@UrologyQuiz Quiz3 Answer: Pus coming from the ureteric orifice=infected, obstructed kidney (secondary to calculus/stone) Differential Diagnosis

Very few- the cause of obstruction & underlying pathology may vary but this is pathognomonic Next step in treatment

a 5Fr JJ uretreric stent was placed in a retrograde fashion over the wire

Place a JJ ureteric stent- send urine for culture (blood if overtly septic) commence broad spectrum antibiotics (typically gram negative cover e.g. gentamicin but also including amoxycillin (amoxicillin) for enterococcus- alternate regimens may include a cephalosporin or other agents depending on local factors). Focus antibiotics once cultures available. The cause of obstruction, in this case urolithiasis will be dealt with when the patient stable medically. Treat underlying risk factors for sepsis such as diabetes and immunosuppression with increased steroids if appropriate etc. Patients may need monitoring and may become extremely unwell with septicaemia- even if drainage has been established. Renal function should be monitored and taken into account especially with gentamicin administration. Data: Access, Stents, and Urinary Drainage Ben H. Chew & John D. Denstedt From: Advanced Endourology: The Complete Clinical Guide; Edited by: S. Y. Nakada and M. S. Pearle Humana Press Inc., Totowa, NJ free access: [http://www.springer.com/cda/content/document/cda_downloaddocument/9781588294463c2.pdf?SGWID=0-0-45-387663-p173728830] Pyonephrosis with an obstructing stone requires urgent decompression using either retrograde ureteral stent placement or antegrade percutaneous nephrostomy tube drainage. Whether urinary drainage to bypass the obstruction is best accomplished via a ureteral stent or a nephrostomy tube is a subject of debate. One study demonstrated that drainage was achieved less with stenting but was not significant. Teaching Points: 1) an infected obstructed system should have minimal manipulation, cultures of urine (and blood) taken with antibiotics - the cause of obstruction may be dealt with when the sepsis has settled 2) consider any underlying cause that contributes to sepsis and manage this as well e.g. diabetes, immunosuppression such as steroids (may need to increase in time of sepsis etc.) 3) Drainage of pyonephrosis by ureteric stent or percutaneous nephrostomy is essential- it is debated which is best form of drainage to relieve obstruction but they are likely equivalent and choice will depend on local practices, patient condition and even the next step in management