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Chapter 16: Obstructive Uropathy

A 64-year-old female patient presents to the emergency department with severe right flank pain and fever. These symptoms have worsened over the past 3 days. Her past medical history includes diabetes and hypertension. Her temperature is 101.8°F, BP 90/50, pulse 110 beats/min. Urinalysis shows many WBCs and bacteria. A renal ultrasound shows severe right hydronephrosis. In addition to intravenous antibiotics, which is the most appropriate next step for this patient?

A. Placement of right percutaneous nephrostomy

B. Observation

C. Extracorporeal shockwave lithotripsy

D. CT urogram

The answer is A. Pyelonephritis in obstructed kidney requires drainage of collecting system. Observation (B) is not correct because patient is at risk of worsening sepsis if source of infection is not drained. Shock wave lithotripsy (C) is not indicated as there is no mention of ureterolithiasis and lithotripsy is not performed during active infection. A CT urogram (D) would not be the next step because serum creatinine is not provided and must be obtained prior to administering IV contrast. CT urogram may be considered once hydronephrosis is drained, but once drain is in place, antegrade urogram can be performed without exposing patient to intravenous contrast.

An 83-year-old male patient reports new onset urine incontinence and frequency. Vital signs are stable. A distended bladder is detected during abdominal examination. He has no peripheral edema. A Foley catheter is placed with some difficulty and initial urine output is 1800 mL. Over the next 4 hours, urine output is 1000 mL. The best option at this time is

A. Replace hourly urine output with intravenous fluids

B. Replace urine output with intravenous fluid 0.5 mL/mL urine output

C. Administer DDAVP (desmopressin acetate injection)

D. Observation

The answer is B. Patient may be experiencing postobstructive diuresis. The treatment of postobstructive diuresis should involve replacing urine output with intravenous fluids at a rate less than urine output to prevent replacement fluids from contributing to diuresis. In addition, many patients with chronic bladder outlet obstruction may be volume overloaded, and diuresis may be appropriate response. DDAVP (C) is used to diagnose and/or treat central diabetes insipidus, which is unlikely in this patient. Observation (D) puts patient at risk for volume depletion.

A 46-year-old male patient complains of left flank pain radiating into his groin. A urinalysis shows 2+ blood and 15 RBC/HPF. CT stone study shows a 4-mm stone in the distal left ureter and mild left hydronephrosis. The most appropriate ...

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