How should an adult male with an acute urinary tract infection and an obstructing renal stone be managed?

Management of Acute UTI with Stone in Adult Male

In an adult male with acute UTI and an obstructing stone, immediate urinary decompression via percutaneous nephrostomy or retrograde ureteral stenting combined with broad-spectrum IV antibiotics is mandatory, as antibiotics alone are insufficient and can result in 40% mortality without drainage. 1, 2, 3

Immediate Assessment and Stabilization

Recognize the Emergency

• This is obstructive pyelonephritis—a urologic emergency requiring urgent intervention within hours, not days. 1, 2
• Look specifically for fever, tachycardia, hypotension, flank pain, and leukocytosis—these signs indicate sepsis requiring immediate decompression. 2, 3
• The presence of pyuria or positive leukocyte esterase confirms infection and mandates urgent action. 2

Obtain Critical Preoperative Studies

• Obtain urinalysis and urine culture immediately before starting antibiotics—this is essential for targeted therapy. 1
• Blood cultures should be drawn if sepsis is suspected. 2
• Non-contrast CT scan is required to define stone size, location, and degree of obstruction. 1
• CBC with differential and serum creatinine to assess for leukocytosis and renal function. 1

Antibiotic Management

First-Line Empiric Therapy

Initiate IV ceftriaxone 1-2g daily immediately as first-line empiric therapy—it demonstrates superior clinical and microbiological cure rates compared to fluoroquinolones for obstructive pyelonephritis. 1, 2, 3

• Ceftriaxone is specifically recommended by the American College of Radiology and European Association of Urology over ciprofloxacin due to better outcomes. 2, 3
• Adjust antibiotics at 48-72 hours based on culture and sensitivity results. 3
• Continue antibiotics throughout the acute phase and until definitive stone treatment is completed. 1

Critical Pitfall to Avoid

Never rely on antibiotics alone without drainage—this approach has only 60% survival compared to 92% with decompression. 2, 3

Urgent Urinary Decompression

Choose Between Two Equivalent Options

Option 1: Percutaneous Nephrostomy (PCN)

• Preferred in hemodynamically unstable or septic patients with hypotension—provides larger-diameter drainage and higher technical success (92% survival rate). 2, 3
• Yields superior bacteriological information for antibiotic tailoring. 2
• Allows for safer drainage when prolonged instrumentation risks worsening sepsis. 1, 2

Option 2: Retrograde Ureteral Stenting

• Equally effective alternative with decreased hospital stay and ICU admission rates compared to PCN. 1, 2
• May be preferred if interventional radiology is unavailable or patient is stable enough for cystoscopy. 2, 3
• However, avoid prolonged guidewire manipulation as this increases urosepsis risk. 1

Intraoperative Management

If purulent urine is encountered during any endoscopic intervention, immediately abort the stone removal procedure, establish drainage only (stent or nephrostomy), culture the purulent material, and continue broad-spectrum antibiotics. 1

• Close monitoring for worsening sepsis is required immediately during and after the procedure. 2
• Post-procedural bacteremia and sepsis are common when draining infected systems. 2

Definitive Stone Management (Delayed)

Timing is Critical

Delay definitive stone removal until the infection is completely resolved and the patient has completed a full antibiotic course—attempting stone removal during active infection risks life-threatening sepsis. 1, 3, 4

Stone Removal Options (Once Infection Cleared)

For distal ureteral stones:

• Ureteroscopy (URS) is first-line with 94-97% stone-free rates. 3
• Shock wave lithotripsy (SWL) is an alternative with 85-90% success but less invasive. 3

For larger or complex stones:

• Percutaneous nephrolithotomy (PCNL) for stones >20mm or complex anatomy. 1
• Complete stone removal is mandatory for suspected infection stones to prevent recurrent UTI, stone growth, and renal damage. 1, 5, 4

Perioperative Antibiotic Prophylaxis

• Administer single-dose prophylactic antibiotic within 60 minutes of the definitive procedure based on prior culture results. 1
• For PCNL with high infection risk, extended preoperative antibiotic course significantly reduces postoperative sepsis. 1

Special Considerations for Infection Stones

If struvite (infection) stones are suspected based on stone composition or urease-producing organisms (Proteus, Klebsiella), complete stone fragment removal is essential—residual fragments perpetuate infection and stone growth. 1, 6, 5

• Send all stone material for analysis to guide metabolic evaluation and prevention. 1
• Maintain sterile urine postoperatively with culture-specific antibiotics. 6, 7

Follow-Up Requirements

• Repeat imaging 5-9 days post-definitive treatment to confirm stone-free status. 3
• Urine culture 1-2 weeks after completing antibiotics to document clearance. 3
• Monitor renal function at 1,3, and 6 months. 3
• Metabolic stone evaluation once acute episode resolved to prevent recurrence. 3, 8

Common Pitfalls Summary

• Never delay decompression waiting for antibiotics to work—obstruction prevents antibiotic delivery to the infected kidney. 3
• Never attempt definitive stone removal during active infection—this can precipitate fatal sepsis. 1
• Never use fluoroquinolones as first-line empiric therapy—ceftriaxone has proven superiority. 2, 3
• Never leave residual stone fragments if infection stones are present—they serve as nidus for recurrent infection. 1, 5