A 66-year-old G3P3 woman is evaluated on postoperative day 2 following a vaginal uterosacr… — USMLE Step 2 CK

A 66-year-old G3P3 woman is evaluated on postoperative day 2 following a vaginal uterosacral ligament hysteropexy and anterior colporrhaphy for symptomatic stage III pelvic organ prolapse. She reports right-sided back pain, nausea, and mild vaginal spotting. The Foley catheter was removed yesterday, and she has been voiding spontaneously in adequate volumes.

Physical examination reveals marked right costovertebral angle tenderness. The vaginal vault is intact with minimal serosanguinous discharge.

Vital Signs	Value
Temperature	$38.4^\circ\text{C}$ ( $101.1^\circ\text{F}$ )
Blood pressure	$140/85\text{ mm Hg}$
Heart rate	$102/\text{min}$

Laboratory Studies	Value
Leukocyte count	$12,000/\text{mm}^3$
Serum creatinine	$1.1\text{ mg/dL}$ (Baseline: $0.8\text{ mg/dL}$ )
Urinalysis
Leukocyte esterase	Negative
Nitrites	Negative
WBCs	1-2/hpf
RBCs	3-5/hpf
Bacteria	None

Which of the following is the most appropriate next step in management?

Renal ultrasonographyCevap
B
Intravenous broad-spectrum antibiotic therapy
C
Lower extremity venous duplex ultrasonography
D
Endometrial biopsy
E
Nasogastric tube decompression

Cevap

Renal ultrasonography

This patient is presenting with signs of a unilateral ureteral obstruction (right-sided flank pain, costovertebral angle tenderness, a mild rise in creatinine, and fever) on postoperative day 2 following a vaginal uterosacral ligament hysteropexy. The uterosacral ligaments lie in close anatomic proximity to the ureters, making ureteral kinking, compression, or ligation a known complication of this procedure (occurring in up to 5% of cases). Unilateral obstruction may not cause oliguria or anuria if the contralateral kidney is functioning properly, but it rapidly leads to acute hydronephrosis and stretching of the renal capsule, causing severe flank pain. Tissue inflammation can lead to a low-grade fever and mild leukocytosis. Crucially, the urinalysis is negative for infectious signs, ruling out acute pyelonephritis, though surgical trauma often causes microscopic hematuria. The most appropriate next step is noninvasive imaging with renal ultrasonography to evaluate for hydroureter and hydronephrosis.

Adım Adım Çözüm

Analyze the patient's postoperative timeline and symptoms.

The patient presents with fever, right-sided flank pain, nausea, and a mild serum creatinine elevation on postoperative day 2 following a uterosacral ligament hysteropexy.

Establishing the timing and localized nature of symptoms helps narrow down the differential diagnosis of postoperative complications.

Evaluate the laboratory findings, specifically the urinalysis.

The urinalysis shows no signs of infection (negative leukocyte esterase, nitrites, and bacteria) but reveals trace hematuria.

A benign urinalysis effectively rules out acute pyelonephritis as the cause of her fever and costovertebral angle tenderness, pointing instead to a non-infectious, mechanical renal etiology.

Correlate the clinical picture with the specific anatomical risks of the surgical procedure.

Uterosacral ligament suspension carries a 1% to 5% risk of ureteral kinking or ligation due to the anatomic proximity of the ureter to the ligament.

Recognizing procedure-specific risks is essential; unilateral ureteral obstruction explains the acute hydronephrosis (causing flank pain and fever) and the mild acute kidney injury.

Determine the most appropriate initial diagnostic modality.

Renal ultrasonography is selected as the next step.

It is a fast, noninvasive, and highly sensitive bedside imaging test for detecting hydroureter and hydronephrosis resulting from suspected ureteral obstruction.

Anahtar Kavram

Ureteral obstruction is a recognized complication of uterosacral ligament suspension. It typically presents acutely with flank pain, fever, and a normal or slightly hematuric urinalysis; the initial diagnostic step is noninvasive imaging with renal ultrasonography.

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