A 52-year-old woman is brought to the emergency department with fever, chills, nausea, skin flushing, and intense right-sided back pain. For the past week, she has experienced on-and-off back pain. She has no urinary urgency or burning on urination. Her past medical history is significant for peptic ulcer disease and right knee osteoarthritis. The patient takes naproxen occasionally for knee pain. She is not sexually active and does not use recreational drugs. Her temperature is 39.4 C (103 F), blood pressure is 90/70 mm Hg, pulse is 120/min, and respirations are 22/min. Physical examination shows costovertebral angle tenderness on the right side. No abdominal tenderness is present. Blood cultures are obtained. Intravenous fluid infusion and broad-spectrum antibiotic therapy are initiated. Helical computed tomography scan shows a right-sided proximal ureteral stone with dilated renal calyces. Which of the following is the most appropriate next step in management of this patient?

Question

A 52-year-old woman is brought to the emergency department with fever, chills, nausea, skin flushing, and intense right-sided back pain.  For the past week, she has experienced on-and-off back pain.  She has no urinary urgency or burning on urination.  Her past medical history is significant for peptic ulcer disease and right knee osteoarthritis.  The patient takes naproxen occasionally for knee pain.  She is not sexually active and does not use recreational drugs.  Her temperature is 39.4 C (103 F), blood pressure is 90/70 mm Hg, pulse is 120/min, and respirations are 22/min.  Physical examination shows costovertebral angle tenderness on the right side.  No abdominal tenderness is present.  Blood cultures are obtained.  Intravenous fluid infusion and broad-spectrum antibiotic therapy are initiated.  Helical computed tomography scan shows a right-sided proximal ureteral stone with dilated renal calyces.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient has a ureteral stone with proximal ureteral obstruction resulting in hydronephrosis, superimposed infection, and hemodynamic instability. Her condition is life-threatening, and immediate intervention is necessary. Drainage of the obstructed portion of the urinary tract via percutaneous nephrostomy or retrograde ureteral stent placement will facilitate prompt stabilization of the patient and rapid relief of symptoms. Either method of drainage is acceptable, depending on the expertise of available clinical staff. However, percutaneous nephrostomy is generally preferred in patients who are clinically unstable or have very large stones. (Choice A) Antibiotic therapy alone is insufficient to manage this patient as long as the ureter remains obstructed. Percutaneous nephrostomy or ureteral stent placement must also be performed to relieve the obstruction. (Choice B) Open stone extraction is associated with a significant operative risk. It has been replaced largely by percutaneous nephrostomy or ureteral stent placement for most indications. (Choice C) Alpha blockers such as tamsulosin have been shown to facilitate stone passage in stable patients with relatively small (<10 mm) ureteral stones. They are not recommended for patients with larger stones or those with clinical instability such as infection or acute kidney injury. (Choice E) Shock-wave lithotripsy is used in the management of uncomplicated proximal ureteral stones. However, it may not lead to immediate relief of ureteral obstruction. As a result, unstable patients with infection or acute kidney injury first require decompression with percutaneous nephrostomy or ureteral stenting. Educational objective: Patients with obstructing ureterolithiasis associated with infection, acute kidney injury, or severe pain that has failed initial measures require decompression of the upper urinary tract with percutaneous nephrostomy or ureteral stent placement. References: Emergency ureteric stent vs percutaneous nephrostomy for obstructive urolithiasis with sepsis: patterns of use and outcomes from a 15-year experience. (http://www.ncbi.nlm.nih.gov/pubmed/23795789) Emergent percutaneous nephrostomy for the diagnosis and management of pyonephrosis. (http://www.ncbi.nlm.nih.gov/pubmed/23997415)

A 52-Year-Old Woman Is Brought to the Emergency Department with Fever