Silent hydronephrosis/pyonephrosis due to upper urinary tract calculi in spinal cord injury patients

Study design: A study of four patients with spinal cord injury (SCI) in who m a diagnosis of hydronephrosis or pyonephrosis was delayed since these pat ients did not manifest the traditional signs and symptoms. Objectives: To learn from these cases as to what steps should be taken to p revent any delay in the diagnosis and treatment of hydronephrosis/pyonephro sis in SCI patients. Setting: Regional Spinal Injuries Centre, Southport, UK. Methods: A retrospective review of cases of hydronephrosis or pyonephrosis due to renal/ureteric calculus in SCI patients between 1994 and 1999, in wh om there was a delay in diagnosis. Results: A T-5 paraplegic patient had two episodes of urinary tract infecti on (UTI) which were successfully treated with antibiotics. When he develope d UTI again, an intravenous urography (IVU) was performed. The IVU revealed a non-visualised kidney and a renal pelvic calculus. In a T-6 paraplegic p atient, the classical symptom of flank pain was absent, and the symptoms of sweating and increased spasms were attributed to a syrinx. A routine IVU s howed non-visualisation of the left kidney with a stone impacted in the pel viureteric junction. In two tetraplegic patients, an obstructed kidney beca me infected, and there was a delay in the diagnosis of pyonephrosis. The cl inician's attention was focused on a co-existent, serious, infective pathol ogy elsewhere. The primary focus of sepsis was chest infection in one patie nt and a deep pressure sore in the other. The former patient succumbed to c hest infection and autopsy revealed pyonephrosis with an abscess between th e left kidney and left hemidiaphragm and xanthogranulomatous inflammation o f perinephric fatty tissue. In the latter patient, an abdominal X-ray did n ot reveal any calculus but computerised axial tomography showed the presenc e of renal and ureteric calculi. Conclusions: The symptoms of hydronephrosis may be bizarre and non-specific in SCI patients. The symptoms include feeling unwell, abdominal discomfort , increased spasms, and autonomic dysreflexia. Physicians should be aware o f the serious import of these symptoms in SCI patients.