What are the next steps for a patient with a history of kidney stones, now experiencing severe unilateral lower back pain, hematuria, urinary retention, and dyspnea?

Emergency Management of Obstructive Kidney Stone with Urinary Retention and Sepsis

This patient requires immediate hospital admission and urgent urological decompression via percutaneous nephrostomy or ureteral stenting—this is a urological emergency that cannot wait. 1, 2

Immediate Actions (Within 30 Minutes)

• Admit to hospital immediately for severe unilateral flank pain with urinary retention (inability to pass urine), hematuria, and dyspnea—these symptoms suggest obstructive uropathy with possible sepsis 2
• Assess for sepsis urgently: Check vital signs for fever, tachycardia, hypotension, and obtain blood cultures, complete blood count, and serum creatinine 1, 2
• Obtain urgent renal ultrasound to confirm hydronephrosis and degree of obstruction 3
• Start IV fluids for resuscitation if septic or dehydrated 1

Pain Management

• Administer intramuscular diclofenac 75 mg as first-line therapy for acute stone pain, which provides superior relief within 30 minutes by directly decreasing ureteral smooth muscle spasm 2
• If NSAIDs are contraindicated due to renal insufficiency (check creatinine first), use opioids such as hydromorphone, pentazocine, or tramadol as second-line 1, 2

Critical Decision Point: Urgent Decompression

If fever is present with obstruction, or if the patient shows signs of sepsis (fever, elevated white blood cell count, hypotension), perform urgent decompression immediately via percutaneous nephrostomy or retrograde ureteral stenting before any definitive stone treatment. 1, 2 This is a urological emergency—delay can lead to irreversible renal damage, overwhelming sepsis, and death 4

The breathlessness (dyspnea) in this context is concerning for systemic sepsis or metabolic acidosis from acute kidney injury due to bilateral obstruction or obstruction of a solitary functioning kidney 2

Diagnostic Workup (After Stabilization)

• Urinalysis with microscopy to confirm hematuria and assess for infection (pyuria, bacteria) 1
• Urine culture if urinalysis suggests infection or if fever is present 1
• Serum chemistries including creatinine, electrolytes, calcium, and uric acid to assess renal function and identify metabolic abnormalities 1, 2
• Non-contrast CT scan once stable to determine stone size, location, and degree of obstruction for surgical planning 1

Definitive Stone Management (After Infection Resolves)

Once sepsis is controlled and the patient is stable:

• For stones >10 mm: Ureteroscopy (URS) is first-line surgical treatment, offering better stone-free rates than extracorporeal shock wave lithotripsy (ESWL) 1, 5
• For stones >20 mm: Percutaneous nephrolithotomy (PCNL) is the standard treatment 1, 5
• Obtain stone analysis when recovered to guide long-term prevention strategies 1, 2

Common Pitfalls to Avoid

• Do not delay admission for fever with obstruction—this represents obstructive pyelonephritis/urosepsis requiring immediate drainage, not outpatient management 1, 2
• Do not use opioids as first-line pain therapy when NSAIDs are appropriate—NSAIDs directly address the underlying ureteral spasm mechanism 2
• Do not attempt definitive stone removal before treating active infection—decompress first, treat infection with antibiotics, then address the stone surgically once sepsis resolves 1, 2
• Do not assume unilateral pain means the contralateral kidney is functioning—urinary retention (anuria) suggests either bilateral obstruction or obstruction of a solitary kidney, both requiring emergency intervention 2

Post-Decompression Management

• Start broad-spectrum IV antibiotics immediately after obtaining cultures if infection is confirmed 1
• Monitor renal function closely with serial creatinine measurements 1
• Plan definitive stone treatment within 4-6 weeks once infection clears 2
• Initiate metabolic evaluation with 24-hour urine collection after acute episode resolves to prevent recurrence 1, 2