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SU29.1-11 | Urinary System Surgery — PBL Case
CLINICAL SETTING
Mr Ravi Kumar, a 42-year-old taxi driver, is brought to the emergency department at 3 a.m. with sudden, severe right-sided loin pain that comes in waves and radiates down to his groin and right testicle. He is restless and cannot find a comfortable position. He has vomited twice. There is no fever yet. He drinks little water during long driving shifts and has had a similar but milder episode last year that settled on its own. This case unfolds in stages — discuss each trigger fully before revealing the next.
Trigger 1: The acute presentation
Examination: Mr Kumar is afebrile, pulse 96, BP 132/84. He has marked right renal-angle tenderness but a soft, non-peritonitic abdomen. Urine dipstick shows microscopic haematuria. He keeps moving because lying still makes the pain worse.
DISCUSSION POINTS
- What is your leading diagnosis, and what features of the pain and examination support it?
- Why does this colicky pain make the patient restless, in contrast to peritonitis where patients lie still?
- What is the gold-standard imaging investigation, and why is it preferred over a plain KUB film for confirming a urinary calculus?
- Which initial analgesia and supportive measures would you institute, and why?
Click to reveal Trigger 2: The investigation results (discuss previous trigger first!)
Trigger 2: The investigation results
Non-contrast CT KUB confirms a 6 mm calculus impacted at the right vesicoureteric junction with moderate proximal hydronephrosis. Renal function is normal and the patient remains afebrile. His pain settles partly with analgesia. He asks whether the stone will pass on its own or whether he needs an operation.
DISCUSSION POINTS
- How does stone size and site guide the choice between conservative management and active intervention?
- What are the commonest stone compositions, and which is radiolucent — how does this affect imaging choices?
- What features in this patient would shift you from conservative management towards intervention?
- What are the principles behind the available interventional options for ureteric/renal stones?
Click to reveal Trigger 3: The deterioration (discuss previous trigger first!)
Trigger 3: The deterioration
Two days later, while awaiting outpatient review, Mr Kumar returns with a temperature of 39.2°C, rigors, tachycardia and worsening right loin pain. He looks unwell and his blood pressure is now 96/60. Investigations suggest an obstructed, infected upper urinary tract.
DISCUSSION POINTS
- Why is an obstructed AND infected kidney a urological emergency rather than a problem that can wait?
- What is the immediate priority — relief of obstruction (e.g. by stent or nephrostomy) and sepsis management — and why must drainage not be delayed?
- How does untreated obstruction threaten the long-term function of this kidney?
- What lifestyle and metabolic advice would you give Mr Kumar to reduce his risk of recurrent stones?
Group Task Assignments
- Construct a flow chart linking stone size and site to a management decision (conservative vs intervention), annotating the trigger points for escalation.
- Prepare a concise teaching summary contrasting the common stone types (calcium oxalate, struvite/staghorn, uric acid) by composition, radiological appearance and predisposing factors.
- Draft the emergency management plan for an obstructed, infected kidney, identifying who must be informed and how urgently.
Learning Issues
Research these questions and bring your findings to the discussion.
- [SU29.5] What are the clinical features, investigations (including the role of NCCT KUB) and principles of management of renal and ureteric calculi, and how does stone size guide management?
- [SU29.4] How does urinary tract obstruction produce hydronephrosis, and how does untreated obstruction threaten renal function?
- [SU29.3] Why is an obstructed, infected urinary tract an emergency, and what are the principles of its management?