What is the treatment for urinoma?

Treatment of Urinoma

Large urinomas require percutaneous drainage combined with empiric antibiotics as initial treatment, while small urinomas can be managed conservatively with observation as they typically reabsorb spontaneously. 1, 2

Initial Assessment and Risk Stratification

The treatment approach depends critically on urinoma size and clinical presentation:

• Small, asymptomatic urinomas can be managed conservatively with observation, as the collection will most often be reabsorbed without intervention 2
• Large urinomas (even without systemic signs of infection) necessitate more aggressive medical treatment 2
• Critically ill or immunocompromised patients, or those with signs of sepsis/septic shock (fever, tachycardia, hemodynamic instability, abdominal guarding) and elevated inflammatory markers (leukocytosis, C-reactive protein, procalcitonin) require urgent multimodal management 1

Primary Treatment Strategy

For Large Urinomas

Percutaneous drainage is the cornerstone of treatment:

• Place a drainage catheter under ultrasound or CT guidance 2
• Consider percutaneous nephrostomy tubes for additional drainage and decompression of the collecting system 2
• Obtain fluid culture to guide targeted antibiotic therapy 2
• Initiate empiric antibiotics immediately at the time of drainage 1

Source Control in Complicated Cases

Address the underlying urinary tract injury:

• For partial ureteral transection causing the urinoma, attempt minimally invasive techniques (endoscopic or radiological) such as retrograde or anterograde stent positioning as first-line treatment 1
• In patients with complicated intra-abdominal infections and sepsis/septic shock, perform urgent source control procedures 1
• Damage control surgery should be considered in selected critically ill patients with ongoing sepsis 1

Antibiotic Regimen

Empiric antimicrobial coverage must target typical urinary and intra-abdominal pathogens:

• Antimicrobial regimens should have activity against gram-negative Enterobacteriaceae, gram-positive cocci, and obligate anaerobes 1
• Avoid first and second-generation cephalosporins as they are generally not effective against Enterobacter infections 1
• Avoid third-generation cephalosporins due to increased likelihood of resistance, particularly for Enterobacter cloacae and Enterobacter aerogenes 1
• Fourth-generation cephalosporins can be used if Extended-Spectrum beta-lactamase (ESBL) is absent 1
• Carbapenems (Meropenem or Imipenem) represent a valid therapeutic option for multidrug-resistant Enterobacter infections 1
• Metronidazole should be administered as the preferred anti-anaerobic agent in combination regimens 1
• For carbapenem-resistant Enterobacter, consider polymyxins, tigecycline, fosfomycin, or double carbapenem regimens 1

Critical Pitfalls to Avoid

Delayed diagnosis and treatment can lead to serious complications:

• Urinoma can progress to abscess formation, worsening hydronephrosis, electrolyte instability, and progressive loss of renal function if treatment is delayed 2
• The encapsulated urine creates a culture medium for bacteria, particularly when diagnosis is delayed in the presence of persisting peritonitis 1
• Urine extravasation into the retroperitoneal space causes local inflammatory response and lipolysis in surrounding perirenal fat, leading to encapsulation 1

Do not routinely use antifungals:

• Antifungals should not be used routinely but should be considered in critically ill patients after multidisciplinary clinical and biological evaluation 1
• Consider empirical antifungal therapy specifically in septic shock with community-acquired infections 1

Monitoring and Follow-up

• Evaluate response to drainage and antibiotics clinically with serial inflammatory markers 1
• Ensure adequate drainage output and resolution of systemic signs of infection 2
• Address the underlying cause (urinary tract injury, obstruction) to prevent recurrence 2, 3, 4