Summary
Definition
History and exam
Key diagnostic factors
- signs of early organ dysfunction (tachypnea, tachycardia, hypotension, altered mental state) in a patient with suspected sepsis
- flank pain
- fever
- lower urinary tract symptoms
- distended abdomen/palpable bladder
- inability to urinate
- enlarged or hard nodular prostate on rectal exam
- costovertebral angle tenderness
- neurologic disease (e.g., spinal cord injury, multiple sclerosis)
Other diagnostic factors
- hematuria
- increasing age
- meatal narrowing
- pelvic or abdominal malignancy
- previous urethral instrumentation
- urinary tract infection in a child
- pelvic mass on internal exam
- weight loss and lymphadenopathy
- recurrent urinary tract infections
- urinary incontinence
Risk factors
- benign prostatic hyperplasia (BPH)
- constipation
- medication (anticholinergic agents, opioid analgesics, alpha receptor agonists)
- urolithiasis (ureteric calculi)
- spinal cord injury, Parkinson disease, or multiple sclerosis
- malignancy
- pregnancy
- hematuria
- posterior urethral valves
- bladder hernia
- cystocele
- iatrogenic injury
- urethral instrumentation
- retroperitoneal fibrosis
- meatal stenosis
Diagnostic tests
1st tests to order
- urinary dipstick
- renal ultrasound
- serum BUN and creatinine
- CBC
- CT abdomen and pelvis without contrast
Tests to consider
- urine culture
- blood culture
- CT scan abdomen and pelvis without and with contrast
- magnetic resonance urography (MRU)
- intravenous pyelogram (excretory urography)
- nuclear renography (triple renal/MAG3 scan)
- voiding cystourethrogram
- bladder ultrasound
- prostate specific antigen
- tumor markers (e.g., serum carcinoembryonic antigen [CEA], CA125)
Treatment algorithm
unilateral or bilateral obstruction with signs of infection
unilateral or bilateral obstruction due to calculi without signs of infection
unilateral obstruction not due to calculi without signs of infection
bilateral obstruction not due to calculi without signs of infection
Contributors
Authors
Harris E. Foster Jr., MD
Professor of Urology
Section Chief of Lower Urinary Tract Dysfunction and Reconstruction
Yale School of Medicine
New Haven
CT
Disclosures
HEF declares that he has no competing interests.
Adam Benjamin Hittelman, MD, PhD
Associate Professor in Urology
Section Chief of Pediatric Urology
Yale School of Medicine
New Haven
CT
Disclosures
ABH declares that he has provided expert testimony and has given lectures on obstructive uropathy.
Parth M. Patel, MD
Assistant Professor of Urology
Department of Urology
University of California Los Angeles
Los Angeles
CA
Disclosures
PMP declares that he has no competing interests.
Acknowledgements
Harris E. Foster Jr., Adam Benjamin Hittelman, and Parth M. Patel would like to gratefully acknowledge Adrienne J. Carmack, a previous contributor to this topic.
Disclosures
AJC declares that she has no competing interests.
Peer reviewers
Brian Cohen, MD
Private Practice Urologist
Asheville
NC
Disclosures
BC declares that he has no competing interests.
Yekutiel Sandman, MD
Private Practice Urologist
Miami
FL
Disclosures
YS declares that he has no competing interests.
Vincent Gnanapragasam, MBBS, BMedSci, PhD, FRCSEng, FRCSEd(Urol)
Lecturer in Uro-oncology and Consultant Urological Surgeon
Department of Urology
Addenbrooke's Hospital
Cambridge
UK
Disclosures
VG declares that he has no competing interests.
References
Key articles
Wessells H, Morey A, Souter L, et al. Urethral stricture disease guideline amendment (2023). J Urol. 2023 Jul;210(1):64-71.Full text Abstract
American College of Radiology. ACR appropriateness criteria: acute onset flank pain-suspicion of stone disease (urolithiasis). 2023 [internet publication].Full text
Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline amendment 2023. J Urol. 2024 Jan;211(1):11-19.Full text Abstract
European Association of Urology. EAU guidelines on urolithiasis. 2024 [internet publication].Full text
American Urological Association; Endourological Society. Surgical management of stones: AUA/Endourology Society guideline. 2016 [internet publication].Full text
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Parapelvic cyst
- Hydronephrosis of pregnancy
- Abdominal aortic aneurysm
More DifferentialsGuidelines
- EAU guidelines on urolithiasis
- EAU guidelines on urolithiasis
More GuidelinesPatient information
Catheterization (female): having a catheter fitted
Catheterization (male): having a catheter fitted
More Patient information
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