AUA Guidelines for Kidney Stone Treatment

 In this blog, I walk you through the American Urological Association Guidelines for Kidney Stones and how they shape your urologist’s treatment decisions. From diagnosis and imaging to surgery or observation, these recommendations outline everything step-by-step. If you’ve ever wondered why your doctor chose a certain path—or what your options actually are—this is your guide.

Key Takeaways:

• AUA guidelines determine treatment based on stone size, type, and location

• CT scans are used for first-time diagnosis; ultrasounds for follow-up

• Expulsive therapy, ureteroscopy, and shock wave lithotripsy are first-line treatments depending on severity

• Observation is often overlooked but is valid for non-obstructive stones

 If you've ever had a kidney stone and visited a urologist, there's a good chance your doctor followed the American Urological Association Guidelines for Kidney Stones—even if they didn’t tell you that directly. These guidelines serve as the playbook for diagnosing, treating, and managing kidney stones.

So today, I’m breaking it all down for you—exactly how they approach diagnosis, what treatments they recommend, and what you should be asking for after passing a stone. 

How Kidney Stones Are Diagnosed

The first step in managing kidney stones, according to the AUA, is proper diagnosis.

For first-time stone formers, they recommend a non-contrast CT scan. CT scans give the most complete picture—not just size and location of the stone, but also stone density, or attenuation.

Why does that matter?
Because density helps identify the type of stone and tells your urologist what kind of treatment might work best.

However, CT scans come with radiation exposure. So once your stone type is identified, the guidelines recommend switching to ultrasound for follow-ups. Ultrasound is safer and gives enough information about location and size without repeated radiation.

Your stone type rarely changes unless you make major dietary or lifestyle changes, so this approach works for most people. 

Don’t Skip the Urine Culture

One of the most overlooked but critical steps in the AUA guidelines is the 24-hour urine culture.

This isn’t just about pH or volume—it’s about detecting infections, which can complicate kidney stone cases quickly and dangerously.

If there's an infection, it must be treated before anything else. This step is simple but often skipped, and it's something I encourage everyone to ask their doctor about.

Treatment Based on Location and Size

The AUA guidelines are very clear: treatment depends on where the stone is, how big it is, and sometimes, what typeit is.

Let’s go through each scenario.

1. Stones in the Ureter

These are the most common. People usually feel pain and go to the ER, where a stone in the ureter is discovered.

• If the stone is less than 10mm and uncomplicated (no severe pain or urine blockage), the AUA recommends expulsive therapy.

• If that doesn’t work, the first recommendation is ureteroscopy. If that’s not an option, shock wave lithotripsycomes next.

Ureteroscopy clears more stones in one session but comes with higher complication risks.
Shock wave lithotripsy is less invasive but may need multiple sessions.

They also fine-tune recommendations based on stone location and type:

• Upper tract stones → shock wave lithotripsy

• Mid or lower tract stones → ureteroscopy

• Cystine or uric acid stones → ureteroscopy

If all else fails, the next option is percutaneous nephrolithotomy—a more invasive but effective procedure.

2. Stones in the Kidney (Non-Lower Pole)

Here’s where gravity starts to matter. The lower pole of the kidney is the hardest place for stones to exit, so the AUA treats these differently.

For non-lower pole stones:

• Under 20mm → Shock wave lithotripsy is preferred

• Over 20mm → Percutaneous nephrolithotomy is recommended

• They do not recommend shock wave lithotripsy for stones over 20mm because of a risk called steinstrasse(German for “stone street”)—where fragments clog the ureter like cobblestones.

3. Asymptomatic Stones

You might have a stone and not feel a thing. If the stone isn’t blocking anything and isn’t causing pain, the AUA suggests something shocking: observation.

That’s right. Do nothing.

This goes against the grain here in the U.S. where surgery is often rushed. But unless the stone is doing damage, watchful waiting is totally valid and even recommended.

4. Stones in the Lower Pole

This is the trickiest spot. Stones here have to work against gravity, and even treatment is harder.

• Under 10mm → Shock wave lithotripsy, then ureteroscopy if needed

• Over 10mm → Percutaneous nephrolithotomy is first choice

• If that’s not possible, they recommend staged ureteroscopy over several sessions

After the Stone Is Passed—Don’t Stop There

Here’s the biggest miss I see—no one sends their stone in for analysis.

The AUA strongly recommends analyzing passed stones, but in practice, almost no one does it.

Why does it matter?
Because stone composition reveals the cause. Each type of stone forms for a specific reason. If you don’t know what your stone is made of, how can you prevent another?

It’s on you to take that stone in and ask for it to be analyzed.

Knowledge Is Power—Use It

I know this is a lot of information. 

This isn't about challenging your urologist—it's about understanding the conversation. If you're getting advice that doesn’t match up with the AUA guidelines, it might be due to other factors. But now you’re informed enough to ask the right questions.

So next time you're sitting in the urologist’s office, bring your stone, bring your guide, and bring your knowledge.

Because the more you know, the more control you have over your health—and your kidney stones.