What is the next step in managing a patient with a 15-mm kidney stone, mild hydronephrosis, and signs of infection, including severe flank pain, fever, and dysuria?

Urgent Urologic Consultation Required

This patient requires immediate urologic consultation for emergent urinary drainage due to obstructive pyelonephritis with a large stone and systemic infection. 1

Critical Clinical Context

This patient presents with obstructive pyelonephritis (infected obstructed kidney), which is a urologic emergency that can rapidly progress to urosepsis and death if not promptly decompressed. 1, 2 The combination of:

• 15-mm stone at the pelvicalyceal junction (too large to pass spontaneously) 1
• Fever (38.3°C) and tachycardia indicating systemic infection 1
• Mild hydronephrosis confirming obstruction 1
• Positive urinalysis for infection 1

...creates a life-threatening scenario requiring urgent intervention within hours, not days. 1, 3

Why Immediate Urologic Consultation (Option C)

Emergent urinary drainage must be established before definitive stone treatment. 1, 4 The urologist will perform either:

• Percutaneous nephrostomy (PCN) - preferred when patient is unstable or has multiple comorbidities 1
• Retrograde ureteral stenting - alternative if technically feasible 1

Both approaches are considered equivalent first-line options for obstructive pyelonephritis, with the choice depending on local expertise and patient factors. 1 PCN has a 92% survival rate versus 60% for medical therapy alone in pyonephrosis. 1

Why Other Options Are Inadequate

Option A (14 days antibiotics + outpatient follow-up) is dangerous:

• Antibiotics alone are insufficient for obstructive pyelonephritis - the obstruction prevents adequate antibiotic penetration and allows continued bacterial proliferation. 1
• Without drainage, this patient faces high risk of septic shock and death. 1, 3, 2
• The 15-mm stone will not pass spontaneously (stones >10 mm have <10% passage rate). 1

Option B (Medical expulsive therapy + repeat imaging) is inappropriate:

• Medical expulsive therapy is contraindicated in the presence of infection. 1
• A 15-mm stone at the pelvicalyceal junction will not respond to medical management. 1
• Delaying drainage for 2 days risks progression to sepsis. 1, 3

Immediate Management Algorithm

1. Continue IV antibiotics (already started) - use third-generation cephalosporin or aminoglycoside combination as empiric therapy 1
2. Obtain urgent urology consultation for drainage procedure 1
3. Establish drainage via PCN or retrograde stent within hours 1, 4
4. Monitor for sepsis using qSOFA criteria (respiratory rate ≥22, altered mental status, systolic BP ≤100 mmHg) 1
5. Delay definitive stone removal until infection completely resolves (typically 7-14 days of antibiotics after drainage) 1, 4

Post-Drainage Definitive Management

After infection resolution and clinical stability for 48 hours, definitive stone treatment options include: 1

• Percutaneous nephrolithotomy (PCNL) - preferred for stones >20 mm 1
• Ureteroscopy with laser lithotripsy - alternative for smaller burden 1
• Treatment duration: 7-14 days of antibiotics (14 days if prostatitis cannot be excluded in males) 1

Critical Pitfalls to Avoid

• Never attempt immediate stone removal in infected obstructed systems - this can precipitate overwhelming sepsis. 4, 2
• Do not delay drainage - every hour increases sepsis risk. 1, 3
• Adjust antibiotics based on culture results within 48-72 hours. 1, 4
• Ensure adequate hydration but avoid fluid overload in setting of obstruction. 5

The patient's tachycardia (102 bpm) and fever indicate early systemic inflammatory response, making this a time-sensitive emergency requiring immediate specialist intervention. 1