What is the appropriate treatment for a patient with a ureteral stone, proteinuria (70 urine protein), leukocyturia (11 urine white blood cells), and mucus in the urine, suggestive of a urinary tract infection?

Management of Ureteral Stone with Concurrent UTI

This patient requires immediate urine culture, empiric broad-spectrum antibiotics, and urgent imaging to assess for obstruction—if obstruction is present, emergency urological drainage must be established before any definitive stone treatment. 1, 2

Immediate Diagnostic and Therapeutic Steps

Obtain Urine Culture Before Antibiotics

• Collect urine culture immediately before initiating antimicrobial therapy to guide subsequent treatment adjustments based on sensitivities 2
• The presence of 11 WBC/HPF, proteinuria, and mucus strongly suggests active UTI in the setting of stone disease 1, 2

Start Empiric Antibiotics Immediately After Culture

• For complicated UTI with ureteral stone, initiate fluoroquinolones (ciprofloxacin 500 mg twice daily) or third-generation cephalosporins (ceftriaxone) as first-line therapy 1, 2
• Recent evidence suggests third-generation cephalosporins may be superior for clinical and microbiological cure in complicated UTIs 2
• Avoid nitrofurantoin and fosfomycin as they have insufficient data for upper tract infections 2
• Trimethoprim-sulfamethoxazole (160/800 mg twice daily) is acceptable only if local fluoroquinolone resistance is <10% 1, 3

Urgent Imaging for Obstruction Assessment

• Order immediate CT scan without contrast or renal ultrasound to evaluate for hydronephrosis, stone size, and location 2
• The 10 mm mid-ureteral stone described has significant risk of causing obstruction 1

Management Based on Obstruction Status

If Obstruction is Present (Hydronephrosis Confirmed)

• Immediate urological consultation for emergency drainage is mandatory 1, 2
• Retrograde ureteral stenting is preferred over percutaneous nephrostomy for most patients with obstructing stones and infection 1
  • Retrograde stenting allows for subsequent ureteroscopic stone removal and has shorter hospital stays 1
  • PCN is reserved for patients at high risk for anesthesia or when pyonephrosis is present requiring larger tube decompression 1
• If purulent urine is encountered during any endoscopic procedure, abort stone removal immediately, establish drainage, and continue broad-spectrum antibiotics 1, 2

If No Obstruction Present

• Continue intravenous antibiotics and close clinical monitoring 1
• Medical management with fluids and antibiotics is appropriate while awaiting culture results 1

Antibiotic Duration and Adjustment

• Adjust antibiotics based on culture and sensitivity results within 48-72 hours 2
• Treat for 7-14 days for complicated UTI (14 days if male patient to exclude prostatitis) 1
• If upper tract infection is confirmed, consider 4-6 weeks of lipid-soluble antibiotics 2

Definitive Stone Management (After Infection Control)

Timing of Stone Treatment

• Delay all definitive stone procedures until sepsis is completely resolved and infection is adequately treated 1, 2
• Stone removal should not be attempted in the presence of active infection due to risk of urosepsis 1

Treatment Options for 10mm Mid-Ureteral Stone

• Ureteroscopy with laser lithotripsy is first-line therapy for mid-ureteral stones of this size 1
• Extracorporeal shock wave lithotripsy (SWL) is less effective for mid-ureteral stones >10 mm 1
• Suspected infection stones must be completely removed to prevent recurrent UTI, continued stone growth, and renal damage 1, 4

Perioperative Antibiotic Prophylaxis

• Administer antimicrobial prophylaxis within 60 minutes of the procedure based on prior culture results and local antibiogram 1
• Single dose prophylaxis is generally adequate for uncomplicated cases 1

Stone Analysis and Prevention

• Send all stone material for analysis to determine if this is an infection stone (struvite/magnesium ammonium phosphate) versus metabolic stone with secondary infection 1, 4
• Perform metabolic stone evaluation after acute infection resolves to identify recurrence risk factors 2
• Do not treat asymptomatic bacteriuria after treatment completion 2

Critical Pitfalls to Avoid

• Never perform blind basket extraction without direct ureteroscopic visualization 1
• Never proceed with stone removal if purulent urine is encountered—this mandates immediate drainage and infection control 1
• Never delay drainage in obstructed, infected systems—this can rapidly progress to urosepsis and permanent renal damage 1
• The combination of obstruction and infection is a urological emergency requiring drainage within hours, not days 1