What is the next step in management for a 75-year-old woman with Impaired renal function, bilateral hydroureteronephrosis, uterine prolapse (procidentia), stress incontinence, and a urinary tract infection (UTI) due to Klebsiella?

Management of Obstructive Uropathy with Uterine Prolapse and Impaired Renal Function

For a 75-year-old woman with bilateral hydroureteronephrosis, elevated creatinine, uterine procidentia, and Klebsiella UTI, the next step in management should be antibiotic therapy and bilateral ureteral stents (option E).

Rationale for Immediate Intervention

The patient presents with a critical clinical scenario requiring urgent intervention:

1. Obstructive Uropathy: Bilateral hydroureteronephrosis on CT scan
2. Impaired Renal Function: Elevated serum creatinine of 3.2 mg/dL
3. Active Infection: Klebsiella UTI (10^5 col/mL)
4. Underlying Cause: Longstanding uterine procidentia (severe prolapse)

According to European Association of Urology guidelines, this combination of UTI and obstructive uropathy requires immediate drainage alongside appropriate antimicrobial therapy 1. The American College of Radiology Appropriateness Criteria specifically indicates that bilateral hydroureteronephrosis with elevated serum creatinine requires urgent decompression 1.

Management Algorithm

Step 1: Urgent Decompression with Ureteral Stents

• Bilateral ureteral stents are preferred over nephrostomy tubes in cases of distal ureter obstruction due to uterine prolapse 1
• This provides immediate relief of the obstruction while allowing time for definitive management of the prolapse
• Stents address the most urgent concern: preserving remaining renal function

Step 2: Appropriate Antibiotic Therapy

• Start empiric antibiotics immediately after obtaining cultures
• Given the known Klebsiella infection, tailor therapy based on susceptibility results
• Consider renal dosing adjustments due to impaired kidney function (CrCl likely <25 mL/min)
• Cephalosporins may be appropriate for Klebsiella infections of the genitourinary tract 2

Step 3: Definitive Management of Prolapse (After Stabilization)

• Once infection is controlled and renal function stabilized, address the underlying prolapse
• A vaginal pessary (option B) would be the next consideration after stabilization, not as the initial intervention 3
• More invasive surgical options (hysterectomy, repair, vesicourethropexy) should be deferred until the patient is stabilized

Evidence Supporting This Approach

Multiple case reports demonstrate that uterine prolapse can cause significant hydroureteronephrosis leading to renal failure 4, 5, 6, 7. The critical nature of this patient's presentation (elevated creatinine, bilateral obstruction, and active infection) necessitates immediate relief of the obstruction.

The staged approach (addressing obstruction and infection first, then the prolapse) is supported by guidelines and minimizes surgical risk in elderly patients 1. While vaginal pessaries have been shown to reverse obstructive uropathy in some cases 3, they are more appropriate as a second-stage intervention after the acute obstruction has been relieved with stents.

Common Pitfalls to Avoid

1. Delaying decompression: Waiting to place stents while treating only the infection could lead to irreversible renal damage
2. Attempting immediate surgical correction: Proceeding directly to surgical repair of prolapse before addressing the obstruction and infection increases perioperative risks
3. Underestimating the severity: The combination of elevated creatinine, bilateral obstruction, and infection represents a urological emergency requiring prompt intervention
4. Inadequate follow-up: After stent placement, close monitoring of renal function and resolution of infection is essential before definitive management of prolapse

The evidence clearly supports bilateral ureteral stents as the most appropriate next step in management for this patient with antibiotic therapy, as this addresses both the immediate threat to renal function and allows for treatment of the infection.