Flank pain
Pain in the flank, the area extending from the ribs to the ilium, is a leading indicator of renal and upper urinary tract disease or trauma. Depending on the cause, this symptom may vary from a dull ache to severe stabbing or throbbing pain, and may be unilateral or bilateral and constant or intermittent. It’s aggravated by costovertebral angle (CVA) percussion and, in patients with renal or urinary tract obstruction, by increased fluid intake and ingestion of alcohol, caffeine, or diuretics. Unaffected by position changes, flank pain typically responds only to analgesics or to treatment of the underlying disorder. (See
Flank pain: Common causes and associated findings,pages 278 and 279.)
Emergency interventions
If the patient has suffered trauma, quickly look for a visible or palpable flank mass, associated injuries, CVA pain, hematuria, Turner’s sign, and signs of shock, such as tachycardia and cool, clammy skin. If one or more is present, insert an I.V. line to allow fluid or drug infusion. Insert an indwelling urinary catheter to monitor urine output and evaluate hematuria. Obtain blood samples for typing and crossmatching, a complete blood count, and electrolyte levels.
History and physical examination
If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.
Ask the patient about changes in his normal pattern of fluid intake and urine output. Explore his history for a urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.
During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.
Medical causes
Calculi
Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of a UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, a low-grade fever, and tenesmus)
Cortical necrosis (acute)
Unilateral flank pain is usually severe. Accompanying findings include gross hematuria, anuria, leukocytosis, and a fever
Obstructive uropathy
With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction
Papillary necrosis (acute)
Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds
Perirenal abscess
Intense unilateral flank pain and CVA tenderness accompany dysuria, a persistent high fever, chills and, in some patients, a palpable abdominal mass
Polycystic kidney disease
Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of a UTI. Later findings include hematuria and perineal, low back, and suprapubic pain
Pyelonephritis (acute)
Intense, constant, and unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include a persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness
Renal cancer
Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include a fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease
Renal infarction
Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, a fever, hypoactive bowel sounds, hematuria, and oliguria or anuria
Renal trauma
Variable bilateral or unilateral flank pain is a common symptom. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin
Renal vein thrombosis
Severe unilateral flank and lower back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include a fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction
Special considerations
Administer pain medication. Continue to monitor the patient’s vital signs, and maintain a precise record of his intake and output.
Diagnostic evaluation may involve serial urine and serum analysis, excretory urography, flank ultrasonography, a computed tomography scan, voiding cystourethrography, cystoscopy, and retrograde ureteropyelography, urethrography, and cystography.
Pediatric pointers
Assessment of flank pain can be difficult if a child can’t describe the pain. In such cases, transillumination of the abdomen and flanks may help in the assessment of bladder distention and identification of masses. Common causes of flank pain in a child include obstructive uropathy, acute poststreptococcal glomerulonephritis, infantile polycystic kidney disease, and nephroblastoma.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Chest discomfort
Read excerpts from these other book chapters related to Chest discomfort:
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Chest discomfort
» Next page: Chest Pain (A Pocket Manual of Differential Diagnosis)
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