DRIUrology clinical guide
Draft clinical resource — local clinical approval required before intranet publication

Urology Emergency management

Renal colic and pyelonephritis

Differentiate uncomplicated stone disease from infection, sepsis and an infected obstructed system.

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Flank pain / suspected stone flowchart

  1. Acute flank pain ± urinary symptomsAssess ABCDE, observations, pregnancy possibility, urinalysis, renal function, FBC/CRP and alternative diagnoses.
  2. Infection or high-risk obstruction?Fever/sepsis, anuria, AKI, bilateral obstruction, solitary/transplanted kidney or clinical deterioration.
  3. Yes — emergency pathwayCultures, current sepsis/antimicrobial pathway and immediate Urology discussion. Infected obstruction requires Urgent decompression planning.
    No — analgesia and imagingNSAID first line if suitable; use NICE population-specific imaging.
  4. Adult and not pregnant?Choose imaging without delaying escalation if the patient deteriorates.
  5. Yes — low-dose non-contrast CTUrgently and within 24 hours. Consider early intervention if pain persists or the stone is unlikely to pass.
    No — ultrasound firstPregnancy and people under 16; specialist/radiology input if uncertainty remains.
  6. Reassess before dispositionPain, vomiting, renal function, infection risk, high-risk anatomy, diagnostic certainty and ability to return.

Focused assessment

History

  • Pain onset/site/radiation, fever/rigors, vomiting and urinary symptoms
  • Previous stones/interventions, solitary or transplanted kidney
  • Pregnancy possibility, medicines, renal disease and analgesic contraindications

Examination

  • Observations, sepsis and hydration
  • Abdomen/loin tenderness and peritonism
  • Consider vascular, gastrointestinal, gynaecological and testicular alternatives

Investigations

  • Urinalysis, pregnancy test where relevant, U&E/creatinine, FBC and CRP
  • Blood/urine cultures before antibiotics when feasible in systemic infection
  • Low-dose CT or ultrasound according to age and pregnancy

Do not miss infected obstruction

Fever or sepsis with suspected upper-tract obstruction is a urological emergency. Start the current sepsis pathway, obtain cultures and blood tests, give antimicrobials according to the current DBTH policy, and contact Urology immediately for urgent source-control planning. Do not delay escalation while waiting for all results.

Suspected renal colic

  1. Assess observations, NEWS2, pregnancy possibility, solitary kidney, renal impairment, infection, analgesic contraindications and alternative diagnoses.
  2. For adults, offer urgent low-dose non-contrast CT within 24 hours. If pregnant, use ultrasound instead. For children and young people under 16, ultrasound is first line.
  3. Offer an NSAID first line if suitable. If contraindicated or insufficient, NICE recommends IV paracetamol; consider an opioid only if both are unsuitable or insufficient. Do not offer antispasmodics.

Disposition

Potential outpatient care

Pain controlled, no infection or AKI, no high-risk anatomy, able to hydrate and take medication, reliable follow-up and clear return advice. Use the current DBTH stone follow-up route.

Discuss or admit

Infection/sepsis, obstruction with renal impairment, solitary/transplanted kidney concern, uncontrolled pain or vomiting, diagnostic uncertainty, pregnancy, bilateral obstruction, or inability to manage safely at home.

Acute pyelonephritis without obstruction

Send urine for culture before antibiotics when feasible, assess severity and sepsis risk, and use current DBTH antimicrobial guidance informed by previous cultures, renal function, pregnancy and local resistance. The supplied fixed cefuroxime/gentamicin regimen is not reproduced as a universal rule.