A 37-year-old woman comes to the emergency department due to severe, left-sided flank pain that started a day ago. The pain began acutely, is intermittent and colicky, and radiates to the groin. The patient has had associated nausea, 2 episodes of vomiting, and hematuria. Today she developed fever and chills. The patient has no prior medical conditions and takes no medications. Temperature is 38.4 C (101.1 F), blood pressure is 140/86 mm Hg, pulse is 105/min, and respirations are 18/min. Physical examination shows left costovertebral angle tenderness to percussion. A CT scan of the abdomen and pelvis without contrast reveals a 5-mm stone in the left midureter with dilation of the proximal ureter. Which of the following is the strongest indication for an urgent urologic consultation with this patient?

Question

A 37-year-old woman comes to the emergency department due to severe, left-sided flank pain that started a day ago.  The pain began acutely, is intermittent and colicky, and radiates to the groin.  The patient has had associated nausea, 2 episodes of vomiting, and hematuria.  Today she developed fever and chills.  The patient has no prior medical conditions and takes no medications.  Temperature is 38.4 C (101.1 F), blood pressure is 140/86 mm Hg, pulse is 105/min, and respirations are 18/min.  Physical examination shows left costovertebral angle tenderness to percussion.  A CT scan of the abdomen and pelvis without contrast reveals a 5-mm stone in the left midureter with dilation of the proximal ureter.  Which of the following is the strongest indication for an urgent urologic consultation with this patient?

Quizplus · Accepted Answer

11ec25c8_d856_da19_bc81_cb12f23535ce_MD0003_00 This patient has acute flank pain and nausea due to ureterolithiasis, which is confirmed on CT scan. Initial management includes hydration, pain medication (nonsteroidal anti-inflammatory drugs [eg, ketorolac, diclofenac] are generally preferred over opioids), and antiemetics (eg, metoclopramide). Patients should be counseled to strain the urine to confirm stone passage and recover the stone for qualitative analysis. Patients with signs of urosepsis (eg, fever, tachycardia), as in this patient; anuria; acute kidney injury; or refractory pain require urgent urologic consultation for possible percutaneous nephrostomy or ureteral stent insertion. In addition, those with large stones that are unlikely to pass spontaneously (≥10 mm), or those whose stones do not pass within 4-5 weeks, also warrant urologic evaluation (eg, in the outpatient setting) to consider more aggressive interventions (eg, lithotripsy, ureteroscopic intervention). (Choices B and E) Hematuria (gross or microscopic) is present in most patients with symptomatic stones. Ureteral dilation is also seen in >80% of those with symptomatic stones and would be expected given that ureteral obstruction is the source of much of the pain in these patients. However, in the absence of complete obstruction (eg, anuria) and marked ureteral dilation or hydronephrosis, acute interventional management is not required. (Choice C) Acute renal colic is often associated with severe pain and vomiting, but these symptoms usually abate with symptomatic treatment. Although urologic intervention is warranted for refractory symptoms, this patient has only had 2 episodes of vomiting and her symptoms are likely to resolve with spontaneous stone passage. (Choice D) Most stones ≤5 mm in diameter pass spontaneously with conservative management and do not require additional intervention. Alpha blockers (eg, tamsulosin) can be used to facilitate passage, especially for intermediate-sized stones (6-10 mm). Urologic evaluation is recommended for stones ≥10 mm. Educational objective: Urologic consultation is advised for ureterolithiasis associated with urosepsis, anuria, acute kidney injury, or refractory pain. Consultation is also warranted for large kidney stones (≥10 mm in diameter) that are unlikely to pass without additional intervention (eg, lithotripsy). Most stones ≤5 mm pass spontaneously, and alpha blockers (eg, tamsulosin) can be used to facilitate passage (especially for intermediate-sized stones 6-10 mm).

A 37-Year-Old Woman Comes to the Emergency Department Due to Severe