What is the best course of action for a 42-year-old female with right flank pain and a CT scan showing mild hydronephrosis secondary to a uterine fibroid in the emergency department (ED)?

Management of Right Flank Pain with Hydronephrosis Secondary to Uterine Fibroid in the ED

For a 42-year-old female with right flank pain and CT showing mild hydronephrosis secondary to uterine fibroid, the recommended disposition is outpatient gynecological referral with appropriate pain management and close follow-up, as this condition rarely requires immediate intervention in the ED setting. 1

Initial Assessment and Management in the ED

• CT findings confirming mild hydronephrosis secondary to uterine fibroid compression require pain control and assessment of renal function before discharge 1
• Evaluate for signs of infection (fever, leukocytosis) or severe obstruction that would necessitate more urgent intervention 1
• Assess urinalysis for blood or infection, as these findings may alter management approach 1
• Color Doppler ultrasound can be used to evaluate ureteral jets, confirming the degree of obstruction and helping determine urgency of intervention 1

Disposition Decision Algorithm

Criteria for Discharge with Outpatient Follow-up:

• Mild hydronephrosis without signs of infection 1
• Adequate pain control with oral medications 1
• Normal or stable renal function 1, 2
• Patient able to follow up with gynecology within 1-2 weeks 3, 4

Criteria for Admission or Urgent Intervention:

• Moderate to severe hydronephrosis with risk of renal damage 1
• Signs of infection suggesting obstructive pyelonephritis 1
• Inadequate pain control with oral medications 1
• Significantly impaired renal function 1, 2

Treatment Options to Discuss with Patient

• Medical management options for fibroids include hormonal contraceptives and NSAIDs for symptom control 4
• Surgical options include myomectomy for women wishing to preserve fertility 3, 4
• Uterine artery embolization is an effective minimally invasive option for treating fibroids causing urinary obstruction 2, 5
• Hysterectomy provides definitive treatment if family planning is complete 3, 4

Follow-up Recommendations

• Gynecological consultation within 1-2 weeks for definitive management planning 3, 4
• Urological consultation if hydronephrosis persists or worsens despite gynecological intervention 1, 2
• Repeat imaging (ultrasound) in 2-4 weeks to assess resolution of hydronephrosis 6
• Clear return precautions for worsening pain, fever, vomiting, or inability to urinate 1

Important Considerations and Pitfalls

• Hydronephrosis due to fibroid compression is typically unilateral and occurs at the pelvic brim where the ureter crosses the iliac vessels 2
• Rapid growth of fibroids should raise concern for sarcomatous change (rare but serious) 3
• Temporary relief with ureteral stenting may be considered in cases of significant obstruction, but is often technically difficult due to fibroid distortion 2
• Patients should be counseled that complete resolution of hydronephrosis may take several weeks after definitive treatment of the fibroid 6, 2