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.
Historical Perspective
Classification
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
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Acute tubular necrosis
- Ischemic colitis
- Ovarian torsion
- Renal abscess
- Renal artery dissection
- Renal cyst rupture or hemorrhage
- Ruptured abdominal aortic aneurysm
- Renal vein thrombosis
Flank pain developed by WikiDoc.org
Common Causes
- Abdominal muscle spasm
- Acute pyelonephritis
- Nephrolithiasis
- Polycystic kidney disease
- Renal cyst
- Urinary tract infection[1][2][3]
Flank pain developed by WikiDoc.org
Causes by Organ System
Flank pain developed by WikiDoc.org
| 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 |
Causes in Alphabetical Order
Flank pain developed by WikiDoc.org
Differential Diagnosis
| 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 |
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications, and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography or Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
References
- ↑ Wolffram, S.; Bisang, B.; Grenacher, B.; Scharrer, E. (1990). "Transport of tri- and dicarboxylic acids across the intestinal brush border membrane of calves". J Nutr. 120 (7): 767–74. PMID 2366111. Unknown parameter
|month=ignored (help) - ↑ Christodoulidou, M.; Thomas, M.; Sharma, SD. (2012). "Hydronephrosis and loin pain as a presentation of tubo-ovarian abscess developing after Mirena coil removal". BMJ Case Rep. 2012. doi:10.1136/bcr-03-2012-6108. PMID 22865801.
- ↑ Smith, HS.; Bajwa, ZH. (2012). "Loin pain hematuria syndrome-visceral or neuropathic pain syndrome?". Clin J Pain. 28 (7): 646–51. doi:10.1097/AJP.0b013e31823d47f3. PMID 22699133. Unknown parameter
|month=ignored (help)