Clinical Case Analysis: Mrs. Pushpa Kumari, 41F - Recurrent Complicated UTI

SUMMARY OF INVESTIGATIONS FROM REPORTS

Urine Routine (Abhay Institute of Medical Sciences)

CBC (ATMS, 18/03/2026)

USG Abdomen & Pelvis (Shree Mangaldeep Diagnostic, 14/03/2026)

• Liver: Mild hepatomegaly with multiple cysts; largest measuring 12.7 mm
• Gallbladder: CBD normal; multiple GB calculi with largest measuring ~12 mm (cholelithiasis)
• Kidneys: Right kidney normal. Left kidney - evidence of a 19x14 mm calculus noted at the midpole calyx - significant stone
• Urinary Bladder: Normal in morphology. Post-void residual = 150 mL - highly significant
• Uterus/Ovaries: Normal in morphology; right ovary 2x2 cm, left ovary 2x2 cm

Urine Dipstick/Routine (Bose Urology & Stone Clinic, 14/03/2026 - earlier visit)

• Blood: Positive (3+)
• Leucocytes: Positive
• Protein: Positive
• Urobilinogen: Normal
• Specific gravity: ~1.022

DIAGNOSIS

Primary Diagnosis:

1. Left Renal Calculus (19x14 mm) - acting as a nidus for persistent bacteriuria and obstruction
2. Elevated Post-Void Residual (150 mL) - bladder voiding dysfunction causing urinary stasis

Secondary/Contributing Diagnoses:

• Cholelithiasis (multiple GB stones)
• Mild hepatomegaly with hepatic cysts (incidental / background)
• Anaemia of mixed origin (chronic blood loss from hematuria + infection-related anaemia of chronic disease)

PATHOPHYSIOLOGY - WHY THIS IS COMPLICATED, RECURRENT UTI

"US assessment of postvoid residual volume can be assessed to determine causes for repeat UTIs or risk for UTI." - Tintinalli's Emergency Medicine

• Acts as a nidus/biofilm where bacteria embed themselves and survive antibiotic courses
• Can cause partial ureteric obstruction leading to pyelocaliectasis
• Urease-producing organisms (Proteus, Klebsiella) can cause struvite stones AND make existing stones grow - the alkaline pH of 7.0 in her urine is highly suggestive of a urease-producing organism colonising the stone

FURTHER WORKUP - STEP BY STEP

IMMEDIATE (Acute Phase):

• Collect midstream clean-catch urine before starting antibiotics
• Technique: Clean the periurethral area with antiseptic, discard the first stream (~50 mL), collect the midstream portion in a sterile container
• Culture on blood agar, MacConkey agar, and CLED medium
• Identify the organism and its antibiogram - this will guide definitive antibiotic therapy
• She has received antibiotics before, so ESBL-producing organisms (especially E. coli) or Proteus (if alkaline pH persists) must be excluded

• Quick identification of organism type (Gram-positive vs negative, cocci vs bacilli)
• If gram-negative rods with alkaline urine - high suspicion for Proteus mirabilis (urease producer)

• Two sets from different sites before antibiotic therapy

• The left renal stone may be causing obstructive uropathy - must assess renal function
• Also guides antibiotic selection (aminoglycosides require dose adjustment in renal impairment)

• Especially if vomiting or systemic illness

• Helps differentiate cystitis vs upper tract infection (pyelonephritis) vs urosepsis
• Procalcitonin >0.5 ng/mL suggests upper tract/systemic bacterial infection

IMAGING WORKUP:

• This patient is 41 years old with hematuria, recurrent UTI, and a known left renal stone
• CT KUB (non-contrast): precisely characterises stone size, location, density (Hounsfield units), and burden; detects hydronephrosis/hydroureter
• Contrast-enhanced CT urogram: evaluates entire urothelium from renal calyces to urethra, looks for:
  • Upper tract urothelial cancer (important in recurrent hematuria)
  • Renal parenchymal lesions
  • Obstruction and degree of hydronephrosis
  • Papillary necrosis
• The AUA guidelines (as cited in Campbell-Walsh Urology) state: "Multiphasic CT urogram is the imaging study recommended for the evaluation of hematuria - it offers complete imaging of the urinary tract and has the highest sensitivity and specificity for detecting lesions."

• X-ray KUB for radiopaque stones (calcium oxalate, struvite)
• USG for hydronephrosis, PVR, bladder wall thickening

AFTER ACUTE PHASE MANAGEMENT:

• This patient is 41 years old with recurrent hematuria
• Campbell-Walsh Urology states: "Cystoscopy should be performed in all adults ≥35 years of age who meet criteria for hematuria evaluation"
• Evaluates: bladder mucosa for tumour, cystitis cystica, bladder stones, trabeculation (indicating chronic outlet obstruction/detrusor hypertrophy), bladder neck pathology, urethral diverticulum
• Can also assess ureteric orifices

• A PVR of 150 mL in a 41-year-old woman is abnormal (normal <50 mL)
• Uroflowmetry will show the flow curve - a plateau (obstructive) vs sawtooth (detrusor underactivity) pattern
• Full urodynamics if indicated: distinguishes detrusor hypocontractility vs bladder outlet obstruction vs detrusor overactivity

• Three consecutive early morning voided specimens
• Rules out in-situ urothelial carcinoma presenting as hematuria + dysuria
• Important because bladder cancer can mimic recurrent cystitis in women (diagnosis is often delayed in females)

• Stone metabolic workup for the left renal stone (19x14 mm)
• Identifies underlying metabolic cause (hypercalciuria, hyperuricosuria, hyperoxaluria, hypocitraturia)
• Guides long-term stone prevention

• Diabetics have dramatically higher risk for complicated UTI, emphysematous pyelonephritis, and fungal UTI
• Her anaemia may have an underlying diabetic or metabolic cause

• Hb 9.1 g/dL - need to characterise: is it iron deficiency from chronic blood loss (hematuria) or anaemia of chronic disease?

TREATMENT PLAN

STEP 1 - ACUTE MANAGEMENT OF CURRENT UTI EPISODE

• Injection Ceftriaxone 1g IV once daily OR
• Tab Ciprofloxacin 500 mg BD x 10-14 days (if local resistance allows; check prior culture results)
• Tab Nitrofurantoin 100 mg SR BD x 5-7 days - NOT suitable if upper tract involvement suspected (poor renal tissue levels)

• Injection Ceftriaxone 1-2 g IV once daily, OR
• Injection Piperacillin-Tazobactam 3.375 g IV every 6 hours (if prior resistant organisms or severe illness)
• Injection Ciprofloxacin 400 mg IV every 12 hours
• Step-down to oral once culture sensitivity returns (total 10-14 days)

STEP 2 - MANAGE THE LEFT RENAL STONE

• First-line for stones up to 20 mm in renal pelvis or upper ureter
• Technique: Focused high-energy shock waves generated externally, focused on the stone under fluoroscopic/ultrasound guidance; stone is fragmented to <2 mm particles (steinstrasse)
• Contraindications: pregnancy, aortic aneurysm, uncorrected coagulopathy, active UTI (must treat UTI first, then plan ESWL)
• Success rate for 10-20 mm stones: ~60-80%

• For stones >20 mm or lower pole stones or those failing ESWL
• At 19x14 mm (approximating 19 mm), ESWL may be first attempted; if hard stone (HU >900 on CT) or lower pole, PCNL preferred
• Technique: Percutaneous access via flank under fluoroscopy/ultrasound guidance; nephroscope introduced; stone fragmented with ultrasonic/pneumatic lithotripter and extracted
• Gold standard for stone clearance

• If stone has migrated to ureter
• Holmium laser fibre passed through ureteroscope; stone vaporised

STEP 3 - ADDRESS THE POST-VOID RESIDUAL (150 mL)

• Urological consultation for formal uroflowmetry + urodynamics
• Rule out urethral stricture (she may need a urethroscopy)
• Rule out bladder neck obstruction, cystocele, or uterine prolapse causing outlet kinking

• If detrusor underactivity: timed voiding, double voiding technique, alpha-agonists to improve outlet relaxation
• If bladder neck obstruction: surgical correction
• If neurogenic: clean intermittent self-catheterization (CISC)
• In the interim: consider a short course of alpha-blocker (Tamsulosin 0.4 mg OD) to reduce outlet resistance and improve bladder emptying

STEP 4 - PROPHYLAXIS FOR RECURRENT UTI

• Continuous low-dose prophylaxis: Tab Nitrofurantoin 50-100 mg at bedtime OR Trimethoprim-Sulfamethoxazole 40/200 mg (half tab) at bedtime - for 6 months
• Cranberry extract / D-mannose (evidence limited but low risk, may be added)
• Adequate hydration: Minimum 2-2.5 L urine output daily - helps flush urinary tract
• Void hygiene counselling (front-to-back wiping, voiding post-intercourse)

STEP 5 - GALLBLADDER STONES

• GB stones are incidental at this stage (no evidence of acute cholecystitis in the report)
• Surgical consultation (Laparoscopic Cholecystectomy) as an elective procedure once the urological issues are addressed and she is stable
• Cholelithiasis in a 41-year-old woman is common (5F rule), and symptomatic stones warrant surgery

STEP 6 - ANAEMIA (Hb 9.1 g/dL)

• Iron profile to characterise type
• If iron deficiency: Tab Ferrous sulfate 325 mg OD or BD + Folic acid 5 mg OD
• If anaemia of chronic disease: treat underlying infection (the Hb should improve once UTI and stones are resolved)
• Reassess Hb at 6-8 weeks after treatment

STEP 7 - LONG-TERM STONE PREVENTION

• Increase fluid intake to >3 L/day
• Reduce dietary oxalate (if hyperoxaluria)
• Potassium citrate 20 mEq BD (if hypocitraturia)
• Allopurinol if uric acid stones
• Avoid excess vitamin C, animal protein
• Urinary pH monitoring: target pH 6-7

DIAGNOSTIC TECHNIQUES - EXPLAINED

Urine Culture & Sensitivity

1. Patient voids first ~50 mL to flush periurethral flora
2. Collects midstream urine (MSU) in sterile wide-mouth container
3. Delivers to lab within 1-2 hours (or refrigerates at 4°C for max 24 hours)
4. Lab inoculates on blood agar (shows haemolysis patterns), MacConkey (Gram-negative detection), and CLED medium (reduces swarming of Proteus)
5. Incubates 24-48 hours at 37°C
6. Colony count >10⁵ CFU/mL = significant bacteriuria; >10³ in symptomatic patient with single organism = significant
7. Identified organism then subjected to antibiotic disc sensitivity (Kirby-Bauer method) or MIC testing

CT Urography (CTU)

1. Non-contrast CT (phase 1): detects stones, calcifications, baseline densities
2. Corticomedullary phase (~30 seconds post-contrast): renal parenchymal vascularity, hypervascular tumours
3. Nephrographic phase (~90 seconds): parenchymal lesions optimally shown
4. Excretory/urographic phase (~10-15 minutes): fills collecting system, ureters, bladder - detects filling defects (TCC), strictures, obstruction
5. 3D reconstruction can show complete urinary tract anatomy

Cystoscopy

• Rigid cystoscope (for biopsy) or flexible (for outpatient diagnostic use)
• Patient in lithotomy position, perineum cleaned
• 21-22 Fr scope introduced transurethrally with sterile water/saline irrigation
• Systematic inspection: urethra, bladder neck, trigone, ureteric orifices (note if erythematous - suggests upper tract infection), bladder walls, dome, anterior wall, posterolateral walls
• Findings in recurrent cystitis: trabeculation, cystitis cystica, bullous oedema, mucosal erythema
• If lesion found: cold cup biopsy or TURBT (transurethral resection)

Uroflowmetry

• Patient voids into a funnel connected to a flowmeter with at least 150-200 mL urine
• Records: maximum flow rate (Qmax, normal >15 mL/sec in women), average flow rate, voided volume, time to maximum flow, flow pattern
• Immediately after, PVR measured by portable ultrasound
• PVR > 100 mL is abnormal; PVR > 300 mL indicates significant retention

SUMMARY TABLE

Resident's Key Takeaway: This is NOT simple recurrent cystitis. The 150 mL PVR and the 19x14 mm left renal stone are the structural reasons she keeps getting infected. Antibiotics alone will never cure this patient. She needs her stone addressed (ESWL/PCNL) and her voiding dysfunction evaluated and treated. A cystoscopy and CTU are non-negotiable at her age with recurrent hematuria to rule out urothelial malignancy. Culture-guided antibiotic therapy, followed by long-term prophylaxis after structural correction, completes the management.

REVISED ANALYSIS - Corrected USG Finding

CORRECTED USG INTERPRETATION

REVISED DIAGNOSIS

Primary Diagnosis:

Underlying Predisposing Structural Causes (revised):

• A transitional epithelium-lined outpouching of a renal calyx communicating with the collecting system through a narrow infundibulum/neck
• The narrow neck creates a ball-valve mechanism - urine enters but drains poorly, creating a stagnant urine pool - an ideal environment for bacterial growth and abscess formation
• The recent PubMed literature (PMID 41552101, 2025) explicitly states: "Calyceal diverticulum may initially present with complications such as UTI... UTI is a complication of calyceal diverticulum and could be its first clinical manifestation"
• The 2024 infected case report (PMID 39285958) describes: "a transitional epithelium-lined outpouching communicating with the main collecting system through a narrow infundibulum... they can cause UTI symptoms including hematuria, pain, and fever"
• This perfectly explains why she keeps getting UTIs - bacteria colonise the stagnant cyst fluid, antibiotics clear the bladder infection but do NOT penetrate adequately into the cyst, and the cyst re-seeds the urinary tract after each treatment course

• A simple cortical or paracalyceal cyst with no communication to the collecting system
• Less directly causative of UTI, but mechanical compression of adjacent calyx can cause focal calyceal obstruction and urine stasis
• The Bosniak classification (Grainger & Allison's Diagnostic Radiology): Bosniak Category I = simple cyst, fluid density, hairline thin wall, no septa/calcification/solid components, no enhancement post-contrast - 0% malignancy risk

• Still a major independent driver of recurrence
• Stagnant urine in the bladder cannot be flushed
• Any ascending infection from bladder persists because the reservoir is never emptied

WHY THE REVISED DIAGNOSIS CHANGES EVERYTHING

REVISED FURTHER WORKUP

IMMEDIATE:

• Collect before antibiotics
• Midstream clean-catch
• Alkaline urine pH 7.0 suggests Proteus mirabilis (urease producer) or Klebsiella - important to identify since these organisms colonise cysts readily
• Request specific sensitivities including ESBL screening given recurrent episodes with prior antibiotic exposure

• Rapid organism identification

• Her Hb is 9.1 g/dL - monitor closely
• Neutrophilia 83% confirms active bacterial infection
• Creatinine baseline before any nephrotoxic agents

• If fever, chills, rigors

IMAGING - CRITICAL REVISION:

• Non-contrast phase: assess density of cyst (simple fluid = <20 HU; complex/infected = higher HU, internal echoes)
• Excretory/urographic phase (10-15 min post contrast): the key test - if contrast fills the cystic lesion from the collecting system, it confirms calyceal diverticulum (communication with calyx demonstrated)
• If contrast does NOT enter the cyst = simple paracalyceal cyst (Bosniak category)
• Assigns Bosniak category I-IV to determine malignancy risk and need for follow-up

• 41-year-old female with recurrent hematuria - urothelial malignancy must be excluded
• Campbell-Walsh Urology states: "CT urogram is the recommended imaging study - it has the highest sensitivity and specificity for detecting lesions of the renal parenchyma and upper tracts"

• Phase 1: Unenhanced CT KUB (stones, calcifications, cyst density)
• Phase 2: Corticomedullary phase (~40 sec post-IV contrast)
• Phase 3: Nephrographic phase (~100 sec)
• Phase 4: Excretory/urographic phase (~10-15 min) - shows pelvicalyceal system, ureter, bladder

• If renal insufficiency (creatinine raised), pregnancy, or contrast allergy
• MRI can characterise cyst wall, internal content, and communication with collecting system

SHORT-TERM WORKUP:

• AUA guideline: cystoscopy required in all adults ≥35 years with hematuria evaluation
• In this patient: evaluate bladder mucosa, look for trabeculation (chronic outlet obstruction due to high PVR), mucosal erythema, cystitis cystica, and exclude urothelial carcinoma
• Also evaluates ureteric orifices - if left ureteric orifice shows efflux of turbid urine, confirms upper tract source

• PVR 150 mL in a 41-year-old woman is pathological
• Uroflowmetry shows Qmax and flow pattern
• If Qmax <12 mL/sec + high PVR = outlet obstruction or detrusor underactivity
• Urodynamic study differentiates: detrusor undercontractility vs bladder neck obstruction vs urethral stricture vs cystocele/prolapse
• This step is ESSENTIAL because treating only the cyst/kidney without fixing the bladder will result in continued recurrence

• Recurrent hematuria in a 41-year-old female must exclude in-situ urothelial carcinoma

• Hb 9.1 - characterise anaemia
• Diabetes screen (complicated UTI risk factor)

• Even without a stone, cyst fluid metabolic composition can be informative
• Rules out underlying metabolic cause predisposing to calyceal pathology

REVISED TREATMENT PLAN

STEP 1 - Treat the Acute UTI

• Tab Ciprofloxacin 500 mg BD x 10-14 days (await culture, adjust accordingly)
• OR Tab Co-amoxiclav 625 mg TDS x 10-14 days
• Add Tab Metronidazole if anaerobic/mixed infection suspected (debris in urine suggests mixed flora)

• Inj Ceftriaxone 1-2 g IV OD, OR
• Inj Piperacillin-Tazobactam 4.5 g IV TDS (broader cover, esp. if prior fluoroquinolone use)
• Step down to oral once afebrile x 48 hours and culture sensitivity known
• Total duration: 10-14 days minimum

If the cyst is infected (calyceal diverticulum with empyema), systemic antibiotics alone may fail because the cyst wall limits antibiotic penetration into the stagnant fluid - surgical drainage may be needed.

STEP 2 - Manage the Calyceal Cyst/Diverticulum

• Percutaneous aspiration ± sclerotherapy: Ultrasound/CT-guided aspiration of cyst contents under sterile conditions; sclerosant (e.g., ethanol 95%, povidone iodine) injected to obliterate the cavity - first-line for symptomatic cysts
• Percutaneous Nephrolithotomy (PCNL) approach: If there are stones within the diverticulum (milk of calcium), percutaneous access, dilation of the infundibular neck, drainage + ablation of cavity
• Laparoscopic unroofing/marsupialization: For large or recurrently infected diverticula; the neck is identified and laid open/closed off from the collecting system
• Retrograde endoscopic approach (Ureteroscopy + Laser): Balloon dilation of the narrow infundibular neck to improve drainage; less durable

• Bosniak I cysts: no imaging follow-up needed per ACR guidelines, 0% malignancy risk
• The cyst itself does not directly cause UTI in this case
• However, if >4-5 cm and causing calyceal compression/obstruction - laparoscopic cyst unroofing
• At 19x14 mm (~2 cm) with no malignant features - observe, no intervention needed for the cyst itself
• Focus shifts entirely to the 150 mL PVR as the primary cause

• IIF: 6-monthly CT/MRI follow-up x 1 year, then annually x 5 years (15% risk of progression)
• Bosniak III/IV: Surgical excision (partial or radical nephrectomy) due to high malignancy risk

STEP 3 - Address Post-Void Residual (150 mL) - UNCHANGED AND CRITICAL

• Formal urological evaluation: uroflowmetry + urodynamics
• Identify cause:

• Interim: Tab Tamsulosin 0.4 mg OD at bedtime (reduces urethral/bladder neck resistance, improves emptying)
• Double-voiding technique: Void, wait 5 minutes, void again - can reduce PVR by 30-50 mL in functional cases

STEP 4 - Prophylaxis (after structural causes addressed)

• Continuous low-dose: Tab Nitrofurantoin 100 mg SR at bedtime for 6 months
• OR Trimethoprim 100 mg at bedtime (if nitrofurantoin not tolerated)
• Cranberry extract / D-mannose 2 g OD - adjunctive, reduces E. coli adhesion to uroepithelium
• Hydration: 2.5-3 L fluid/day - ensures adequate urine flow and mechanical flushing
• Voiding hygiene education: Post-coital voiding, front-to-back wiping

STEP 5 - Anaemia Management

• Hb 9.1 g/dL, normocytic (MCV 86.9) - consistent with anaemia of chronic disease + possible iron deficiency from chronic hematuria
• Iron studies first to characterise
• If iron deficiency confirmed: Tab Ferrous Sulfate 325 mg BD + Folic acid 5 mg OD
• Target Hb >11 g/dL before any planned surgical procedure (PCNL/laparoscopy)

STEP 6 - Gallbladder Stones (elective)

• Symptomatic cholelithiasis: Laparoscopic cholecystectomy electively, after urological issues stabilised
• No urgent intervention unless acute cholecystitis develops

UPDATED DIAGNOSTIC PATHWAY SUMMARY

CURRENT PRESENTATION
        ↓
Urine C&S + Gram stain + Blood cultures
        ↓
Empirical antibiotics (complicated UTI protocol)
        ↓
CT UROGRAPHY (key investigation)
    ├── Contrast fills cyst on excretory phase → CALYCEAL DIVERTICULUM
    │         → Percutaneous aspiration/sclerotherapy or
    │           Laparoscopic unroofing (surgical criteria met)
    │
    └── No contrast → SIMPLE PARACALYCEAL CYST (Bosniak I)
              → Observe cyst, focus on PVR
        ↓
CYSTOSCOPY + UROFLOWMETRY + URODYNAMICS (bladder evaluation)
        ↓
Address PVR 150 mL (the primary recurrence driver)
        ↓
Urine cytology (exclude urothelial malignancy)
        ↓
Long-term prophylaxis + hydration + voiding education

KEY TEACHING POINTS FOR THE RESIDENT

1. USG cannot reliably distinguish a calyceal diverticulum from a simple paracalyceal cyst - only CT urogram with excretory phase (or MRI urogram) can show communication with the collecting system. This is the decisive investigation.
2. A calyceal diverticulum is a "stealth" cause of recurrent UTI - antibiotics treat the symptoms but cannot sterilise the stagnant pool inside the diverticulum. The bacteria re-emerge after each course. This is textbook "complicated UTI with an unresolved focus."
3. The 150 mL PVR is an independent, equally important cause - even if the cyst is treated, without fixing the voiding dysfunction, recurrence will continue from stagnant bladder urine.
4. In a 41-year-old woman with recurrent hematuria, always exclude urothelial malignancy - cystoscopy and urine cytology are non-negotiable. Bladder cancer is frequently missed in women because symptoms are attributed to recurrent UTI.
5. Never just repeat antibiotics for recurrent UTI without looking for the structural reason - three episodes in 2 months demands a full urological structural workup.