What is the line of management for a patient with hydronephrosis presenting with intense pain?

Management of Hydronephrosis with Intense Pain

For a patient with hydronephrosis presenting with intense pain, immediately administer intramuscular diclofenac 75 mg to achieve pain relief within 30 minutes, and if pain persists beyond 60 minutes or if fever/shock are present, arrange immediate hospital admission for urgent imaging and possible decompression. 1, 2

Immediate Pain Management

First-Line Analgesia

• Administer intramuscular diclofenac 75 mg as the preferred first-line analgesic because the intramuscular route provides rapid, reliable pain control while oral and rectal routes are unreliable in acute settings 1, 2, 3
• Pain relief should be achieved within 30 minutes of assessment, with complete or acceptable pain control maintained for at least 6 hours 1, 2
• The intramuscular route is specifically preferred over intravenous administration in outpatient settings due to practicality 1, 2

Alternative Analgesia When NSAIDs Are Contraindicated

• Use morphine sulfate combined with cyclizine (antiemetic) when NSAIDs are contraindicated due to renal impairment, cardiovascular disease, gastrointestinal bleeding history, or pregnancy 1, 2, 3
• For patients with renal impairment specifically, fentanyl is preferred because it does not accumulate active metabolites, whereas morphine, codeine, and tramadol should be avoided 2, 3
• When administering intravenous morphine, start with 0.1-0.2 mg/kg every 4 hours, injected slowly to avoid chest wall rigidity 4

Critical Assessment and Red Flags

Immediate Hospital Admission Required If:

• Pain fails to respond to appropriate analgesia within 60 minutes 1, 2, 3
• Fever or signs of systemic infection are present (suggesting pyonephrosis requiring urgent decompression) 1, 2
• Shock or hemodynamic instability 1, 2
• Patient age >60 years (to exclude leaking abdominal aortic aneurysm) 1, 2
• Abrupt recurrence of severe pain after initial control 1, 2

Urgent Decompression Indications

• Sepsis and/or anuria in an obstructed kidney requires urgent decompression via percutaneous nephrostomy or ureteral stenting 3
• Infection with obstruction (pyonephrosis) necessitates urgent drainage, as this cannot be reliably distinguished from simple hydronephrosis even on CT imaging 1

Diagnostic Imaging Strategy

Initial Imaging Based on Clinical Context

• For symptomatic hydronephrosis with moderate to severe dilatation on ultrasound, CT abdomen/pelvis (with or without contrast) is appropriate to identify the cause and assess for stone passage failure risk 1
• Point-of-care ultrasound showing moderate to severe hydronephrosis in patients with moderate or high risk of ureteric calculi provides definitive evidence of obstruction without requiring high-dose CT initially 1
• Low-dose CT can be reserved for surgical planning when stone size and location need to be determined 1

When CT May Not Change Management

• In patients with clear renal colic and moderate to severe hydronephrosis on ultrasound, CT may not alter immediate management if the provider does not expect it to change the treatment plan 1
• However, CT is useful when ultrasound is nondiagnostic or when alternative diagnoses are suspected 1

Follow-Up Protocol

Monitoring After Initial Treatment

• Conduct telephone follow-up one hour after initial assessment and analgesia administration to verify pain control 1, 2
• Patients should be instructed to contact their physician immediately if pain worsens or unexpected symptoms develop 1
• Instruct patients to maintain high fluid intake and strain urine to capture any passed calculi 1, 2

Ongoing Surveillance

• For patients with known hydronephrosis, perform kidney ultrasound at least every 2 years to monitor for progression or bladder dysfunction 1

Common Pitfalls to Avoid

• Never delay analgesia while waiting for diagnostic tests – pain control is the immediate priority 2
• Do not discharge patients before ensuring adequate pain control for at least 6 hours 2
• Avoid missing signs of infection with obstruction, which requires urgent decompression rather than conservative management 2, 3
• Do not use oral or rectal analgesics as first-line treatment in acute severe pain, as absorption is unreliable 1, 2
• Be cautious about issuing take-home oral analgesics due to potential for drug misuse 1