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Suspected infected obstructed upper urinary tract (possible pyonephrosis) — MSRA MCQ

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HardHematuriaSuspected infected obstructed upper urinary tract (possible pyonephrosis)MSRA

A 64-year-old woman presents to her GP with 8 hours of severe right loin pain radiating to the groin, vomiting and visible haematuria. She has had rigors since this morning. Her temperature is 39.1°C, pulse 116 beats/minute, blood pressure 102/64 mmHg and respiratory rate 22 breaths/minute. There is marked right renal angle tenderness. Urine dipstick shows 3+ blood, 2+ leucocytes and positive nitrites. Her creatinine is 146 micromol/L; it was 78 micromol/L 4 months ago. She has no previous renal disease and is not pregnant. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Transfer immediately to hospital for sepsis management, urgent urinary-tract imaging and urological assessment for drainage

Explanation lettering: B = shown as A · A = shown as B · D = shown as C · C = shown as D

This presentation is concerning for an infected obstructed upper urinary tract (possible pyonephrosis): the colicky loin-to-groin pain and haematuria suggest ureteric obstruction, while fever, rigors, tachycardia, hypotension, nitrite-positive urine and acute kidney injury indicate systemic infection with physiological compromise. This requires immediate hospital transfer for resuscitation, parenteral antimicrobial treatment, urgent imaging and urological assessment for decompression. A is inadequate because suspected sepsis and possible obstruction require hospital-level assessment, not oral treatment with delayed review. B would be appropriate for uncomplicated suspected renal colic, but the usual urgent-within-24-hours CT pathway is superseded by concern about infected obstruction; NSAID use is also unattractive in acute kidney injury and relative hypotension. C misapplies the visible-haematuria cancer pathway: the immediate threat is sepsis from obstruction, not occult malignancy investigation. E delays assessment despite acute kidney injury and suspected pyonephrosis; NICE advises immediate ultrasound when pyonephrosis is suspected in a person with AKI.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — recommendations (2019) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG111: Pyelonephritis (acute): antimicrobial prescribing — recommendations (2018) — https://www.nice.org.uk/guidance/ng111/chapter/recommendations NICE NG118: Renal and ureteric stones: assessment and management — recommendations (2019) — https://www.nice.org.uk/guidance/ng118/chapter/Recommendations