What is the best course of treatment for an adult patient with a history of urinary tract infections (UTIs) and persistent hematuria, presenting with symptoms suggestive of urolithiasis, such as flank pain, dysuria, or hematuria?

Management of Urolithiasis with Recurrent UTIs and Persistent Hematuria

For an adult patient with recurrent UTIs and persistent hematuria presenting with symptoms suggestive of urolithiasis (flank pain, dysuria), you must pursue urgent diagnostic imaging with non-contrast CT or low-dose CT to confirm stone disease, followed by complete urologic evaluation including cystoscopy to exclude malignancy, while simultaneously treating any active infection and addressing stone management based on size and location. 1

Initial Diagnostic Approach

Confirm Stone Disease and Assess Complications

• Non-contrast CT abdomen/pelvis is the gold standard for diagnosing urolithiasis, as it detects stones of all compositions, assesses stone size and location, and identifies complications like hydronephrosis 1
• Low-dose CT protocols can replace traditional CT to minimize radiation exposure while maintaining diagnostic accuracy 1
• Obtain urine culture before initiating antibiotics if infection is suspected, as positive cultures occur not only with struvite stones but also with calcium oxalate and apatite stones 1, 2
• Measure serum creatinine to assess renal function, particularly important given the history of recurrent UTIs 1

Critical Red Flags Requiring Urgent Intervention

• Fever with obstructive stone indicates potential urosepsis and requires emergency urologic consultation for drainage (percutaneous nephrostomy or ureteral stent) plus IV antibiotics 1, 2
• Uncontrolled pain despite analgesia, solitary kidney with obstruction, or bilateral obstruction mandate immediate urologic referral 1
• Acute kidney injury (elevated creatinine) with obstruction requires urgent decompression 1

Addressing the Hematuria Component

Do Not Attribute Hematuria Solely to Stones

• Gross hematuria carries a 30-40% malignancy risk and requires complete urologic evaluation even when stones are present 3, 4
• Microscopic hematuria (≥3 RBCs/HPF) in adults with risk factors (age >35-40 years, smoking history, occupational chemical exposure, recurrent UTIs) necessitates cystoscopy and upper tract imaging regardless of stone presence 3, 5
• Cystoscopy is mandatory for all patients with gross hematuria and for those with microscopic hematuria plus risk factors to exclude bladder cancer 3, 4

Risk Stratification for Malignancy

• High-risk features include: age ≥60 years, smoking history >30 pack-years, >25 RBCs/HPF, history of gross hematuria, irritative voiding symptoms, or occupational exposure to benzenes/aromatic amines 3, 5
• Recurrent UTIs themselves are a risk factor for urothelial malignancy and should not delay evaluation 3
• Never defer hematuria workup due to the presence of stones—both conditions can coexist 3, 4

Stone Management Strategy

Conservative Management (Medical Expulsive Therapy)

• Stones ≤5mm have high spontaneous passage rates and can be managed conservatively with NSAIDs plus alpha-blocker (tamsulosin) 1, 6
• Adequate hydration is important, but avoid excessive fluid intake in acute obstruction as an obstructed kidney protects itself from further damage 6
• Provide analgesia with NSAIDs as first-line; avoid opioids when possible 1

Indications for Invasive Stone Treatment

• Stones >6mm are unlikely to pass spontaneously and require intervention (ureteroscopy, percutaneous nephrolithotomy, or shock wave lithotripsy) 1, 7
• Larger and more proximally located stones have lower spontaneous passage rates 1
• Persistent obstruction, uncontrolled pain, or infection with obstruction mandate urgent intervention 1, 2

Managing Infection Stones

Recognize Infection Stone Characteristics

• Struvite stones form in the presence of urease-producing bacteria (Proteus, Klebsiella, Pseudomonas) and indicate chronic infection 2
• Positive cultures occur with all stone types, not just struvite 2
• Stone analysis is essential in every case to guide metabolic evaluation and prevention strategies 6

Antibiotic Management

• Pre-operative antibiotic therapy is mandatory when infection is suspected or proven prior to any stone procedure 2
• For infection stones, long-term antibiotic therapy is recommended to prevent recurrence and stone regrowth after treatment 2
• Fluoroquinolones show excellent results for prophylaxis and treatment of post-operative infections after percutaneous or ureteroscopic stone removal 2
• Mid-stream urine culture has poor predictive value for post-procedure sepsis, but remains the easiest available parameter 2

High-Risk Patients for Urosepsis

• Immunocompromised patients, those with diabetes, anatomical urinary tract anomalies, or infection stones have higher risk of post-treatment sepsis 2
• These patients require prophylactic antibiotics and close monitoring 2

Metabolic Evaluation and Stone Prevention

Mandatory Metabolic Workup

• All patients with urolithiasis require metabolic evaluation, particularly those with recurrent stones 6, 7
• Common causes include: low urine output, hypercalciuria, hyperoxaluria, insufficient urinary citrate excretion, hyperuricosuria, and mechanical obstruction 6
• 24-hour urine collection for calcium, oxalate, citrate, uric acid, volume, pH, and creatinine guides targeted prevention 6

Specific Metabolic Interventions

• Hypercalciuria: thiazide diuretics reduce urinary calcium excretion 6
• Hypocitraturia: potassium citrate supplementation (15-30 mL diluted in water, 4 times daily) maintains urinary pH 7.0-7.6 and prevents stone formation 8
• Hyperuricosuria: allopurinol reduces uric acid production 6
• Hyperoxaluria: dietary oxalate restriction and calcium supplementation with meals 6

Universal Prevention Measures

• Adequate fluid intake to maintain urine output >2 liters/day is the cornerstone of prevention 6, 7
• Dietary modifications: reduce sodium, limit animal protein, maintain normal calcium intake (do not restrict calcium) 7
• Maintain healthy weight through physical activity 7

Follow-Up Protocol

For Persistent Hematuria After Stone Treatment

• Repeat urinalysis 6 weeks after stone treatment to confirm resolution of hematuria 5
• If hematuria persists (≥3 RBCs/HPF), proceed with complete urologic evaluation including cystoscopy and CT urography 5, 4
• Annual urinalysis at 6,12,24, and 36 months with blood pressure monitoring if hematuria persists after negative workup 3, 4

Stone Recurrence Monitoring

• Urolithiasis is a recurrent disease with higher recurrence rates in those with ≥2 previous stone episodes 1
• Long-term metabolic treatment and dietary modification are essential 7
• Repeat imaging if new symptoms develop (flank pain, hematuria, dysuria) 6

Critical Pitfalls to Avoid

• Never ignore hematuria even when stones are present—30-40% of gross hematuria cases harbor malignancy 3, 4
• Do not attribute hematuria to anticoagulation or the stone alone without complete evaluation 3, 4
• Absence of hydronephrosis does not exclude obstruction—early obstruction may not show pelvic dilatation 6
• Hematuria may be absent in 20-80% of urolithiasis cases, so its absence does not exclude stones 6
• Do not delay antibiotic therapy when infection is suspected—obtain culture first, then treat immediately 1, 2
• Recurrent UTIs with the same organism warrant imaging to exclude stones, particularly struvite-forming bacteria like Proteus 5