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    Challenging cases in urology: A case of hydronephrosis, sepsis, and pain

    “Challenging Cases in Urology” is a new Urology Times section in which residents from the nation’s leading urology programs present their toughest cases and how they ultimately managed them. Cases inform readers of the problem-solving process and provide a lesson from the authors’ experience.       


    Sara Valente, MDSara Valente, MD

    Sara Valente, MD, is a fourth-year urology resident at the University of Connecticut School of Medicine, Farmington.


    A 61-year-old female presented to the emergency department with a complaint of acute-onset right-sided flank and abdominal pain that awoke her from sleep. She described associated nausea, but denied urinary symptoms, hematuria, fever, or chills. One month ago she had been treated for a presumed urinary tract infection after presenting with dysuria and urinary frequency. She also reported intermittent abdominal pain dating back approximately 2 months.

    Her past medical and surgical history was notable for a right-sided UPJ repair in 1978 as well as a history of nephrolithiasis and right-sided ESWL. She did not know the stone composition. Additional surgical history included only a previous tonsillectomy.


    Evaluation in the emergency department revealed a leukocytosis of 16.7 thou/µL, a normal serum creatinine, and a clean catch urinalysis with 1 WBC/HPF, 4 RBC/HPF, nitrite positive, and leukocyte esterase negative. Complete metabolic panel and liver function tests were all within normal limits. A CT scan demonstrated moderate right-sided hydronephrosis, symmetric nephrograms, and a small calcification that appeared to be within the distal right ureter (figures 1 and 2).

    Figure 1. Initial CT scan revealed moderate right hydronephrosis. (Photo courtesy of Sara Valente, MD)

    Figure 1. Initial CT scan revealed moderate right hydronephrosis.

    gure 2. Right hydroureteronephrosis and small calcification near the right iliac artery. (Photo courtesy of Sara Valente, MD)

    Figure 2. Right hydroureteronephrosis and small calcification near the right iliac artery.

    Based upon these findings, the patient was taken to the operating room for stent placement. Cystoscopic evaluation of the bladder revealed no pathology. A right retrograde pyelogram showed a normal distal ureter with moderate hydronephrosis proximally, but no filling defect suggestive of a stone. A right ureteral stent was placed without difficulty. The patient remained afebrile and was discharged home.

    The following day, the patient called and complained of persistent abdominal pain, nausea, urinary frequency, and urgency. She was encouraged to return to the emergency department where she was found to be afebrile, hemodynamically stable, but clearly uncomfortable. Her examination was significant for generalized abdominal pain and right CVA tenderness.

    Next: What’s your working diagnosis and how would you proceed?


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