Emergent Treatment of Obstructive Pyelonephritis

[Dr. Jodi Antonelli]
I'd like to know about the patient's vital signs. Do they have a temperature, tachycardia, hypotension? Did they do any preliminary blood work, specifically with an interest in knowing their creatinine, their serum white blood cell count, and then a urinalysis, and then, obviously, have they obtained imaging at that point? I'd go and see the patient myself, but getting a little bit more history as well from the provider who has seen them, presenting symptoms, duration of the pain, if they have a history of stones previously, and do they appear toxic, non-toxic, is their pain controlled now, are they tolerating PO.

[Dr. Aditya Bagrodia]
Okay. Yeah. Clearly, a comprehensive history, physical, review of information. What are going to be your dead ringers, "This is a sick patient. Time to do something, urgent decompression"?

[Dr. Jodi Antonelli]
The immediate triggers to want to intervene and do something to drain the kidney would be if the patient is febrile, if they're at all hemodynamically unstable, and sometimes pain can give you tachycardia, but tachycardia coupled with hypotension certainly is worrisome. Then from the standpoint of the objective lab work that you get, putting that in the context of the patient's presentation and elevated white blood cell count in isolation sometimes could be just due to inflammation, but that coupled with a patient who may have some of those other signs, again, certainly heightens my concern.
Then the urinalysis. So, the urinalysis is tricky. Some of the parameters could be elevated in the setting of inflammation. Additionally, sometimes surprisingly, the urinalysis is not that impressive if a stone is truly obstructing. Sometimes it doesn't look as bad as you would expect, but if you have a urinalysis with positive nitrate, that really heightens my concern. Very severe gross hematuria or Pyridium, things that change the color of the urine can sometimes falsely elevate a nitrite that isn't actually a sign of infection, but a positive nitrate is worrisome. Then Leukocyte esterase I think more often can be elevated with just pure inflammation, and then elevated white cells or presence of bacteria on a UA can also be worrisome.

[Dr. Jodi Antonelli]
Yeah. So, I think it's important to get an idea from the patient how long had they been having symptoms when they are presenting to the ER because that's where your clock starts in terms of how long you want to attempt a trial of passage. So, I mean, the limited data that's out there, obviously, there's not a real ethical way to test this in humans, it's basically animal data, is we try not to leave a stone in a location that could potentially be obstructing or partially obstructing for more than six weeks.
So, typically, I'll make sure a patient has pain medication. There's a lot of emerging data now that NSAIDs actually may be better in terms of pain control than narcotics. So, if a patient has a normal renal function, no contraindications to NSAIDs, I actually prefer a ketorolac or diclofenac over narcotics. Sometimes I'll give the patient a breakthrough narcotic prescription as well like Tylenol 3 or tramadol or occasionally hydrocodone, but recommend that the patient uses the NSAIDs as our first line.
Then there's a lot of mixed data, and I think a lot of differing opinions around the globe about medical expulsive therapy, so the use of alpha blockers for promoting stone passage. The US versus Europe, and specifically the UK, I think, have very different thoughts on what should be done. So, there's a large trial, probably 2015, that was conducted in the UK and they had a very different outcome measure than many of the other studies that were done that was basically not a radiographic outcome in terms of stone passage, but lack of needed intervention.
Based on that trial, I think, the UK and most Europe are less inclined to prescribe alpha blockers for medical expulsive therapy. I think in the US it's still recommended in our AUA guidelines specifically for larger distal stones. The data is greatest there. So, I think prescribing a patient an alpha blocker is something that even if it's a proximal stone I tend to do.
My thought is that potentially some of these studies may not actually be powered to really show a difference that maybe matters clinically. I mean, if taking a pretty well-tolerated medication even has a 1% chance of preventing me from needing a surgery and a stent. I think it's worth it. So, certainly for larger distal stones over 5 mm distally I would definitely recommend an alpha blocker, but I'm usually inclined to prescribe it for any ureteral stone, and then plus/minus on anti-emetics depending on how the patient is feeling.