What is the best course of action for a patient with a nephroureteral stent, presenting with mild right-sided hydronephrosis/hydroureter, delayed nephrogram, periureteral stranding, and an enlarged liver, who is currently on Augmentin (amoxicillin/clavulanate) and declined admission for pain control?

Management of Persistent Hydronephrosis with Nephroureteral Stent in Place

The patient should be discharged on Augmentin with close outpatient follow-up, but requires urgent reassessment if fever, worsening pain, or signs of sepsis develop, as the current imaging findings suggest possible stent dysfunction that may necessitate percutaneous nephrostomy if symptoms progress. 1, 2

Immediate Assessment and Decision-Making

The clinical scenario presents mild hydronephrosis/hydroureter with periureteral stranding despite a functioning stent, which raises concern for:

• Partial stent obstruction or dysfunction - The presence of persistent hydronephrosis and delayed nephrogram despite stent placement suggests inadequate drainage 2
• Early infection/inflammation - Periureteral stranding can indicate developing pyelonephritis or stent-associated infection 1
• Stent colonization risk - Indwelling stents carry significant risk of bacterial colonization (42% in studies) even when urine cultures are negative 3

Why Outpatient Management is Acceptable (For Now)

The patient can be safely discharged because:

• Hemodynamic stability - The patient is not septic, hypotensive, or showing signs of systemic infection requiring emergent intervention 1
• Pain is manageable - The patient declined admission for pain control, indicating symptoms are tolerable 1
• Antibiotic coverage is appropriate - Augmentin provides adequate coverage for common urinary pathogens in non-septic patients 4

However, this is a conditional discharge requiring specific safety parameters.

Critical Red Flags Requiring Immediate Return

The patient must return immediately for any of the following:

• Fever >38°C or rigors - These indicate progression to obstructive pyelonephritis, where antibiotics alone are insufficient and decompression becomes lifesaving 1
• Worsening flank pain - May signal increasing obstruction or developing pyonephrosis 1
• Nausea/vomiting or inability to tolerate oral intake - Compromises oral antibiotic efficacy 1
• Altered mental status or hypotension - Signs of urosepsis requiring urgent drainage 1, 5

Why Percutaneous Nephrostomy May Be Needed

If the patient deteriorates, PCN should be strongly considered over stent revision because:

• Higher technical success rates - PCN approaches 100% success versus 80% for retrograde stenting, particularly with extrinsic compression or tight strictures 2
• Superior in stent failure scenarios - When hydronephrosis persists despite stent presence, PCN provides more reliable decompression 2
• Better outcomes in infection - In obstructive pyelonephritis/pyonephrosis, PCN achieved 92% patient survival versus 60% with medical therapy alone 1
• Allows targeted antibiotic therapy - PCN drainage provides bacteriological information to guide antibiotic selection 1

Outpatient Management Plan

Antibiotic continuation:

• Continue Augmentin as prescribed - provides adequate coverage for most urinary pathogens including amoxicillin-resistant organisms 4
• Complete the full antibiotic course even if symptoms improve 1

Monitoring parameters:

• Daily temperature checks - fever indicates need for immediate evaluation 1
• Pain assessment - escalating pain suggests worsening obstruction 1
• Urine output monitoring - decreasing output may indicate progressive obstruction 2

Follow-up timing:

• Urgent urology follow-up within 48-72 hours to reassess stent function 2
• Consider repeat imaging if symptoms persist or worsen 2
• Stent replacement should occur every 3 months routinely to prevent obstruction and infection 2

The Enlarged Liver Finding

The 20cm liver requires separate evaluation but does not change acute urological management:

• Document any history of liver disease, alcohol use, or hepatitis 1
• Arrange outpatient hepatology evaluation or primary care follow-up for liver assessment 1
• This finding is not directly related to the urological issue but requires investigation 1

Common Pitfalls to Avoid

Do not assume the stent is functioning adequately just because it is in place - persistent hydronephrosis indicates inadequate drainage requiring intervention if symptoms progress 2

Do not delay drainage if sepsis develops - antibiotics alone are insufficient in obstructive pyelonephritis, and decompression can be lifesaving 1

Do not ignore stent-related symptoms - mechanical irritation, biofilm formation, and encrustation are common complications that may require earlier stent replacement 6, 7, 3