Admission to the hospital is indicated if there is (1) infection with concurrent obstruction, (2) a solitary kidney and complete obstruction, (3) uncontrolled pain, or (4) intractable emesis.2 Patients with an infection and concurrent obstruction have the potential for severe systemic toxicity and represent a urologic emergency. Patients with renal impairment are candidates for consideration of a drainage procedure, since they have little functional renal reserve. Because of lower rates of spontaneous passage, patients with large (>5 mm), irregular, or proximal stones should be considered for admission. If there is severe concurrent underlying disease (e.g., angina or chronic obstructive pulmonary disease) or in the fragile elderly, when the patient may be unable to tolerate the stress of renal colic, a lower admission threshold is indicated. When the IVP or CT scan demonstrates complete obstruction, or dye extravasation, the admission decision requires individualization and discussion with a urologist. Patients who have previously been diagnosed and managed as outpatients are more likely to require admission if they return with continued pain. A careful history and physical examination are indicated to ensure that the diagnosis is correct, but repeat imaging is probably unnecessary.
In most situations, unilateral renal obstruction has minimal acute or permanent effects. Discharge is appropriate in patients with smaller, rounded stones, in the absence of infection, and when pain is controlled by oral analgesics. Patients should be given a urinary strainer with instructions to save any stones that are passed for pathologic evaluation. Patients should be counseled to return promptly for fever, vomiting, or uncontrolled pain, and they require a prescription for an oral narcotic. Follow-up with a urologist should be arranged within 7 days. 24 Patients whose stone passes in the emergency department require no further treatment. Elective urologic consultation should be arranged so that the etiology of the stone can be determined and a prophylactic strategy arranged. Patients with hematuria, negative imaging study findings, and no other attributable source require urologic follow-up to determine the etiology of their hematuria.
The management of patients with protease-inhibitor-induced urolithiasis is similar to the management of other causes of stone disease; however, adequate hydration is particularly important.21 In addition, discontinuation of the offending agent for a short period of time may be necessary. Such a decision should be made in consultation with a urologist and an infectious disease specialist. Disposition should be discussed with a urologist if there is (1) renal insufficiency, (2) severe underlying disease, (3) an IVP showing extravasation or complete obstruction, (4) multiple visits, (5) a large stone, or (6) sloughed renal papillae. 2
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