁸	RCT	130	Not mentioned	USSQ	After stent insertion, randomized into 2 groups receiving for 4 weeks: (1) alfuzosin (2) placebo	Fewer urinary symptoms and lower pain scores in group 1	Decreased bothersome urinary symptoms and decreased pain
Liu et al, 2015¹⁰	RCT	70	Not mentioned	IPSS, VAS	Patients with pigtail after RIRS received either alfuzocin or placebo, and had their urinary GAG measured at 1, 2, 3 weeks postoperatively	GAG excretion lower at 1, 2, and 3 weeks in group 1, compared with placebo group	Decreased urinary GAG after alfuzocin administration can be the key to the reduction of stent-associated LUTS
Mokhatri et al, 2011¹¹	RCT	73	Pigtail, 4.8 Fr.	USSQ, VAS, and hematuria	After stent insertion, randomized into 2 groups receiving for 4 weeks: (1) terazosin (2) placebo	Flank pain in 54.5% of group 1, as opposed to 100% of placebo patients	Frequency, nocturia, urgency, pain during voiding, and flank pain better in tamsulosin group
Park et al, 2009¹²	RCT	52	Polyurethane, 6 Fr./24–28 cm	USSQ	After stent insertion, randomized into 3 groups receiving for 6 weeks: (1) alfuzocin 10 mg (2) tolterodine 4 mg ER (3) placebo	No difference in urinary symptoms, pain levels, and other domains between tolterodine and alfuzocin	Alfuzocin and tolterodine improve LUTS and body pain
Wang et al, 2009¹³	RCT	146	Silicon, 7 Fr./26 cm	IPSS, VAS	After stent insertion, divided into 2 groups receiving for 2 weeks: (1) placebo (2) tamsulosin 0.4 mg	Group 2 with lower pain scores, frequency, urgency, and nocturia, as well as better QoL	Tamsulosin improves a subset of urinary symptoms, pain, and QoL
Wang et al, 2009¹⁴	RCT	154	Silicon, 7 Fr.	USSQ, IPSS	After stent insertion, divided into 2 groups receiving for 2 weeks: (1) placebo (2) tamsulosin 0.4 mg	Group 2 with better urinary symptoms, body pain, and general health in 1st week, but not during 4th week	Tamsulosin improves stent-related urinary symptoms and pain
Zhang et al, 2016¹⁵	RCT	239	Polymer, 6 Fr.	USSQ	After stent insertion, divided into 2 groups receiving: (1) placebo (2) doxazosin 4 mg	In stenting period lower frequency, nocturia, urgency, and pain in group 2. In post-stenting period, no differences between the 2 groups	Doxazosin positively affects urinary symptoms, pain, and QoL
Sahin et al, 2020¹⁶	RCT	120	28/4.7 Fr.	VAPS, OAB-q index, IPSS preoperatively and in 6 weeks	After stent insertion, randomized into 3 groups receiving for 6 weeks: (1) oral hydration (2) tamsulosin 0.4 mg and solifenacin 10 mg (3) mirabegron 50 mg	Group 2 had a lower incidence of LUTS, whereas irritative symptoms were better in group 3	OAB symptoms improved with mirabegron, whereas LUTS had a lower incidence in patients treated with tamsulosin and solifenacin in combination
Abdelhamid et al, 2013¹⁷	RCT	210	Not mentioned	USSQ	URS, 3 groups: (1) solifenacin 10 mg (2) trospium chloride 60 mg (3) placebo USSQ questionnaire	The overall symptom scores were better in group 1 compared with the other groups	Solifenacin recommended for SRS
Hekal et al, 2016¹⁸	RCT	200	Silicon, 6 Fr./24 cm	USSQ	Stents placed after uncomplicated URS and divided in 5 groups: (1) solifenacin 5 mg (2) trospium chloride, 20 mg (3) antispasmodic (4) alpha blocker (5) placebo	Less LUTS in group 1 and 2, significant nocturia in group 5, dry mouth in group 1. Less frequency in group 2 compared with group 1, whereas the other symptoms were better in group 1	Trospium chloride and solifenacin better at controlling LUTS, whereas anticholinergics are better at controlling frequency. An alpha blocker should be added when nocturia exists
Yavuz et al, 2020¹⁹	RCT	180	Polyurethane, 4.8 Fr.	USSQ	After stent insertion, divided into 3 groups receiving for 4 weeks: (1) placebo (2) tamsulosin 0.4 mg (3) mirabegron 50 mg	Analgesic requirements better in groups 2 and 3, whereas urinary symptoms better in group 2	Mirabegron and tamsulosin decrease the need for analgesics, whereas tamsulosin improves urinary symptoms
El- Nahas et al, 2015²⁰	RCT	131	Percuflex, 6 Fr.	USSQ	After stent placement, randomized in 3 groups each receiving: (1) solifenacin 5 mg (2) tamsulosin 0.4 mg (3) placebo	All USSQ domains, except sexual, were better with solifenacin than with tamsulosin	Solifenacin more effective in stent-related LUTS
Maldonado-Avila et al, 2016²¹	RCT	51	Polyurethane, 6 Fr./22 or 24 cm	USSQ	After stent insertion, randomized into 3 groups receiving: (1) tamsulosin (2) oxybutynin (3) combination	Mean urinary symptom index, mean work performance, and mean sexual scores better in group 3. No difference in pain scores and general health index	Combination therapy improves irritative symptoms as well as work and sexual health
Bhattar et al, 2018²²	RCT	335	Polyurethane, 6 Fr.	USSQ	After stent insertion, randomized into 8 groups receiving: (1) silodosin 8 mg, solifenacin 10 mg, and tadalafil 5 mg (2) silodosin 8 mg (3) solifenacin 10 mg (4) tadalafil 5 mg (5) silodosin 8 mg and solifenacin 10 mg (6) silodosin 8 mg and tadalafil 5 mg (7) solifenacin 10 mg and tadalafil 5 mg (8) placebo	Better USSQ in all domains in groups 1 to 7, compared with group 8. QoL and mean USSQ score better in group 5, with less analgesic requirement	Combination therapy with silodosin and solifenacin more effective than any other combination therapy or monotherapy in relieving SRS
Svalingam et al, 2016²³	RCT	80	Silicon	USSQ	After stent insertion, divided into 2 groups receiving: (1) tamsulosin 0.4 mg and tolterodine ER 4 mg (2) tamsulosin 0.4 mg and placebo	No difference in urinary symptoms, pain, or QoL. In both groups urinary symptoms were improved	Combination therapy is not more effective than tamsulosin monotherapy
Ragab et al, 2017²⁴	RCT	500	Not mentioned, length according to the formula L = 0.125 × body height in cm +0.5	USSQ	After stent insertion, randomized into 4 groups receiving: (1) solifenacin 5 mg and pregabalin 75 mg bid (2) solifenacin 5 mg (3) pregabalin 75 mg bid (4) placebo	Total USSQ and general health index lower in group 1 as compared with other groups. Urinary symptom index improved in groups 1 and 2. Pain symptom index lower in groups 1 and 3.	Pregabalin effective in reducing pigtail-related pain. Combination with solifenacin also improves the total USSQ scores and urinary symptoms
Gupta et al, 2010²⁵	RCT	51	Not mentioned	USSQ	Stents placed after uncomplicated URS and divided into 2 groups receiving: (1) injection of botulinum A toxin in 3 locations around the ureteral orifice in concentration of 10 U/mL (2) no injection	Decrease in postoperative pain score and need for analgesics in group 1, with no difference in LUTS	No improvement of irritative bladder symptoms
Kuyumcuoglu et al, 2012²⁶	RCT	108	Polyurethane, 4.8 Fr./26 or 28 cm	IPSS, QoL components of IPSS, OABq	After stent insertion, randomized into 5 groups receiving: (1) anti-inflammatory (2) spasmolytic (3) anticholinergic (4) alpha blocker (5) placebo	IPSS, IPSS-QoL, and OAB-q were increased in all groups	None of the medical therapy can prevent stent-associated LUTS
Lee et al, 2010²⁷	RCT	53	Percuflex, 6 Fr.	IPSS, VAS on 1st and 7th day	After stent insertion, randomized into 3 groups receiving: (1) analgesics (2) tamsulosin (3) tolterodine Also divided according to stent position: (1) appropriate (2)inappropriate	Storage symptoms in groups 2 and 3 on the 1st postoperative day for appropriate stent placement. No change in symptoms for inappropriate stent placement	Proper stent placement more important for LUTS than medication
Lee et al, 2013³⁴	Prospective	70	Polyurethane	USSQ 2 weeks postoperatively	Patients who underwent URS and pigtail placement received solifenacin	Lower urgency and urge incontinence, pain, and hematuria scores for solifenacin group	Lower stent-related LUTS, pain, and hematuria when receiving solifenacin

ER, extended release; Fr., French; GAG, glycosaminoglycans; ICS, International Continence Society; IPSS, International Prostate Symptom Score; IPSS-QoL, International Prostate Symptom Score – Quality of Life; LUTS, lower urinary tract symptoms; OAB, overactive bladder; OAB-q, Overactive Bladder Questionnaire; QoL, quality of life; USSQ, Ureteral Stent Symptom Questionnaire; VAS, visual analog scale.

Results

According to 8 original articles and 1 meta-analysis alpha blockers, especially alfuzosin, exert a positive influence on SRS in all domains.^{7-11, 13-15} Four of the studies refer to the effect of alfuzosin, 3 studies refer to the effect of terazosin, and 1 study refers to the effect of doxazosin. Two studies claim that patients receiving alfuzosin had lower urinary scores on the Ureteral Stent Symptom Questionnaire (USSQ) and experienced lower pain levels,^{7, 8} whereas the 3rd study indicates that alfuzosin has a positive effect on urinary symptoms, as depicted by the International Prostate Symptom Score (IPSS), and pain, as measured by visual analog scale (VAS), as well as diminished bladder inflammation, which was measured by the excretion of urinary glycosaminoglycans (GAG).¹⁰

The meta-analysis identified 5 studies that also agree with the results described above, and show reductions in other aspects of the USSQ, such as the general health score and sexual matters score, although those results were not statistically significant.⁹

One randomized study proved that terazosin can lower the IPSS score, VAS score, and lower flank pain by half in patients treated for stent symptoms.¹¹

Two studies explore the effect of terazosin on SRS, with the first study claiming that tamsulosin leads to lower VAS scores and diminished urgency, nocturia, and urinary frequency, as measured by IPSS. This study also quantifies the quality of life (QoL), showing that tamsulosin improves QoL.¹³ Another study shows that tamsulosin improves the USSQ domains, particularly urinary symptoms, body pain, general health, and work performance. However, it does not affect sexual performance.¹⁴

A randomized trial showed that patients who received doxazosin reported significant lower daytime frequency, nocturia, and urgency. Flank pain score and analgesic use were both significantly reduced, whereas the QoL score was improved.¹⁵

Anticholinergics were studied in 4 studies. However, in most of the studies they were either compared with alpha blockers or with beta-3 agonists. In 1 study, alfuzosin proved superior to tolterodine for the urinary symptom index of USSQ, as well as for pain, but not for the rest of the domains.¹² In contrast, another researcher seems to suggest that solifenacin is superior to tamsulosin, with the total USSQ being better for solifenacin, except for the sexual health index.²⁰ One study claims that solifenacin is superior to trospium chloride in controlling the symptoms attributed to pigtails,¹⁷ whereas another study suggests that they are equal in all urinary domains of USSQ.¹⁸

Some studies have explored the effects of a beta-3 agonist, namely mirabegron, on pigtail symptoms, where the patients that received mirabegron after pigtail insertion exhibited lower postoperative IPSS values and higher Overactive Bladder Questionnaire (OAB-q) values, compared with those who received a combination of tamsulosin and solifenacin,¹⁶ whereas another study proves that mirabegron and tamsulosin have similar adequacy for the relief of SRS and that patients on mirabegron had lower analgesic requirements.¹⁹

Regarding combination therapies, 1 study claims that they act faster on SRS than monotherapies and have a positive effect on almost all domains of the USSQ, except in the work and sexual domains, in patients receiving a combination of oxybutynin and tamsulosin, compared with patients that received only tamsulosin.²¹

However, 1 study shows that combination therapy with silodosin and solifenacin is more effective than any other combination therapy or monotherapy in relieving SRS, and even pain, with patients reporting better QoL scores.²²

In contrast, another study claims that combination therapies are not more effective than monotherapies in relieving SRS, demonstrating that patients that received monotherapy with tamsulosin and patients that received a combination therapy with tolterodine and tamsulosin for SRS had similar improvements in urinary symptoms.²³

Pregabalin was used in a study and showed that it could decrease pain levels in patients after urinary stent insertion. However, urinary symptoms were not greatly affected.²⁴

A novel approach of periureteral injection of botulinum toxin A that seems to have an effect on pain, but not urinary symptoms, has been reported.²⁵

Finally, contrary to all of these reports, 2 studies claim that no drug could possibly have an effect on SRS, and only the position of the pigtail plays an important role on symptoms.^{26, 27}

Discussion

There are many factors that cause SRS, such as trigonal and renal irritation by ureteral stents, vesicoureteral reflux through the stent, stent size, stent length, stent position, and stent materials,^{28, 29} whereas the principal sources of patient discomfort are a long intravesical segment, inefficient drainage, displacement, and stiffness of the ureteral stent.³⁰

Pain, lower urinary tract symptoms (LUTS), flank pain, body pain, hematuria, and fever are usually signs of early complications related to double-J stents.^{31, 3}

Possible late stent complications include stent migration, encrustation, stone formation, and fragmentation. Stent occlusion may be frequent and requires simple catheter exchange.³¹ Other complications include poor work performance and sexual dysfunction.²⁸

To assess ureteral SRS, Joshi et al described and validated the USSQ in 2003.⁶ This self-administered questionnaire includes questions in 6 sections: urinary symptoms, body pain, general health, work performance, sexual matters, and additional problems. The total score is the sum of the scores for all questions. This questionnaire can define and compare SRS,^{6, 33} and has been validated in different languages to standardize the ureteral SRS described in the literature.²⁸

The SRS are similar to those of the overactive bladder (OAB) and are thought to be mediated by muscarinic receptors, after bladder mucosal irritation.¹⁷ Others think that intramural ureter irritation is responsible for these symptoms.²⁵

Many studies have investigated the effect of various medications on SRS. The most prominent studies have investigated the effects of alpha blockers. According to Deliveliotis et al, patients had a lower mean urinary index score (21.6) when administered with alfuzosin, versus patients that received a placebo (P < .001). Pain was present in 44% of patients in group 1 versus 66% of patients of group 2 (P < .047). No statistical difference in sexual matters was found,⁷ with the same conclusion reported by Nazim et al.⁸

A recent meta-analysis proved that alpha blockers have a positive effect on stent-associated LUTS, including 5 studies that showed a reduction in USSQ urinary symptom score and body pain scores, with mean reductions of 8.4 (95%CI 5.6-11.1) and 7.2 (95%CI 2.5-11.8), respectively. There were also reductions in other aspects of the USSQ, such as the general health score and the sexual matters score, although these results were not statistically significant.⁹ This could result from the decreased excretion of GAG in those patients, which has a protective role against SRS, as evidenced by the improved IPSS score in patients receiving alfuzosin, according to Liu et al.¹⁰

According to Zhang et al, doxazosin alleviates pain and improves urinary symptoms and QoL. In particular, Zhang et al showed that patients who received doxazosin in the first 2 weeks, and then again in the second 2 weeks with the stent in situ, expressed significant lower daytime frequency (P = .028 and P = .038, respectively), nocturia (P = .021 and P = .008, respectively), and urgency (P = .012 and P = .014, respectively). Flank pain score, QoL score, and analgesic use were also significantly reduced in the stenting period, whereas those parameters did not differ during the post-stent period.¹⁵

According to Wang et al, tamsulosin improves most of the SRS, pain, and QoL in patients with a stent in situ.^{13, 14} The patients were divided into the placebo group (group 1) and the tamsulosin group (group 2). Analysis of the USSQ questionnaire at the end of the first week revealed a significant difference in the main score index of urinary symptoms, body pain, and general health between groups 1 and 2. When comparing the questionnaires in the first week and the fourth week after removal of the double-J stent, both groups showed significant worsening of urinary symptoms, body pain, general health, and work performance, except sexual performance. The mean score for QoL in IPSS was 4.21 in group 1 and 1.6 in group 2.¹⁴

Anticholinergics also seem to play a role in controlling SRS. According to Abdelhamid et al, patients with pigtail stents following uncomplicated ureteroscopy had lower symptoms in all of USSQ domains, including urgency, urge incontinence, flank pain, urethral pain, and gross hematuria, when administered solifenacin 10 mg, compared with patients who received trospium chloride or even placebo (P < .001). However, there was no difference in frequency and nocturia among the groups. The trospium chloride group had higher incidence of complications, especially constipation.¹⁷

In contrast, Hekal et al showed that there was a lower incidence of LUTS in groups receiving solifenacin and trospium chloride (groups A and B) (P < .05), whereas dry mouth was significantly reported in group A. Individual comparisons with the placebo group (group D) showed a non-significant difference with those receiving antispasmodics (group C), whereas those receiving alpha blockers (group E) had a significant improvement in nocturia. Selective comparison of the 2 best groups (A and B) showed less frequency in group B, whereas the other LUTS were less in group A. The side effects between those 2 groups were comparable.¹⁸

According to El- Nahas et al, solifenacin is superior to tamsulosin as pharmacotherapy for alleviating SRS, with the total USSQ scores being 61 in the solifenacin group, 76 in the tamsulosin group, and 83 in the placebo group (P < .001). The USSQ scores, except the sexual health index, were better in the solifenacin group (P < .05).²⁰

Park et al claimed that both alfuzosin and tolterodine have a beneficial effect on all USSQ domains. The mean urinary symptom index was 22.1 in patients receiving alfuzosin (group 1), 22.1 in patients receiving tolterodine (group 2), and 28.1 in the placebo group (P = .032). The mean pain scores were 8.2, 11.7, and 16.2, respectively (P = .020). There were no significant differences in urinary symptoms, general health, work performance, and sexual performance scores and pain between the first 2 groups.¹²

Beta-3 agonists were also studied for their effect on symptoms resulting from pigtail insertion and were compared with alpha blockers. Yavuz et al compared the effects of tamsulosin and mirabegron on urinary SRS and concluded that both have similar adequacy, also showing that analgesic usage was lower in the tamsulosin (5.1 ± 1.8) and mirabegron (4.5 ± 1.4) groups, compared with the placebo group (5.9 ± 2.1) (P < .001). The urinary symptoms score was lower in the tamsulosin group than in the control group (22.1 vs 27.8) (P = .001); however, the other scores were similar between the groups, indicating that mirabegron does not affect urinary symptoms, in contrast to tamsulosin.¹⁹

Some researchers have studied the effect of combination therapies on SRS. Liu et al have demonstrated that combination therapy with tamsulosin and solifenacin acts faster than monotherapies.⁵ However, Sivalingam et al have reported that combination therapy with tamsulosin and tolterodine is not more effective in alleviating SRS than tamsulosin monotherapy, showing that there was no significant difference in urinary symptoms, body pain, and activities of daily living (P = .95, .40, and .95, respectively). Both groups showed an improvement in urinary symptoms.²³

Maldonado-Avila et al showed that combination therapy with tamsulosin and oxybutynin decreases irritative symptoms and has a positive influence on sexual and work health, but does not affect pain and general health. The mean urinary symptom index score was 22.3 versus 15.5 in the group receiving the combination therapy of tamsulosin and oxybutynin (group 3) (P < .001) at days 7 and 21, respectively. The mean work performance index was 6.6 versus 8.1 (P = .049) favoring the tamsulosin group, and the mean sexual score was 0.5 versus 1.5 (P = .03). There was no difference in pain, general health index, and side effects between the groups.²¹

Sahin et al showed that OAB symptoms improved with mirabegron, whereas LUTS had a lower incidence in patients treated with a combination of tamsulosin and solifenacin. According to Sahin et al, there was no significant difference between the groups in terms of preoperative and postoperative pain values (P > .05). There was a significant difference in postoperative IPSSs values (P < .001), which was higher in the hydration group than in the tamsulosin/solifenacin and mirabegron groups (21.78 ± 2.54, 15.6 ± 4.37, and 13.65 ± 4.97, respectively). The OAB-q values in the tamsulosin/solifenacin group were significantly higher than in the mirabegron group and the hydration group (18.15 ± 4.1, 23.68 ± 4.07, and 29.95 ± 5.21, respectively) (P = .001 for both comparisons).¹⁶

Bhattar et al found the combination therapy with silodosin and solifenacin was more effective than any other combination therapy or monotherapy in relieving SRS. The USSQ score was similar in all groups after the first week, but groups A to G had a significant decrease in USSQ scores across all the domains compared with the placebo (group H) after the third week, thus requiring less analgesia. When the groups were compared with each other, silodosin and solifenacin groups (group E) were better in terms of mean USSQ scores, analgesic requirements, and QoL (P < .05).²²

Newer techniques or other types of medications have also been tested in some research on alleviating SRS. According to Ragab et al, pregabalin decreases the incidence of pigtail-associated pain and could have a positive impact on LUTS when combined with solifenacin. This article assesses the positive effect of pregabalin on SRS, particularly pain. In this research, the total USSQ score and the general health index was lower in the group receiving both pregabalin and solifenacin (group A), compared with other groups. The urinary symptom index was significantly improved in both group A and the group receiving only solifenacin (group B), compared with the group receiving only pregabalin (group C) and the control group (group D). The pain symptom index was significantly improved in both groups A and C, compared with groups B and D. However, no statistically significant differences were found in the sexual index and the work performance index among the cohorts.²⁴

A novel approach by Gupta et al, injecting botulinum toxin A in the periureteral region, has been shown to decrease the need for analgesics; however, this procedure does not seem to have an effect on the other urinary tract symptoms. There was a decrease in the reported postoperative pain score between the botulinum toxin type A and control group at 3.4 versus 6.0 (P = .02), as well as in the use of postoperative narcotics, with 7.7 pills consumed during an average of 2.7 days versus 24.7 during an average of 7.0 days in control patients (P = .03). There was no reported difference in the postoperative LUTS between the 2 groups.²⁵

Most of the articles study a population that received pharmacotherapy 2-4 weeks after stent placement. Not enough quantitative data were included in those articles for us to be able to draw a safe conclusion, and most of the analyses did not account for other parameters that could be responsible for LUTS, such as a possible co-existing urinary tract infection. Contrary to the belief that alpha blockers have a clear advantage in improving most urinary symptoms, and even though this pharmacotherapy seems to be beneficial to patients, as is evident in a multitude of articles, we still do not have a high level of evidence to draw safe conclusions for treatment of SRS with alpha blockers.

Conclusions

Pharmacotherapy seems to improve SRS, either as monotherapy or combination therapy. It seems that alpha blockers are the most effective therapy in alleviating SRS, with alfuzosin being the most studied drug. Following that, solifenacin has, according to most studies, positive effects in most of the USSQ domains. However, there seems to be contradictory evidence on the effect of different medical therapies. More research is needed to establish the effectiveness of different medical treatments in improving SRS. This research should include larger series of patients in randomized control trials using the USSQ questionnaire.

Conflicts of Interest

The article has been read and approved by all the authors, the requirements for authorship have been met, and each author believes that the article represents honest work.

Funding

No funding was received for this work.

Open Research

Data Availability Statement

None.

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Volume63, Issue10

October 2023

Pages 1091-1100

Ureteral Stent-Related Symptoms and Pharmacotherapy: A Brief Narrative Review

Abstract

Methods

Results

Discussion

Conclusions

Conflicts of Interest

Funding

Open Research

Data Availability Statement

References

References

Information

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