Urosepsis is a common urological and medical emergency. As a foundation doctor, you may be the first point of contact to assess and manage the patient. This article provides a structured approach to guide you.

You’re Bleeped: A Patient with Urosepsis 

Definition

Urosepsis (life-threatening organ dysfunction) due to infection from the urinary tract.[1]

Why it matters

Rapid deterioration and death if not recognised.[1]

Urgency

An infected obstructed kidney is a surgical emergency requiring urgent drainage (ureteric stent or nephrostomy).[1] 

Pyruria. Image from https://wtcs.pressbooks.pub/healthalts/chapter/8-2-review-of-anatomy-physiology-of-the-urinary-system/

First Things First — Sepsis 6 (BUFALO)

Carry out the Sepsis 6 bundle within 1 hour and escalate to seniors, ITU, +- urologist:

• Bloods – FBC, U&E, CRP, lactate, VBG/ABG, blood cultures.
• Urine output – insert catheter and monitor.
• Fluids – IV access, fluid balance chart, boluses if hypotensive.
• Antibiotics – broad spectrum IV (local policy, within 1h).
• Lactate – measure and trend.
• Oxygen – High flow 15L non-rebreather.

Keep patient nil by mouth in case urgent surgery is needed.

Causes — Medical vs Surgical 

Medical (non-obstructive)

• Catheter-associated infection.
• Recurrent or untreated pyelonephritis.
• Immunosuppression, diabetes.[1]

Surgical (obstructive)

• Stones (most common).
• Strictures, BPH, vesicoureteric reflux, bladder tumours, ureteric tumours.
• Recent surgery or instrumentation.[1]

Common organisms

E. coli, Enterococci, Staphylococci, Pseudomonas, Klebsiella, and Proteus. [1]

Hydronephrosis secondary to obstructive ureteric stone. Image from https://litfl.com/abdominal-ct-flank-pain-imaging/ 

Red flags for obstruction

• Known/suspected stone.
• AKI or septic.
• Recurrent UTIs.
• Recent catheter change.
• No improvement on antibiotics in 48–72 hrs.

Investigations

• Bloods & blood cultures > Renal function, inflammatory markers, organisms.
• Urine MC&S > Organism.
• Imaging to identify if there is an obstruction:

• Bladder scan >Acute urinary retention or high post void residual (inadequate emptying).
• Ultrasound > Hydronephrosis/hydroureter.
• CT KUB > Gold standard for stones/obstruction. Usually accessible all hours.
• CT Urogram > Best when you suspect strictures, tumours, or extrinsic compression, or need to assess the function and anatomy of the upper tracts.[1,2,3]

Renal ultrasound. Image from UltrasoundCases

CT KUB (non-contrast). Image from https://www.kidney-international.org/article/S0085-2538(22)00291-5/abstract 

CT urogram (contrast). Image from https://cairibu.urology.wisc.edu/wp-content/uploads/sites/1064/2021/12/Whittemore-Concurrent-1.pdf 

Management Principles 

Medical

• Sepsis 6.
• Change/remove catheters if suspected source.[1]

Surgical

If sepsis is due to an obstructive cause > urgent decompression is indicated.

• Ureteric stent (retrograde via cystoscopy).
• Percutaneous nephrostomy (tube into renal pelvis under imaging).[1]

Flexible cystoscopy. Image from http://quizlet.com/644236207/kidney-stones-acute-kidney-injury-flash-cards/

Nephrostomy. Image from https://quizlet.com/863430169/exam-3-m8-10-flash-cards/ 

Stent vs Nephrostomy 

Ureteric stent (Retrograde Cystoscopic)

• First choice if access possible.
• Requires GA/spinal.
• Good for distal stones or lower tract obstruction.[1]

Nephrostomy (Percutaneous)

• Done under local by radiology.
• Better if patient unstable for anaesthetic.
• Used when stent passage not possible. [1]

Tip: Both are effective; the choice depends on patient stability, anatomy, and availability.

Summary

• Urosepsis = sepsis from urinary tract > treat as an emergency.
• Always do sepsis 6 within 1 hour.
• Infected obstructed system needs urgent stent/nephrostomy.
• Stent if possible, nephrostomy if not/stable access difficult.
• Escalate early to seniors, urology, and critical care.

References

Written by Nia Davies (FY2)
Edited by Joseph Latham (CT3)