Flank pain

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Jaspinder Kaur, MBBS[2]

Synonyms and keywords:

Overview

Flank pain is a sensation of discomfort, distress, or agony in the part of the body below the rib and above the ilium, generally beginning posteriorly or in the midaxillary line and resulting from the stimulation of specialized nerve endings upon distention of the ureter or renal capsule. Similar pain is sometimes caused by extraurinary abnormalities.

Pathophysiology

Flank pain originating in the urinary system is caused by distention of the ureter or renal pelvis or distention of the renal capsule. The severity of the pain is directly related to the rapidity of the distention and not to the degree of distention. Therefore, a patient with acute distention of the ureter will have extremely severe pain. This patient usually has mild dilation of the ureter and no irreversible renal damage. However, a patient with a greatly dilated ureter and irreversible renal damage might have no pain or mild pain because the ureteral dilation has developed over a long period of time. Distention of the renal capsule causes a milder flank pain. This can be caused by aucte pyelonephritis, ureteral obstruction, or renal subcapsular hematoma. Kidney and ureteral pain is through visceral afferent fibers that accompany the sympathetic nerves of the lower thoracic and upper lumbar segments.

Flank pain due to ureteral obstruction: Flank pain that radiates to the ipsilateral testicle is usually caused by proximal ureteral or renal pelvic obstruction due to the common innervation of the testicle and the renal pelvis (T11–12). This pain usually originates in the posterior part of the flank and radiates to the testicle of the male or the labia of the female. The pain becomes lower and more anterior in the flank when the obstruction occurs in the middle third of the ureter. The pain is still lower, radiates to the scrotal skin (rather than the testicle), and is associated with voiding symptoms such as urinary frequency and urgency when the obstruction occurs at the level of the ureterovesical junction.

The degree of severity of the pain is directly related to the acuteness of the obstruction rather than the degree of obstruction. Therefore, a stone that passes into the ureter and suddenly becomes lodged in one position usually causes extremely severe pain. But flank pain can be very mild or absent in the presence of very severe but chronic obstruction. Mild and chronic flank pain associated with severe ureteral obstruction can produce irreversible renal damage. A stone passing through the ureter will often cause severe but intermittent pain. The intermittent pain is related to obstruction produced when the stone becomes lodged in the ureter. Therefore, each episode of pain is likely to be associated with a stone becoming lodged in a new and more distal position in the ureter. Flank pain is often associated with less specific symptoms including fever, nausea and vomiting, and tachycardia. Fever suggests infection proximal to the ureteral obstruction. Flank pain associated with fever requires a prompt diagnosis of ureteral obstruction and relief of the obstruction because infection proximal to the obstruction causes much more rapid renal damage than occurs with obstruction in the absence of infection. Also, the patient is susceptible to septicemia in the presence of infection proximal to a ureteral obstruction.

Gross or microscopic hematuria helps to confirm a urinary cause of the pain. Hematuria is occasionally absent with acute ureteral obstruction, however, and is often absent with chronic obstruction.

Congenital anomalies related flank pain Congenital anomalies such as ureteropelvic junction obstruction produce flank pain associated with a diuresis after oral intake of a large volume of fluid. Bilateral chronic ureteral obstruction or ureteral obstruction of a solitary kidney can be associated with symptoms of renal failure such as apathy, lethargy, anorexia, muscle twitching, headache, hypertension, and poor growth of a child. A dull or mild flank pain should make the clinician consider many possible causes including congenital ureteral obstruction, ureteral tumor or an extrinsic tumor compressing the ureter, acquired stricture of the ureter due to a previous operation or radiation therapy, retroperitoneal fibrosis, and a ureteral stone.

Extraurinary disorders related flank pain These diseases produce pain less characteristic of the typical "renal colic" seen with acute ureteral obstruction. Nevertheless, this vague, dull, mild flank pain is similar to the pain seen with chronic ureteral obstruction, making the differential diagnosis unclear. The correct diagnosis is made by thinking of all the diseases that have been discussed, considering the associated symptoms, physical examination, urinalysis, and performing carefully selected laboratory tests and radiographic studies.

Causes

Type	Characteristics
Urinary
Acute ureteral obstruction	Stone, Blood clot, Papillary necrosis
Chronic ureteral obstruction	Congenital anomaly, Tumor, Stricture of ureter, Previous surgery, Radiation therapy, Retroperitoneal fibrosis, Stone
Renal inflammation	Acute pyelonephritis, Perinephric abscess
Renal tumor	Renal cell carcinoma, Transitional cell carcinoma, Wilms" tumor
Trauma of kidney	Calcium Oxalate Nephrolithiasis and Oxalate Nephropathy After Roux-en-Y Gastric Bypass, Nephrotoxic drug induced Nephropathy (Analgesics, NSAIDs)
Renal infarction	Abdominal Aortic Aneurysm Repair
COngenital anomalies	Vesicoureteral reflux, Solitary kidney, Ureteropelvic junction obstruction, Autosomal Dominant Polycystic Kidney Disease
Extraurinary	Gallbladder disease, Appendicitis, Diverticulitis, Other gastrointestinal disease, Chest disease, Salpingitis

Differentiating ((Page name)) from other Diseases

System	Differential Diagnosis
Gastrointestinal	Acute appendicitis, Diverticular disease, Bowel obstruction, Acute pancreatitis,
Gyanecological	Ecotopic pregnancy, Ovarian cyst, Ovarian torsion
Musculoskeletal disorders	Spinal arthritis, Muscle strain or tear

Risk Factors

There are no established risk factors for [disease name].

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The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].

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Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

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Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

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According to the [guideline name], screening for [disease name] is not recommended.

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According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].

Natural History, Complications, and Prognosis

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

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Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

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Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Diagnosis

Diagnostic Study of Choice

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

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The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

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The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

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There are no established criteria for the diagnosis of [disease name].

History and Symptoms

The majority of patients with [disease name] are asymptomatic.

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The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

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Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

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The presence of [finding(s)] on physical examination is diagnostic of [disease name].

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The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].

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Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

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[Test] is usually normal among patients with [disease name].

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Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].

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There are no diagnostic laboratory findings associated with [disease name].

Electrocardiogram

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An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

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An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

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There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

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Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

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There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

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[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

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There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

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[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

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There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

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[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

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[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

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Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

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Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

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The majority of cases of [disease name] are self-limited and require only supportive care.

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[Disease name] is a medical emergency and requires prompt treatment.

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The mainstay of treatment for [disease name] is [therapy].

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[Therapy] is recommended among all patients who develop [disease name].

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Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

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Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

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Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

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Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Surgery

Surgical intervention is not recommended for the management of [disease name].

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Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]

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The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].

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The feasibility of surgery depends on the stage of [malignancy] at diagnosis.

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Surgery is the mainstay of treatment for [disease or malignancy].

Primary Prevention

There are no established measures for the primary prevention of [disease name].

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There are no available vaccines against [disease name].

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Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

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[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].

Secondary Prevention

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Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].

References

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