Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

unilateral or bilateral obstruction with signs of infection

1st line – nephrostomy tube or ureteric stent

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INITIAL
|
unilateral or bilateral obstruction with signs of infection
1st line – 

nephrostomy tube or ureteric stent

An obstructed and infected kidney requires urgent intervention to prevent renal damage and overwhelming sepsis.[29][40]​​[41]

In any situation where obstructive uropathy is present with signs of infection, a stent or nephrostomy tube is usually indicated regardless of underlying aetiology. A nephrostomy tube may be preferred as it can provide better drainage of the kidney, but choice will depend on local resources and expertise.[42][43][44]

It is advisable to seek the advice of a urologist if infection exists in the setting of urinary tract obstruction.

Plus – antibiotics

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INITIAL
|
unilateral or bilateral obstruction with signs of infection
Plus – 

antibiotics

Treatment recommended for ALL patients in selected patient group

Urinary tract infection (UTI) in a patient with obstruction at any site in the urinary tract is a complicated UTI. Clinical presentation can vary and can include imminent urosepsis.[29]

Sepsis should be clinically suspected in those with fever or hypothermia, leukocytosis or leukopenia, tachypnoea, and tachycardia. A validated scoring system such as the quick Sequential [sepsis-related] Organ Failure Assessment (SOFA) score can identify those at risk of deterioration due to sepsis. Patients with at least two of the following three criteria: respiratory rate of 22 breaths per min or greater, altered mental state (Glasgow Coma Scale score <15), or systolic blood pressure of 100 mmHg or less, are likely to have poor outcomes requiring escalation of therapy as appropriate.[29][30]

Parenteral broad-spectrum antimicrobials should be initiated within 1 hour of the suspicion of sepsis. Empiric antibiotic therapy should be started pending sensitivity results based on urinalysis cultures. Examples of suitable first-line empiric antibiotics include a third-generation cephalosporin (e.g., cefotaxime, ceftriaxone), piperacillin/tazobactam, or a carbapenem (e.g., meropenem).[29]

Definitive treatment, such as lithotripsy to remove obstructing stones, can be carried out with the nephrostomy or stent in situ once infection has resolved. This may be days, weeks, or months later.

Primary options

cefotaxime: 2 g intravenously every 8 hours

OR

ceftriaxone: 1-2 g intravenously every 24 hours

OR

piperacillin/tazobactam: 4.5 g intravenously every 8 hours.

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OR

meropenem: 1 g intravenously every 8 hours

ACUTE

unilateral or bilateral obstruction due to calculi without signs of infection

1st line – trial of passage with analgesia and rehydration

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ACUTE
|
unilateral or bilateral obstruction due to calculi without signs of infection
|
small stones (<10 mm)
1st line – 

trial of passage with analgesia and rehydration

All patients with ureteric calculi will initially require analgesia and rehydration (either oral or intravenous). Often a full assessment is difficult without adequate pain relief.

Stones less than 5 mm will usually pass without intervention.[19] Stones between 5 mm and 10 mm frequently require treatment but may warrant a trial of conservative management. Stones larger than 10 mm require intervention.[40] Ideally, urine should be strained in order to collect the stone as it passes allowing it to be sent for composition analysis.

Patients with unrelenting pain, bilateral obstruction, renal failure, and/or a solitary kidney should be considered for immediate treatment regardless of size of the stone. If the stone does not pass within 4 to 6 weeks, definitive intervention is also recommended.

During observation, regular imaging to delineate stone position and degree of hydronephrosis is recommended. If the stone is visible on plain film, abdomen and pelvis x-ray (kidneys, ureter, bladder) can be used for monitoring. If not, intravenous pyelogram or computed tomography scan may be used.

Start with simple analgesics such as paracetamol and progress to non-steroidal anti-inflammatory drugs such as diclofenac or ketorolac, or opioids such as morphine, if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Secondary options

ketorolac: 30 mg intravenously/intramuscularly every 6 hours when required for up to 5 days, maximum 120 mg/day

More

Tertiary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 10-30 mg orally (immediate-release) every 4 hours when required initially, adjust dose according to response

Plus – alpha-blockers

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ACUTE
|
unilateral or bilateral obstruction due to calculi without signs of infection
|
small stones (<10 mm)
Plus – 

alpha-blockers

Treatment recommended for ALL patients in selected patient group

Patients with uncomplicated ureteral stones smaller than or equal to 10 mm should be offered medical expulsive therapy with alpha-blockers.[40][45] [ Cochrane Clinical Answers logo ] [Evidence C]

Primary options

tamsulosin: 0.4 mg orally once daily

OR

alfuzosin: 10 mg orally once daily

2nd line – active stone removal

Back
ACUTE
|
unilateral or bilateral obstruction due to calculi without signs of infection
|
small stones (<10 mm)
2nd line – 

active stone removal

Options for the removal of urinary stones that are not able to pass spontaneously include extracorporeal shock wave lithotripsy, ureteroscopy with laser lithotripsy, and percutaneous nephrolithotomy.[40][46]​​ Removal is usually required for stones larger than 10 mm. Stones between 5 mm and 10 mm frequently require treatment as well.

The decision on which treatment to use depends on stone location, stone size, and patient preference. Patients with unrelenting pain, bilateral obstruction, renal failure, and/or a solitary kidney should be considered for immediate treatment regardless of size of the stone. If the stone does not pass within 4 to 6 weeks, definitive intervention is also recommended.

During observation, regular imaging to delineate stone position and degree of hydronephrosis is recommended. If the stone is visible on plain film, abdomen and pelvis x-ray (kidneys, ureter, bladder) can be used for monitoring. If not, intravenous pyelogram or computed tomography scan may be used.

1st line – analgesia and rehydration

Back
ACUTE
|
unilateral or bilateral obstruction due to calculi without signs of infection
|
large stones (≥10 mm)
1st line – 

analgesia and rehydration

All patients with ureteric calculi will initially require analgesia and rehydration (either oral or intravenous). Often a full assessment is difficult without adequate pain relief. Start with simple analgesics such as paracetamol and progress to non-steroidal anti-inflammatory drugs such as diclofenac or ketorolac, or opioids such as morphine, if required.

Patients with unrelenting pain should be considered for immediate treatment regardless of size of the stone. Stones less than 5 mm will usually pass without intervention.[19] Stones between 5 mm and 10 mm frequently require treatment but may warrant a trial of conservative management. Stones larger than 10 mm require intervention.[40] Ideally, urine should be strained in order to collect the stone as it passes allowing it to be sent for composition analysis.

Patients with unrelenting pain, bilateral obstruction, renal failure, and/or a solitary kidney should be considered for immediate treatment regardless of size of the stone.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Secondary options

ketorolac: 30 mg intravenously/intramuscularly every 6 hours when required for up to 5 days, maximum 120 mg/day

More

Tertiary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 10-30 mg orally (immediate-release) every 4 hours when required initially, adjust dose according to response

Plus – nephrostomy tube or ureteric stent or active stone removal

Back
ACUTE
|
unilateral or bilateral obstruction due to calculi without signs of infection
|
large stones (≥10 mm)
Plus – 

nephrostomy tube or ureteric stent or active stone removal

Treatment recommended for ALL patients in selected patient group

If there is no evidence of sepsis but the stone is larger than 10 mm, definitive intervention will be required.

Initial options include a nephrostomy or stent to decompress the kidney or urgent active stone removal with lithotripsy. If a nephrostomy tube or stent is inserted, then lithotripsy will usually be required subsequently. The choice of initial procedure will depend on the patient and resources available.

unilateral obstruction not due to calculi without signs of infection

1st line – nephrostomy tube or ureteric stent

Back
ACUTE
|
unilateral obstruction not due to calculi without signs of infection
1st line – 

nephrostomy tube or ureteric stent

A ureteric stent is usually the first choice of intervention to relieve unilateral obstruction. This is particularly important if there is evidence of infection, a solitary kidney, or renal insufficiency.

A nephrostomy tube may be used if a stent cannot be placed due to technical difficulties.

Definitive management will depend on the underlying cause.

Consider – analgesia

Back
ACUTE
|
unilateral obstruction not due to calculi without signs of infection
Consider – 

analgesia

Additional treatment recommended for SOME patients in selected patient group

Patients are not always in acute distress, as obstructive uropathy may develop slowly, but often analgesia will be required and can be titrated to the level of pain.

Start with simple analgesics such as paracetamol and progress to non-steroidal anti-inflammatory drugs such as diclofenac or ketorolac, or an opioid such as morphine, if required.

Primary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

Secondary options

ketorolac: 30 mg intravenously/intramuscularly every 6 hours when required for up to 5 days, maximum 120 mg/day

More

Tertiary options

morphine sulfate: 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required; 10-30 mg orally (immediate-release) every 4 hours when required initially, adjust dose according to response

Consider – treatment of underlying cause

Back
ACUTE
|
unilateral obstruction not due to calculi without signs of infection
Consider – 

treatment of underlying cause

Additional treatment recommended for SOME patients in selected patient group

Once the cause of obstruction is identified, treatment plans can be made based on each circumstance.

If a patient has malignancy, appropriate therapies should be determined by the treating team. Advanced malignancy causing ureteral obstruction carries a poor prognosis. However, many options are available for palliative relief of symptoms such as pain, uraemia, and urinary tract infections. The benefits of these treatments often far outweigh the risks.[47]

If the patient has obstruction due to a ureteral stricture or other urological cause, an evaluation by a urologist is necessary.

In the event of severe loss of renal function, nephrectomy may be indicated. This is a complex decision requiring the input of consultants and consideration of the overall clinical scenario.

bilateral obstruction not due to calculi without signs of infection

1st line – urethral catheter

Back
ACUTE
|
bilateral obstruction not due to calculi without signs of infection
1st line – 

urethral catheter

Catheterisation is the first-line treatment for a patient presenting with acute urinary retention or in an infant with a posterior urethral valve. Intermittent self catheterisation or an indwelling catheter are both options for chronic obstruction, either on a temporary basis while awaiting treatment for underlying cause or on a permanent basis if the underlying condition cannot be corrected.

If difficulty catheterising occurs, a catheter should never be forced but attention paid to where the resistance is felt. If the catheter cannot be passed due to meatal stenosis, dilating the meatus or placing a suprapubic tube may be required. If the blockage is within the penile urethra, it is most likely due to urethral stricture disease. A smaller silicone catheter may pass more easily, or a suprapubic tube may be required. Resistance near the level of the prostate is a sign of benign prostatic hyperplasia. A Coude tip (curved) catheter can often be inserted successfully in these patients. If urethral catheterisation is unsuccessful, a urologist may try to insert a urethral catheter with an introducer or perform suprapubic catheterisation. If both are unsuccessful or contraindicated, direct placement using a cystoscope may be possible.

Consider – treatment of underlying cause

Back
ACUTE
|
bilateral obstruction not due to calculi without signs of infection
Consider – 

treatment of underlying cause

Additional treatment recommended for SOME patients in selected patient group

The treatment of bilateral obstruction varies depending on the aetiology.

Benign prostatic hyperplasia may be treated with medication or surgical intervention.[50]​​​[51]

Obstructive disorders such as meatal stenosis, a posterior urethral valve, or urethral stricture may require surgical correction.

Long-term management is necessary if obstruction is due to bladder dysfunction (e.g., due to spinal cord injury). This may include urodynamic flow tests.

Plus – alpha-blockers

Back
ACUTE
|
bilateral obstruction not due to calculi without signs of infection
|
due to benign prostatic hyperplasia
Plus – 

alpha-blockers

Treatment recommended for ALL patients in selected patient group

Alpha-blockers can be started at the time of catheterisation.[52]

Primary options

tamsulosin: 0.4 mg orally once daily

OR

alfuzosin: 10 mg orally once daily

Consider – 5-alpha-reductase inhibitor

Back
ACUTE
|
bilateral obstruction not due to calculi without signs of infection
|
due to benign prostatic hyperplasia
Consider – 

5-alpha-reductase inhibitor

Additional treatment recommended for SOME patients in selected patient group

Combination therapy of doxazosin and finasteride has been shown to significantly decrease the progression in symptoms and the development of acute urinary retention more than either drug alone.[13]

Based on this evidence, 5-alpha-reductase inhibitors such as finasteride may be considered as adjunctive therapy for men whose prostate is thought to be larger than 40 grams on digital rectal examination or transrectal ultrasound.

Primary options

finasteride: 5 mg orally once daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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