What is the next step in management for a patient with uterine prolapse, bilateral hydroureteronephrosis, and a Klebsiella urinary tract infection, in addition to antibiotic therapy?

Management of Bilateral Hydroureteronephrosis Due to Uterine Prolapse

Bilateral ureteral stents should be placed immediately following antibiotic therapy for this patient with hydroureteronephrosis, elevated creatinine, and Klebsiella UTI secondary to uterine prolapse. This approach addresses both the urgent need to relieve obstruction and treat the infection, prioritizing preservation of renal function and prevention of further complications.

Assessment of Current Situation

The patient presents with:

• 75-year-old woman with lower limb phlebitis
• Marked bilateral hydroureteronephrosis on CT scan
• Long-standing uterine procidentia (complete prolapse)
• Stress incontinence controlled with daily pad
• Residual urine of 100 mL
• Significantly elevated serum creatinine (3.2 mg/dL)
• Active Klebsiella urinary tract infection (105 col/mL)

Management Algorithm

Step 1: Immediate Intervention

• Antibiotic therapy + bilateral ureteral stents
• Rationale: The patient has both infection and obstruction that must be addressed urgently to prevent further renal damage and sepsis 1, 2

Step 2: Antibiotic Selection

• For Klebsiella UTI with obstructive uropathy:
  • If local resistance patterns permit: Ciprofloxacin or levofloxacin
  • If resistance concerns: Carbapenem (particularly ertapenem) 2
  • Adjust based on culture sensitivity results
  • Dose adjustment required for creatinine clearance 2

Step 3: Drainage Approach

• Retrograde ureteral stenting is preferred over percutaneous nephrostomy (PCN) in this case because:
  • It provides internal drainage without external tubes
  • Lower rate of subsequent interventions compared to PCN 1
  • Better patient comfort and quality of life
  • Reduced hospital stay compared to PCN 1

Step 4: Definitive Management (after stabilization)

• After infection control and improvement in renal function:
  • Consider vaginal pessary as a temporary measure 3, 4
  • Plan for definitive surgical correction of prolapse

Evidence Supporting This Approach

1. Urgent decompression is critical: The ACR Appropriateness Criteria emphasizes that in cases of obstructive uropathy with infection, decompression is lifesaving and should not be delayed 1.

2. Stents vs. PCN: Retrograde ureteral stenting has been shown to be as effective as PCN with fewer subsequent interventions and better patient comfort 1.

3. Uterine prolapse causing renal failure: Multiple case reports document that uterine prolapse can cause bilateral hydroureteronephrosis leading to renal failure, and timely intervention is necessary to prevent irreversible kidney damage 3, 5, 6, 4, 7.

4. Reversibility of renal dysfunction: Early intervention with decompression can improve renal function before permanent damage occurs 4.

Common Pitfalls to Avoid

1. Delaying decompression: Waiting too long can lead to irreversible renal damage and progression to end-stage renal disease 7.

2. Treating only the infection: Antibiotics alone are insufficient without addressing the underlying obstruction 2.

3. Immediate surgical repair without stabilization: Attempting definitive surgical correction before treating infection and stabilizing renal function increases perioperative risks.

4. Overlooking the relationship between prolapse and hydroureteronephrosis: The connection between severe uterine prolapse and obstructive uropathy must be recognized early 5.

By following this approach, the patient's immediate risks from infection and obstruction are addressed while preserving the opportunity for definitive management of the underlying uterine prolapse once stabilized.