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, of course, to treatment of the underlying disorder.
Emergency Actions
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, complete blood count, and electrolyte levels.
History
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 any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.
Physical assessment
During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.
Medical causes
Bladder cancer
With bladder cancer, dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of this cancer is gross, painless, intermittent hematuria, usually with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.
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 usually accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).
Cystitis (bacterial)
Unilateral or bilateral flank pain occurs secondarily to an ascending UTI. The patient with bacterial cystitis may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.
Glomerulonephritis (acute)
Flank pain in acute glomerulonephritis is bilateral, constant, and moderately intense. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.
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.
Pancreatitis (acute)
Bilateral flank pain may develop in patients with acute pancreatitis as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.
Papillary necrosis (acute)
Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms of acute papillary necrosis include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.
Perirenal abscess
With a perirenal abscess, intense unilateral flank pain and CVA tenderness accompany dysuria, 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 UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.
Pyelonephritis (acute)
With acute pyelonephritis, intense, constant, 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 in acute pyelonephritis include 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 in patients with renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.
Renal infarction
With 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, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.
Renal trauma
Variable bilateral or unilateral flank pain is a common symptom of renal trauma. 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 low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include 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 the patient’s intake and output.
Diagnostic evaluation may involve serial urine and serum analysis, excretory urography, flank ultrasonography, 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 assessment of bladder distention and identification of masses. Common causes of flank pain in children include obstructive uropathy, acute poststreptococcal glomerulonephritis, infantile polycystic kidney disease, and nephroblastoma.
Patient counseling
Encourage the patient to increase his intake of fluids to 3 qt (3 L)/day, unless contraindicated. Tell him to report such signs and symptoms as hematuria and cloudy, foul smelling urine. Explain the importance of taking all medications as prescribed. Make sure he understands the importance of follow-up appointments to assess renal function.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Lower abdominal pain
Read excerpts from these other book chapters related to Lower abdominal pain:
Medical Books Excerpts
- FLANK PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Abdominal Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- Abdominal pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- Flank pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Dyspepsia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Flank pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Abdominal Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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- Dyspepsia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Lower abdominal pain
» Next page: Abdominal Pain (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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