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NSAIDs and Analgesics

NSAIDs and analgesics play several roles in urology: (1) acute renal colic (the most evidence-based application, where NSAIDs are first-line over opioids); (2) perioperative pain management in urologic surgery; (3) ureteral stent symptoms; (4) analgesia during observation / medical expulsive therapy (MET) for ureteral stones; (5) chronic prostatitis / chronic pelvic pain syndrome (CP/CPPS); (6) interstitial cystitis / bladder pain syndrome (IC/BPS); (7) bladder cancer chemoprevention (investigational); and (8) urinary tract analgesia (phenazopyridine). NSAIDs carry significant nephrotoxicity risk that is amplified in urologic patients (obstructive uropathy, solitary kidney, CKD, RAAS-inhibitor use), and the opioid-stewardship movement has fundamentally reshaped analgesic prescribing in the field.[1][2][3][4]

For the analgesia comparator classes (broadly framed as nonnarcotic methods of pain management[9]), see Gabapentinoids, SNRIs, and Tricyclic antidepressants.

Mechanism — Why NSAIDs Work in the LUT​

NSAIDs inhibit COX, which reduces prostaglandin synthesis. The class effects are urologic at four levels:[2]

  1. Renal pelvis and ureter. Prostaglandins drive ureteral spasm, mucosal inflammation, and renal vasodilation around an obstructing stone. NSAIDs blunt all three, lowering urine output and intra-pelvic pressure, a mechanism different from opioids, which only mask central pain
  2. Ureteral smooth muscle. Reduced peristaltic spasm; a proposed, not established, stone-expulsion effect[5]
  3. Bladder and prostate. COX-2 is upregulated in inflamed prostate and urothelium[6]
  4. Bladder cancer biology. COX-2 is overexpressed in transitional cell carcinoma; COX-2 inhibition induces apoptosis, blocks EMT, and reduces tumor growth in preclinical models[7][8]

Urologic Applications at a Glance​

ApplicationPreferred agent(s)EvidencePosition
Acute renal colicDiclofenac IM, ibuprofen IV, ketorolac IVCochrane + multiple meta-analyses[1][2][10]EAU first choice after individual risk assessment; CDC favors nonopioid therapy[19]
Post-ureteroscopy painNSAID when safe; US oral ketorolac requires prior IV/IM ketorolacSKOPE tested oral ketorolac in selected patients, not IV ketorolac[11][46]Expert consensus: 0 opioid tablets acceptable[4]
Ureteral stent symptomsNSAID for pain when safeNarrative review without meta-analysis[15]EAU strongly recommends MET for stent symptoms; α-blockers have level 1a evidence, without an NSAID-specific recommendation[48]
Pain during stone observation / METNSAID if appropriateAnalgesia is established; celecoxib expulsion data are limited[12]Do not prescribe celecoxib specifically to promote expulsion[48]
CP/CPPSIbuprofen, diclofenac, celecoxib (short-term)Cochrane and network meta[6][23][24]Small average benefit; low-certainty evidence
IC/BPSNSAIDs (general principles)AUA Clinical Principle[3][25]Pain-management framework only
Bladder cancer chemopreventionCelecoxibNegative randomized trials[13][14]Not recommended (CV risk; negative)
Perioperative urologic surgeryAcetaminophen with ketorolac, ibuprofen, or celecoxib when appropriateMultimodal surgery review and procedure-specific ERAS guidance[21][55][60]Select by operation, renal function and bleeding risk; EAU cystectomy guidance reserves ketorolac for breakthrough pain

Acute Renal Colic — the primary urologic application​

The most evidence-based use of NSAIDs in urology, supported by multiple Cochrane reviews and large meta-analyses.

Headline evidence​

  • Cochrane 2025 (29 RCTs, n = 3,593; search through August 2023): the placebo comparison favored NSAIDs at 30 minutes (MD −3.84 cm on a 10-cm VAS; 95% CI −6.41 to −1.27), but this came from only three studies / 250 participants, with high heterogeneity and low certainty. Evidence about harms was uncertain; IV and IM routes probably have similar analgesic effects.[2]
  • Pathan 2018 meta (36 RCTs, n = 4,887): NSAIDs marginally outperform opioids at 30 min (small mean difference with substantial heterogeneity); in route-of-administration subgroup analyses, fewer rescue treatments (7 RCTs, n = 541; NNT 11) and less vomiting (5 RCTs, n = 531; NNT 5) versus opioids; fewer rescue treatments than paracetamol (2 trials, n = 1,145; RR 0.56; p < 0.001)[1]
  • EAU 2026 strongly recommends an NSAID as the first drug of choice when appropriate, and renal decompression or ureteroscopic stone removal for analgesia-refractory colic.[48] An obstructed kidney with UTI signs or anuria is a urological emergency that often needs urgent decompression regardless of analgesic response.[48]
  • Pathan 2016 Lancet RCT (1,645 randomized; 1,644 intention-to-treat): at least 50% pain reduction by 30 minutes occurred in 68% with IM diclofenac, 66% with IV paracetamol and 61% with IV morphine. Diclofenac was superior to morphine in the primary analysis (p = 0.0187); paracetamol was not (p = 0.0629).[18] Both comparisons favored the nonopioid drug in the smaller imaging-confirmed, per-protocol population.[18]
  • CDC Guideline 2022: opioids are not recommended as first-line therapy for kidney-stone pain[19]

Agent selection and dosing boundaries​

The following are adult examples. Select the agent, route and dose for the patient and the local product label.

AgentExample / boundaryKey limitation
Diclofenac75 mg IM was used in the large renal-colic trialCheck cardiovascular, GI and renal risk; formulation availability differs by country[18][48]
KetorolacUS single IV dose: 30 mg if under 65; 15 mg if ≥65, renally impaired or under 50 kgUse lower effective doses when appropriate. All IV/IM and oral treatment combined must stay within 5 days; US oral dosing is continuation of parenteral therapy, not initial therapy, and is capped at 40 mg/day[46]
IbuprofenOral or IV according to clinical need and the product labelComparative studies do not justify routinely choosing the highest IV dose[2]
Acetaminophen / paracetamol IV≥50 kg: 1,000 mg every 6 h or 650 mg every 4 h; under 50 kg requires weight-based dosingInfuse over 15 minutes; include every route and combination product in the total dose (see below)[47]
NSAID safety before prescribing

Ketorolac is contraindicated with active or prior peptic ulcer / GI bleeding, advanced renal impairment or risk of renal failure from volume depletion, concurrent aspirin / other NSAIDs, and CABG surgery. Because it inhibits platelet function, it is also contraindicated with suspected or confirmed cerebrovascular bleeding, hemorrhagic diathesis, incomplete hemostasis or high bleeding risk, and as prophylactic analgesia before any major surgery (postoperative use still requires caution when hemostasis is critical). Other labeled contraindications include prior ketorolac hypersensitivity or allergic manifestations to aspirin or another NSAID, labor and delivery, neuraxial (epidural / intrathecal) administration because of the alcohol content, and concurrent probenecid or pentoxifylline. Injectable daily totals are capped at 120 mg, or 60 mg for patients ≥65 years, renally impaired or under 50 kg. NSAIDs carry serious GI bleeding and cardiovascular thrombotic risks. Check bleeding risk and anticoagulants as well as renal function.[46]

FDA recommends limiting NSAIDs at 20–30 weeks of pregnancy because of fetal renal dysfunction / oligohydramnios, and avoiding them from about 30 weeks because of premature ductus arteriosus closure. If use at 20–30 weeks is necessary, use the lowest dose for the shortest duration; consider amniotic-fluid monitoring if treatment exceeds 48 hours.[49]

Perioperative Pain Management​

After selected urologic procedures, NSAIDs are an opioid-sparing component of multimodal analgesia when renal function and bleeding risk permit.[11][21][60]

Opioid-sparing magnitude (literature review of 32 trials)[21]​

These ranges come mainly from patient-controlled-analgesia studies across surgical fields.

  • Diclofenac reduces opioid consumption 17–50%
  • Ketorolac 9–66%
  • Ibuprofen 22–46%
  • Ketoprofen 34–66%

Several included trials reported less nausea, vomiting, sedation and pruritus with NSAIDs. The reviewed trials reported no surgery-related bleeding complications, but gastrointestinal bleeding occurred as an NSAID-related adverse event; assess bleeding risk by operation, patient, NSAID and dose, with attention to contraindications.[21]

SKOPE RCT — ketorolac vs oxycodone post-URS[11]​

This double-blind noninferiority trial included 81 selected patients and compared as-needed oral ketorolac 10 mg with oxycodone 5 mg over postoperative days 1–5.[11] The registered protocol required GFR >60 mL/min/1.73 m² and excluded solitary kidney, antiplatelet or anticoagulant use, chronic pain, chronic NSAID use, and opioid or other pain-medication use for more than 12 weeks.[59] Both groups also received three oxycodone rescue tablets. Pain outcomes supported ketorolac as an alternative for suitable patients, with fewer days confined to bed (1.3 versus 2.3; p = 0.02). It supports reducing routine opioid prescribing, not withholding rescue analgesia or ignoring ketorolac contraindications / the US oral-continuation restriction.[46]

Opioid-stewardship results in urology​

NOPIOIDS protocol (Mian 2023)[17]​

This single-center, nonrandomized cohort study followed 647 opioid-naive patients through sequential prescribing pathways after radical cystectomy, radical / partial nephrectomy, or radical prostatectomy:

  • Discharge opioid prescription rate: from 80.9% (control) to 57.9% (lead-in) to 2.2% (NOPIOIDS)
  • Median tablets prescribed: from 14 to 4 to 0 (p < 0.001)
  • The pathway recorded low pain scores and high satisfaction, with no detected increase in complications. Selection, temporal confounding and incomplete patient-reported follow-up limit causal or universal safety claims; individualized rescue access remains necessary.

ORIOLES — post-prostatectomy[22][45]​

In 205 RP patients with 100% follow-up, median prescribed 225 mg OMEQ but median used 22.5 mg OMEQ; 77% of prescribed opioids unused; 84% required ≤ 112.5 mg OMEQ; only 9% appropriately disposed of leftover medication.[22] Prescribing more was independently associated with greater use.

Prolapse and incontinence surgery[53][54][55]​

  • AUGS-IUGA 2022 ERAS consensus: multimodal analgesia with restrictive opioid use is among the components graded as high-level evidence for urogynecologic surgery.[55]
  • Consumption versus prescribing (Dahl 2022, 261 women, 9 centers): median 28 MME consumed (about three to four oxycodone 5-mg tablets) against 75 MME prescribed. Higher use tracked with BMI above 30, chronic pain, high baseline pain, greater blood loss and longer operations, which helps identify who needs more.[54]
  • Restrictive prescribing RCT (Yuan 2024, 133 randomized; 127 analyzed for the primary outcome, single center, unblinded): in opioid-naive women having minor or major prolapse / incontinence surgery and receiving multimodal analgesia, no routine opioid prescription (opioid only on request) was noninferior to 3–10 oxycodone 5-mg tablets for satisfaction at 6 weeks (92.1% versus 92.2%). The trial excluded women with high pain-catastrophizing scores or contraindications to all multimodal drugs. No opioid use in the first week was reported by 70.8% versus 48.4%; refills (6.7% versus 9.4%) and pain calls were similar.[53]

Expert-panel prescribing ranges[4]​

Koo and colleagues’ multidisciplinary Delphi consensus concerned opioid-naive patients without chronic pain undergoing 16 endourological / minimally invasive procedures. AUA did not issue these expert-consensus ranges. The minimum suggested quantity was zero; procedure-specific upper ranges varied from zero to 15 oxycodone 5-mg-equivalent tablets. Match prescribing to expected need, contraindications to nonopioid drugs, prior opioid exposure and access to reassessment.[4][16]

Ureteral Stent–Related Symptoms​

NSAIDs are part of multimodal stent-symptom pharmacotherapy.[15]

  • Alpha-blockers carry the strongest monotherapy evidence
  • NSAIDs target the inflammatory and pain components
  • Antimuscarinics target the urinary symptom components
  • Sedation and respiratory risks matter if considering Gabapentinoids.

Medical Expulsive Therapy​

NSAIDs treat pain during conservative stone management; they are not established stone-expulsive treatment. EAU 2026 strongly recommends offering off-label α-blockers as an option for distal ureteral stones 5–10 mm in patients suitable for observation.[48]

  • Lv & Tang 2014 (RCT, 105 consented, 103 completed): distal-stone expulsion was 94.3% with naftopidil plus celecoxib (200 mg every 12 h after a 400-mg load), 82.9% with naftopidil alone and 60.6% with celecoxib alone. Celecoxib alone was significantly worse than either naftopidil arm; the combination was not significantly better than naftopidil alone in the reported comparisons[12]
  • Small adjunct trials and mechanistic reviews are insufficient to recommend adding celecoxib specifically for stone passage.[5]

CP/CPPS​

AUA 2025 permits anti-inflammatory agents within multimodal CP/CPPS pain management , and discourages long-term use because of harms.[50] Its discussion identifies musculoskeletal pain and inflammation as a likely target rather than presumed prostate inflammation. Average improvements in reviews are small and uncertain; individual response should be reassessed.[6][23][24][50] EAU 2026 weakly recommends NSAIDs in primary prostate pain syndrome (level 1a, moderate effect that lasted only for the treatment period in the celecoxib trial) with attention to long-term side effects, and describes the evidence for NSAIDs in chronic pelvic pain generally as weak or absent. It advises withdrawing an NSAID if function does not improve or side effects limit use.[58]

  • Cochrane 2019 (7 RCTs, n = 585 men): anti-inflammatories versus placebo: NIH-CPSI MD −2.5 (95% CI −3.74 to −1.26), a small average difference with low-certainty evidence; a within-person 6-point response threshold is not identical to a between-group mean difference[23]
  • Network meta-analysis 2022 (25 RCTs, n = 3,514; 26 treatments): few oral drugs beat placebo.[24] The only ibuprofen-containing signal was a single-study doxazosin plus ibuprofen plus thiocolchicoside combination, with low- to very-low-quality evidence and a possible excess of adverse events.[24]
  • Use an individualized short trial within multimodal treatment; the guideline does not prescribe a universal 4–6-week high-dose ibuprofen course. Routine opioid treatment is inappropriate for this chronic condition.[6][50]
  • Reasonable as part of multimodal therapy; limit to short courses to minimize nephrotoxicity and GI risk.

IC/BPS​

The 2022 AUA IC/BPS Guideline (Statement 13) addresses pain pharmacology as a Clinical Principle: pain management for IC/BPS should mirror other chronic-pain conditions; non-opioid agents should be used preferentially; pain management alone is not sufficient treatment; a multimodal approach is likely to be most effective; chronic opioids call for judicious use after informed decision-making.[3][25]

Use for selected symptoms within the broader bladder-directed and pain-management plan; reassess benefit and toxicity.

Phenazopyridine — the urinary-tract analgesic​

Phenazopyridine offers short-term symptom relief and does not treat infection or its cause. The cited US prescription product is marketed as unapproved drug other; a DailyMed listing does not establish FDA approval. Follow the phenazopyridine hub for dosing, the two-day limit with antibacterials, renal contraindication, discoloration and methemoglobinemia / G6PD precautions.[26] TRPM8 inhibition is a proposed mechanism from laboratory work.[27]

Celecoxib and Bladder Cancer Chemoprevention​

Strong preclinical rationale; clinical trials are negative, and CV risk precludes routine use.

Preclinical (strong)[7][8][29][30]​

  • In a female Fischer-344 rat model, celecoxib begun before carcinogen exposure reduced bladder-cancer incidence by roughly 65%; begun one week after the last carcinogen dose, it reduced incidence by >95%[7]
  • Mechanisms include COX-2-dependent and -independent pathways: apoptosis, anti-EMT (miR-145 / TGFBR2 / Smad3), anti-inflammatory, anti-proliferative, antioxidant

Clinical (negative)​

TrialDesignResult
BOXIT (Kelly 2019)Phase III RCT, n = 472, intermediate / high-risk NMIBCNo significant benefit: 3-year recurrence-free rates 68% vs 64% (HR 0.82, 95% CI 0.60–1.12; p = 0.2). Serious CV events were numerically higher (5.2% vs 1.7%; p = 0.07)[13]
Sabichi 2011RCT, n = 146, high-risk NMIBCDid not significantly prolong time to recurrence (p = 0.17; median follow-up 2.49 years). 12-month recurrence-free rates were 88% vs 78%; adjusted HR 0.69 (95% CI 0.37–1.29).[14]

Celecoxib is not recommended for bladder-cancer chemoprevention.

NSAIDs and Erectile / Gonadal Function​

The relationship between NSAIDs and ED is controversial and likely confounded by indication.

StudyDirection
Gleason 2011 (n = 80,966)Regular NSAID use associated with ED (aOR 1.38)[31]
Shiri 2006 (n = 1,126 men without moderate or complete ED at baseline)Relative to men with neither NSAID use nor arthritis, NSAID use was associated with incident ED in men without arthritis (adjusted IDR 2.0) and men with arthritis (adjusted IDR 1.9)[32]
Senbel preclinicalIndomethacin reduced rat erectile responses; diclofenac less; celecoxib unaffected[33]
Patel PCPT (n = 4,726)After controlling for indication, NSAID use not associated with ED — apparent association attributable to confounding[34]
Halpern NHANES (n = 3,749)Regular NSAID use not associated with testosterone, AMH, or compensated hypogonadism[35]
Li 2018 systematic reviewMixed; methodologically heterogeneous[36]

Nephrotoxicity — the critical urologic concern​

NSAID nephrotoxicity is amplified in urologic patients.[37][38][39][40]

Mechanisms​

  1. Hemodynamic AKI (most common, usually reversible). NSAIDs blunt prostaglandin-mediated compensatory vasodilation in low-perfusion states, reducing GFR
  2. Acute interstitial nephritis (rare, idiosyncratic). Any NSAID
  3. Renal papillary necrosis. Chronic use
  4. Electrolyte disturbance. Sodium / water retention, hyperkalemia, hyponatremia
  5. CKD. Regular use may raise CKD incidence; relationship with progression less clear

Risk factors that matter for the urologist​

  • Pre-existing CKD (CrCl < 60)
  • Volume depletion / dehydration
  • Concurrent RAAS inhibitors and diuretics (the "triple whammy")
  • Advanced age (> 65)
  • Solitary kidney. Common after nephrectomy
  • Bilateral or high-grade obstruction
  • Heart failure, cirrhosis

Practical implications​

  • Renal colic. NSAIDs remain first-line in patients with adequate renal function; check baseline function and avoid in significant CKD, dehydration, or bilateral obstruction[1][40]
  • Solitary-kidney patients. Favor acetaminophen as primary analgesic
  • Stone formers on thiazides. Combination raises nephrotoxicity risk
  • Lowest effective dose for the shortest appropriate time is a general NSAID risk-reduction principle[38][39]

Acetaminophen / Paracetamol in Urology​

A first-choice analgesic for mild-to-moderate acute pain in many adults when NSAIDs are unsuitable; individualize dosing in higher-risk conditions.[42]

  • Renal colic. IV paracetamol is an alternative when NSAIDs are unsuitable; the Pathan intention-to-treat analysis did not establish superiority over morphine[1][18][20]
  • Perioperative. Core component of multimodal analgesia in ERAS protocols; reduces opioid consumption when paired with NSAIDs; the cited emergency-general-surgery guideline supports its use[41]
  • Renal safety. Often preferable to NSAIDs when renal risk is high, but dose must reflect body weight, liver health and total exposure; little evidence that chronic paracetamol monotherapy causes CKD or analgesic nephropathy; a suitable first-line choice in CKD with dose individualization in advanced renal failure[42][43][44]
  • CP/CPPS. AUA 2025 permits acetaminophen and other non-opioid pain agents after counseling about risks and benefits .[50] Controlled CP/CPPS studies of common analgesics are lacking.[6][50]

Acetaminophen dose safeguards​

The cited IV label limits total exposure from all routes and all combination products to 4 g/24 h for adults ≥50 kg. Under 50 kg, use 15 mg/kg every 6 h or 12.5 mg/kg every 4 h, maximum 75 mg/kg/day. Lower limits may be needed with hepatic risk, malnutrition or alcohol use. Severe hepatic impairment / severe active liver disease is a contraindication. Avoid accidental duplication with opioid–acetaminophen products.[47]

Opioid and Tramadol Label Safety​

When an opioid is needed, the US immediate-release oxycodone label starts at 5–15 mg every 4–6 hours as needed, at the lowest dose that works, and titrates to response.[56] The class boxed warning covers addiction, abuse and misuse; life-threatening respiratory depression (highest at initiation or dose increase); accidental ingestion; neonatal opioid withdrawal syndrome; interaction with CYP3A4 inhibitors; and profound sedation, respiratory depression and death with benzodiazepines or other CNS depressants (reserve co-prescribing for patients without alternatives). The label also directs prescribers to a REMS-compliant education program.[56][57]

Tramadol carries opioid boxed warnings and additional risks relevant to pelvic-pain regimens:[57]

  • Ultra-rapid CYP2D6 metabolism: deaths from respiratory depression in children, some after tonsillectomy / adenoidectomy. It is contraindicated under 12 years and under 18 years after tonsillectomy / adenoidectomy.
  • CYP interactions: CYP3A4 inducers or inhibitors and 2D6 inhibitors change exposure in complex ways; review the full medication list.
  • MAOI contraindication: do not use tramadol during or within 14 days after MAOI treatment, including linezolid.[57]
  • Seizure: can occur at recommended doses; risk rises with epilepsy, prior seizures and other seizure-risk drugs.
  • Serotonin syndrome: possible with tramadol alone and more likely with serotonergic drugs. Check for SNRIs, SSRIs and tricyclics, which are common in chronic pelvic pain regimens (see SNRIs).
  • Dosing limits: Start at the lowest needed dose. When rapid analgesia is unnecessary, the label describes starting at 25 mg/day with gradual titration; after titration, 50–100 mg every 4–6 hours as needed, maximum 400 mg/day.[57] The label also permits 50–100 mg initially when rapid onset is needed and the benefit outweighs the higher-dose risk.[57] Above 75 years, maximum 300 mg/day.[57] With creatinine clearance below 30 mL/min, dose every 12 hours with a 200 mg/day maximum; in severe hepatic impairment, 50 mg every 12 hours.[57]

For chronic pelvic pain, AUA 2025 does not include opioids among its treatments and advises that urologists not act as the long-term opioid prescriber for chronic pain syndromes; refer such patients to a pain specialist.[50] EAU 2026 permits opioids for chronic urogenital pain only after multidisciplinary assessment and after other reasonable treatments have failed , with any decision to start long-term opioid therapy made by a trained specialist in consultation with the patient and family doctor . It advises stopping opioids that are not working, annual review above 50 mg/day morphine-equivalent, pain-specialist involvement above 90 mg/day, and notes that harm rises substantially above 120 mg/day.[58]

New nonopioid option — suzetrigine​

Suzetrigine (Journavx), a peripheral NaV1.8 inhibitor, received FDA approval in January 2025 for moderate-to-severe acute pain in adults. Two phase-3 trials after abdominoplasty (n = 1,118) and bunionectomy (n = 1,073) showed benefit over placebo over 48 hours, but neither established superiority to hydrocodone / acetaminophen.[51][52]

The July 2026 label includes postoperative pain and notes that acute-pain use beyond 14 days has not been studied. The usual regimen is 100 mg orally on an empty stomach, then 50 mg every 12 hours starting 12 hours later. Strong CYP3A inhibitors are contraindicated, and grapefruit should be avoided during treatment. With a moderate CYP3A inhibitor or moderate hepatic impairment, give the first four doses on that schedule, then 50 mg every 24 hours from dose 5. Avoid treatment with strong or moderate CYP3A inducers, in severe hepatic impairment, or when eGFR is <15 mL/min. Check effects on sensitive CYP3A substrates. With hormonal contraceptives containing progestins other than levonorgestrel or norethindrone, use an additional nonhormonal method or an alternative contraceptive during treatment and for 28 days afterward.[28]

Opioid Stewardship in Urology — Key Principles​

  • Opioids are not first-line for kidney-stone pain[19]
  • When opioids are warranted, prescribe immediate-release at the lowest effective dose for the shortest expected duration[19]
  • Maximize NSAIDs and acetaminophen; explore non-pharmacologic options
  • Expert consensus offers procedure-specific ranges, for opioid-naive patients without chronic pain.[4]
  • NOPIOIDS-style protocols support reducing routine discharge opioid prescribing after major cancer surgery, with patient education and reassessment; the evidence is observational[17]
  • After radical prostatectomy. In the 205-patient ORIOLES cohort, 77% of prescribed postdischarge opioids went unused.[22] Calibrate discharge quantities to expected need.[45]
  • Screen for benzodiazepines, other sedatives, serotonergic drugs and CYP interactions before any opioid or tramadol prescription[56][57]
  • Outpatient opioid safeguards. When starting outpatient opioid therapy, review state PDMP data for cumulative dose and high-risk combinations, and offer naloxone, particularly with prior overdose, substance use disorder, sleep-disordered breathing, benzodiazepines or ≥50 MME/day (CDC 2022, Recommendations 8 and 9; Category A and B, respectively; evidence type 4).[19]

Clinical Positioning​

  • Renal colic: NSAID first-line in patients with adequate renal function (IM diclofenac, IV ibuprofen, IV ketorolac); IV paracetamol is the alternative when NSAIDs are contraindicated; opioids may be needed when nonopioid treatment is contraindicated or inadequate[1][2][10][19]
  • Post-URS, post-cystectomy, post-RP. Multimodal acetaminophen with an NSAID when appropriate is an opioid-sparing option. Radical-cystectomy ERAS pathways vary; select analgesia around renal function, bleeding risk and the operation. SKOPE and NOPIOIDS support reduced routine discharge opioid prescribing in their studied populations.[11][17][60]
  • Stent symptoms. NSAIDs as adjunct to α-blockers ± antimuscarinics; select adjuncts by symptoms and adverse-effect risk[15]
  • MET. For distal ureteral stones 5–10 mm amenable to observation, EAU 2026 strongly recommends offering off-label α-blockers as a MET option; NSAIDs provide analgesia and are not established expulsive agents.[48][12]
  • CP/CPPS. An individualized short NSAID trial may fit multimodal care; average benefit is small and evidence uncertain[6][50]
  • IC/BPS. NSAIDs as part of general non-opioid pain management within a multimodal plan[3]
  • Phenazopyridine provides short-term urinary symptom relief; 2-day limit with antibacterials, contraindicated in renal insufficiency[26]
  • Bladder cancer chemoprevention. Celecoxib is not recommended despite preclinical signal[13][14]
  • Nephrotoxicity is the dominant safety concern in urologic patients; assess renal function, assess volume depletion, interacting drugs, CKD and obstruction rather than assuming safety from a normal single creatinine, use the lowest effective dose for the shortest possible time[37][38][39][40]
  • NSAID use and ED show inconsistent observational associations. In a PCPT secondary analysis of 4,726 men, adjustment for treatment indications attenuated the association.[32][34][36]

See Also​

References​

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2. Afshar K, Gill J, Mostafa H, Noparast M. "Nonsteroidal anti-inflammatory drugs (NSAIDs) for acute renal colic." Cochrane Database Syst Rev. 2025;3:CD006027. doi:10.1002/14651858.CD006027.pub3

3. Clemens JQ, Erickson DR, Varela NP, Lai HH. "Diagnosis and treatment of interstitial cystitis/bladder pain syndrome." J Urol. 2022;208(1):34–42. doi:10.1097/JU.0000000000002756

4. Koo K, Faisal F, Gupta N, et al. "Recommendations for opioid prescribing after endourological and minimally invasive urological surgery: an expert panel consensus." J Urol. 2020;203(1):151–158. doi:10.1097/JU.0000000000000514

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7. Grubbs CJ, Lubet RA, Koki AT, et al. "Celecoxib inhibits N-butyl-N-(4-hydroxybutyl)-nitrosamine-induced urinary bladder cancers in male B6D2F1 mice and female Fischer-344 rats." Cancer Res. 2000;60(20):5599–5602. PMID 11059745

8. Liu X, Wu Y, Zhou Z, et al. "Celecoxib inhibits the epithelial-to-mesenchymal transition in bladder cancer via the miRNA-145/TGFBR2/Smad3 axis." Int J Mol Med. 2019;44(2):683–693. doi:10.3892/ijmm.2019.4241

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10. Gu HY, Luo J, Wu JY, et al. "Increasing nonsteroidal anti-inflammatory drugs and reducing opioids or paracetamol in the management of acute renal colic: based on three-stage study design of network meta-analysis of randomized controlled trials." Front Pharmacol. 2019;10:96. doi:10.3389/fphar.2019.00096

11. Fedrigon D, Faris A, Kachroo N, et al. "SKOPE — Study of Ketorolac vs Opioid for Pain after Endoscopy: a double-blinded randomized control trial in patients undergoing ureteroscopy." J Urol. 2021;206(2):373–381. doi:10.1097/JU.0000000000001772

12. Lv JL, Tang QL. "Comparative evaluation of efficacy of use of naftopidil and/or celecoxib for medical treatment of distal ureteral stones." Urolithiasis. 2014;42(6):541–547. doi:10.1007/s00240-014-0708-6

13. Kelly JD, Tan WS, Porta N, et al. "BOXIT — a randomised phase III placebo-controlled trial evaluating the addition of celecoxib to standard treatment of transitional cell carcinoma of the bladder (CRUK/07/004)." Eur Urol. 2019;75(4):593–601. doi:10.1016/j.eururo.2018.09.020

14. Sabichi AL, Lee JJ, Grossman HB, et al. "A randomized controlled trial of celecoxib to prevent recurrence of nonmuscle-invasive bladder cancer." Cancer Prev Res (Phila). 2011;4(10):1580–1589. doi:10.1158/1940-6207.CAPR-11-0036

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