Flank Pain

Differential Overview

❑ Ureteral calculus

❑ Acute pyelonephritis

❑ Latissimus strain

❑ Perinephric abscess

❑ Renal infarction

❑ Renal trauma

❑ Renal cancer

❑ Mononeuritis

❑ Papillary necrosis

Diagnostic Approach

Renal pain occurs with stretching of the capsule and distension of the collecting system. The pain is usually severe and aching, with nausea, vomiting, and ileus. There may be hyperesthesia in the T 9 to 10 dermatome.

Ureteral pain begins in the costovertebral angle and radiates to the lower abdomen, upper thigh, testis, or labia. The pain is excruciating, with crescendo waves of colic. The patient writhes but is unable to obtain relief. Hyperesthesia over the T 12 dermatome often occurs along with tenderness over the kidney or ureter.

Clinical Findings

Ureteral calculus  The sudden-onset pain radiates from the flank to the testicle or labia. The patient is unable to find a comfortable position. The degree of severity is related to the acuteness of the obstruction and the degree of ureteral distension. The pain may be intermittent as the stone passes through the ureter, and the symptoms progress anteriorly and downward. Microscopic/dipstick hematuria is a key to the diagnosis, and its absence should prompt a search for other causes.

Acute pyelonephritis  The classic presentation involves fever, nausea, vomiting, and exquisite costovertebral angle tenderness.

Latissimus strain  Pain occurs after physical strain and is reproduced by twisting and lateral bending of the torso.

Perinephric abscess  Its presence is suggested by findings consistent with pyelonephritis, but systemic toxicity does not clear rapidly with appropriate antibiotics.

Renal infarction  It most often occurs acutely in the setting of atrial fibrillation or recent myocardial infarction.

Renal trauma  Dull pain persists after flank or abdominal blunt trauma. Microscopic hematuria is a key clue.

Renal cancer  Flank pain or fullness is a late sign. The classic triad of gross hematuria, flank pain, and a palpable flank/abdominal mass occurs in the minority. Inferior vena cava invasion may produce the abrupt appearance of left varicocele or leg edema. Fever or hormonal effects (e.g., hypertension, masculinization, Cushing syndrome) may be prominent.

Mononeuritis  Pain, which is burning or electrical in nature, is in a unilateral dermatomal distribution. It may occur as a prodrome to or consequence of zoster, as a consequence of nerve root entrapment, or as a diabetic mononeuritis multiplex.

Papillary necrosis  Consider this when there is a history of analgesic abuse or when the patient has diabetes.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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