Obstructed upper tract in the presence of infection and fevers is a urological emergency.
Patient is at risk of rapidly progressive sepsis.
I would see the patient immediately
- In conjunction with ED / ICU +/- anaesthetics +/- ID
- Simultaneous assessment and management in keeping with CCrISP principles
- Large IV access and IV fluids
- Bloods including cultures
- Urine cultures and catheter
- Broad spectrum antibiotics i.e. piptaz
- Drainage (stent or nephrostomy) as soon as possible
Pathophysiology of (uro)sepsis:
The septic response is initiated by the pathogen, but the dysregulated host response then drives the sepsis.
Different pathogens have different ways of initiating a host response – classically described are lipopolysaccharide (LPS) endotoxins in the cell wall of gram -ve bacteria but can also be exotoxins such as in pseudomonas species.
These bacterial toxins, or the bacteria themselves, bind to cellular receptors (eg Toll like receptors) of innate immune cells such as macrophages, neutrophils and endothelial cells.
This triggers a cascade of cytokine release (interleukins, TNF-a) and synergistic activation of complement system which produces an overwhelming inflammatory response – resulting in widespread vasodilation and increased vessel permeability secondary to mediators like nitric oxide which can lead to shock.
After this initial overwhelming inflammatory response, there is a subsequent immunosuppressive response due to leukocytes and lymphocytes no longer working or undergoing apoptosis, which leaves patients vulnerable to secondary infections, and relapse of dormant viruses.
Other systems outside the immunological system can be involved – for example complement system activation is intimately connected to coagulation system and leads to hypercoagulability and risk of DIC.
- Toxins/mediators produced by bugs bind to receptors of innate immune system cells
- Massive inflammatory response driven by cytokine cascade
- Secondary immunosuppression
RCT (Pearle 1998) – no different between stent or nephrostomy.
Theoretical risk of worsening or causing bacteraemia with retrograde pyelogram or catheterisation has not been demonstrated.
Relief of obstruction is required to improve antibacterial effectiveness.
Definitive stone removal must be delayed until infection adequately treated.
Stone manipulation in the setting of concomitant undrained infection can lead to life threatening sepsis.