Obstructed infected ureteric stone — FFICM MCQ

Correct answer: A — Urgent urinary tract decompression with stent or nephrostomy

The correct answer is A, urgent urinary tract decompression with stent or nephrostomy. This woman has an infected, obstructed kidney (obstructing calculus plus fever, hypotension, hydronephrosis and stranding) with rapidly worsening AKI despite antibiotics and vasopressor support, which is a urological emergency requiring immediate source control. Antibiotics cannot penetrate or sterilise an obstructed collecting system, so the pus and infected urine remain trapped upstream of the stone, driving ongoing bacteraemia, septic shock and renal deterioration until the obstruction is relieved. Definitive stone treatment can wait; the priority is temporising drainage via retrograde ureteric stent or percutaneous nephrostomy, chosen according to local expertise and patient stability. Why the other options are wrong: B. Continue antibiotics alone for 48 hours: antibiotics alone cannot achieve source control in an obstructed system, and delaying drainage for 48 hours in a septic, deteriorating patient risks progression to irreversible renal damage or death. C. Arrange elective lithotripsy after discharge: lithotripsy is a definitive stone treatment for a stable, non-infected patient; it does nothing to relieve the acute obstruction and cannot be safely delayed to an outpatient setting in active sepsis. E. Give high-dose diuretics to force drainage: diuretics increase urine output proximal to a mechanical obstruction, risking worsening hydronephrosis, renal parenchymal pressure injury and further deterioration rather than relieving the blockage. D. Perform immediate open nephrectomy: nephrectomy is reserved for a non-salvageable, destroyed kidney or uncontrollable sepsis after failed decompression; it is far more invasive and morbid than the minimally invasive drainage options that should be tried first. Key point: in sepsis with an obstructing stone, emergency drainage (stent or nephrostomy) is the immediate life-saving intervention, and stone clearance is always deferred until the sepsis has resolved.

Reference: NICE NG118, Renal and ureteric stones: assessment and management (2019, updated), section on infected obstructed kidney requiring urgent decompression; https://www.nice.org.uk/guidance/ng118