What is the next step in managing a 75-year-old woman with bilateral hydronephrosis, uterine prolapse, stress incontinence, and a Klebsiella urinary tract infection, besides antibiotic therapy?

Management of Bilateral Hydronephrosis Due to Uterine Prolapse

The next step in managing this patient should be urgent urinary tract decompression via percutaneous nephrostomy (PCN) placement to relieve the obstruction and prevent further renal deterioration. 1

Patient Assessment and Rationale

This 75-year-old woman presents with:

• Bilateral hydronephrosis and hydroureter
• Marked uterine prolapse (likely causing the obstruction)
• Elevated serum creatinine (3.2 mg/dL) indicating acute kidney injury
• Klebsiella urinary tract infection
• Stress incontinence with significant post-void residual (100 mL)
• Lower limb phlebitis (complicating factor)

This clinical picture represents obstructive uropathy secondary to severe pelvic organ prolapse with concurrent infection and renal impairment, requiring immediate intervention.

Management Algorithm

1. Immediate Management

• Urgent percutaneous nephrostomy (PCN) placement bilaterally to decompress the collecting system 1
  • This is superior to retrograde ureteral stenting in this scenario due to:
    • Elevated creatinine indicating renal failure
    • Presence of infection (Klebsiella UTI)
    • Anatomical distortion from severe prolapse making retrograde access difficult

2. Infection Management

• Targeted antibiotic therapy based on Klebsiella susceptibility testing
  • Empiric therapy with ciprofloxacin or a third-generation cephalosporin while awaiting culture results 2
  • Adjust antibiotics based on susceptibility testing
  • Continue for 7-14 days for complicated UTI with obstruction 3

3. Post-Decompression Evaluation (within 24-48 hours)

• Monitor renal function (creatinine trends)
• Repeat imaging to confirm adequate decompression
• Urine output monitoring from nephrostomy tubes

4. Definitive Management (after stabilization)

• Surgical correction of uterine prolapse via:
  • Vaginal hysterectomy with pelvic floor repair
  • Colposuspension or sacrocolpopexy 4, 5
• Consider converting PCN to internal ureteral stents prior to definitive surgery if renal function improves

Evidence and Rationale

Bilateral hydronephrosis with elevated creatinine represents a urological emergency requiring prompt decompression. The American College of Radiology guidelines emphasize that progressive dilation of the upper urinary tract can lead to acute kidney injury and permanent nephron loss if not corrected promptly 1.

In patients with obstructive uropathy and infection (as evidenced by the Klebsiella UTI), PCN is the preferred initial approach. According to the ACR guidelines, PCN has a higher technical success rate in relieving obstruction compared to retrograde stenting, especially in cases with extrinsic compression 1.

Several case reports demonstrate that severe uterine prolapse can cause bilateral hydronephrosis leading to renal failure 6, 7, 4, 8. These reports consistently show that decompression followed by correction of the prolapse results in resolution of the hydronephrosis and improvement in renal function.

Important Considerations

• Avoid delay in decompression: Prolonged obstruction can lead to irreversible kidney damage 7
• Infection risk: Pyonephrosis may develop in obstructed systems with UTI, which can rapidly progress to urosepsis
• Post-decompression diuresis: Monitor fluid status and electrolytes closely after decompression
• Definitive management timing: Plan for definitive surgical correction of prolapse after stabilization of renal function and resolution of infection
• Long-term follow-up: Regular monitoring of renal function and upper tract imaging is necessary after definitive treatment

By following this approach, the immediate risk to renal function can be addressed while preparing for definitive correction of the underlying anatomical problem.