Brief Answer:
Yes, go in.

Detailed Answer:
Hello and welcome,

I am sorry you are having so much pain. Stones that are 4 mm or less usually pass spontaneously, without need for lithotripsy or surgery. Drinking lots of fluids is key. But that said, it would still be a good idea, if you are in severe pain, to go in to the ER. My reason for saying that is because they can help manage the pain, and also, if they can do a low-dose radiation CT or ultrasound, they can see if there is hydronephrosis behind the stone,which a plain X-ray can't show. Hydronephrosis happens when a stone blocks the path of the urine enough that fluid backs up in the ureter and kidney and that too can cause a lot of pain. So if you have an ER nearby, particularly a university or large hospital ER, they can evaluate you more thoroughly and help with your pain.

In terms of what can be done to break it up, perhaps there may be alternative medical things that are helpful, such as herbal preparations, but I am not knowledgeable of that. I am going to copy, below, a section on that topic from the medical resource UpToDate which reviews the most current research on various medical topics for physicians.

So - to answer your question, I think it would be a good idea to go in to the hospital to see what is going on with imaging (ultrasound, etc) and for pain management.

Here is the section of the article:
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Facilitating stone passage — Several different medical interventions increase the passage rate of ureteral stones, including antispasmodic agents, calcium channel blockers, and alpha blockers, which have been used in combination with or without steroids [94-103].

The benefits of medical therapy have been examined in meta-analyses, which have analyzed different agents [101,104]:

●In a 2014 meta-analysis of 32 trials that enrolled 5864 patients, ureteral stone passage was significantly more likely with alpha blocker therapy versus conservative treatment alone (77 versus 52 percent); in addition, stone passage occurred an average of three days faster with alpha blocker therapy [105].

●Another meta-analysis of nine controlled trials included 693 patients with mean stone size between 3.8 and 7.8 mm [101]. Compared with the control group, patients treated with a calcium channel blocker (usually nifedipine) or alpha blocker (usually tamsulosin) had a 65 percent greater likelihood of stone passage (95% CI 45-88 percent). In analyses of the individual agents, there was a 90 and 54 percent greater likelihood of stone passage with calcium channel blockers and alpha blockers, respectively, relative to controls.

A subsequent trial randomly assigned 1167 adult patients presenting with ureteric colic caused by nephrolithiasis to four weeks of therapy with tamsulosin, nifedipine, or placebo [106]. All patients had a stone size of 10 mm or less, and 75 percent had a stone size of 5 mm or less. The primary endpoint, which was the need for further intervention (such as lithotripsy) within four weeks, and all secondary endpoints (including days until stone passage and pain) were assessed by self-administered questionnaires at four weeks; follow-up imaging was not routinely performed. There was no benefit from tamsulosin or nifedipine for any endpoint. However, patients with small stones infrequently require intervention, and self-reported stone passage is likely to be inaccurate. These limitations raise serious concerns about the conclusions of this trial.

Studies directly comparing nifedipine with tamsulosin have reported similar rates of stone passage, although rates were slightly higher with tamsulosin [99-101,103,105]. A potential advantage of tamsulosin is somewhat faster stone passage and fewer hospitalizations and procedures. Other alpha blockers appear to be similarly effective [102,107].

In addition to tamsulosin and nifedipine, tadalafil (a phosphodiesterase type 5 inhibitor) and silodosin (a selective alpha-1A receptor blocker) can be used as medical expulsive therapy (MET) [108,109]. In a trial, 285 patients with distal ureteral stones sized 5 to 10 mm in diameter were randomly assigned to tamsulosin (0.4 mg/day), silodosin (8 mg/day), or tadalafil (10 mg/day) until stone passage or for a maximum of four weeks [109]. Silodosin resulted in significantly higher rates of stone expulsion (83 compared with 64 percent with tamsulosin and 67 percent with tadalafil) and significantly faster mean expulsion times (15 days versus 17 days with tamsulosin and 16 days with tadalafil).

International guidelines from the XXXXXXX Urological Association and the European Association of Urology on the management of ureteral calculi suggest that:

●"In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are controlled, observation with periodic evaluation is an option for initial treatment. Such patients may be offered an appropriate medical therapy to facilitate stone passage during the observation period. In a choice between active stone removal and conservative treatment with MET, it is important to take into account all individual circumstances that may affect treatment decisions. A prerequisite for MET is that the patient is reasonably comfortable with that therapeutic approach and that there is no obvious advantage of immediate active stone removal" [51,110].

Based upon data suggesting faster stone passage with an alpha blocker versus calcium channel blockers, we initiate treatment with tamsulosin (0.4 mg once daily) for four weeks to facilitate spontaneous stone passage in patients with stones ≤10 mm in diameter. Patients are then reimaged if spontaneous passage has not occurred. Routine use of tadalafil and silodosin in such patients is not recommended pending further data showing safety and efficacy.

Patients will typically require analgesics such as ketorolac. Concurrent antibiotics are used by some groups but have not been studied to determine their value in the setting of a patient receiving MET. Patients with stones larger than 10 mm in diameter, patients with significant discomfort, those with significant obstruction, or who have not passed the stone after four to six weeks should be referred to urology for potential intervention.

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