Principle of Management of Right flank pain in a Man

byDr Badmus A. M

Outline• Introduction/Definition

• Anatomy

• Causes of right flank pain

• Management

history taking

Examination

Investigation

Definitive management • Conclusion

IntroductionFlank pain is a common complaints in Urology outpatient

clinics and emergencies. Conditions from other specialty

can also present with flank pain.

Its usually unilateral but can also be bilateral.

It results from the stimulation of specific nerve endings

upon stretching of the renal capsule or vessels.

Anatomy

Causes of Right flank pain• Ureteric calculi

• Pyelonephritis

• Renal abscess

• Renal tumor

• Nephrolithiasis

• Renal papillary necrosis

• Ureteric blood clot

• Muscle pain

• Acute renal infarction

• Radiculitis

• Muscle pain

• Appendicitis

• Gastrointestinal diseases eg pancreatitis

• Adrenal tumors

• Gall bladder disease

• Liver disease

Management

• Adequate history taking, characterising

the flank pain, associated symptoms.

• Examination should be thorough to rule

out possible causes of flank pain and not

just limiting to Urology causes alone

Investigation

• urinalysis+mcs

• plain abdominal xray

• Abdominal ultrasound scan

• Abdominal CT scan

• IVP

• Serum uric acid

• Lumbosacral xray

Plain abdominal X-ray

CT scan

Ureteral Calculi• Classic presenting symptoms is flank pain.

• Prominent cause of flank pain in the absence of

fever

• Might radiates to the groin, anterior

abdomen,testicle

• Microscopic or gross hematuria

• Nausea and vomiting

Pyelonephritis• Common cause of flank pain

• Relatively described as dull ache pain

• Associated fever, chills ,nausea and vomiting.

• Flank and costovertebral angle tenderness are

present.

• Patient tend to be very still when compared to

patient with renal colic

Abdominal Aortic Aneurysm(AAA)

• Present with flank pain, mimicking renal colic.

• Occurs in 10% of patients initially being

investigated for renal cause.

• Aneurysm caused by injury or stretching of

nerve plexus around celiac axis.

• The aneurysm can lie adjacent to the ureter

Renal abscess• More intense pain than pyelonephritis

• There might be flank mass palpable

• Fever and chills are common.

• Diaphragmatic irritation may cause rales and

decreased breath sound on the affected side.

• Diabetes mellitus is a risk factor

• Consider renal abscess in a patient with

pyelonephritis, not improving with antibiotics

therapy. There are of two types:• Corticomedullary type

Ascending UTI, Urinary tract abnormality, E.coli

most common

• Cortical type hematogenous spread,S.aureus

Blood clots• Cause acute renal colic attack when they form

ureteral obstruction.

• Can be iatrogenic such as percutaneous renal

biopsy

• Underlying medical pathology such as blood

dyscrasias, renal pelvis or parenchymal tumors,

angiomyolipomas, hemophilia, sickle cell

disease, glomerulonephritis

Papillary Necrosis• Can cause acute ureteral obstruction from the

sloughed papilla.

• The ring sign in the renal calyx on IVP is

characteristic of this disorder.

• Women more affected than men

• Underlying pathologies:

Analgesic abuse, liver cirrhosis, recurrent pyelonephritis,

tuberculosis, Sickle cell disease, systemic vasculitis

Renal Tumors• Renal tumor causes flank pain directly or

indirectly.

• Renal tumor cause renal capsular stretching and

pain as well as hematuria with possible ureteral

obstruction from the blood clot

UreteroPelvic Junction (UPJ) Obstruction

• UPJ obstruction is one of the more common cause

of renal pain.

• Usually an incidental finding

• Pain usually follows ingestion of large amount of

fluid, causing a brisk diuresis resulting in renal pelvis

distension.

• Diagnosis confirmed by a diuretic-enhanced renal

nuclear scan

Retroperitoneal fibrosis• Idiopathic disease.

• When it involves the ureters, it causes ureteral

midline deviation, hydronephrosis and even

renal failure.

• Pain usually located in lower flank, but

abdominal, testicular or periumbilical pain

develops later.

Ureteral strictures• Resulting from trauma, surgical intervention,

radiation, stone passage, infection.

• Commonly affect UPJ,ureterovesical junction

and overlying the bifurcation of the iliac vessels.

Acute renal infarction

• Affect both kidneys and sexes equally.

• Risk factors include age > 50yrs,patient with

increased risk of thromboembolism e.g chronic

atrial fibrillation with inadequate anticoagulation

• Usually unilateral flank pain and hematuria

Other causes

• Muscle pain: arising from strain or other injury

of the back or flank

• Dull aching pain.

• Herpes zoster: moderately severe burning

pain around the flank corresponding to a

dermatone

• Radiculitis: When a lumbar or lower thoracic

nerve root are injured

• When the pain affects the 10th,11th or 12th rib, the

discomfort mimic renal colics.

• Fungal bezoars: Most commonly are candida or

Aspergiluus.

• Usually in immunocomprosed men

Treatment Renal abscess

• Drainage of the abscess either by open surgery

or percutaneous methods.

•Culture specific antibiotics

•Analgesic

Blood clots

Ureteral stent or percutaneous nephrostomy

Pyelonephritis

• Culture specific antibiotics

• Analgesic

Renal tumors

• Optimise patient

• Radical nephrectomy

Retroperitoneal fibrosis

• Analgesic

• Ureterolysis

Papillary Necrosis

•Resuscitation

•Treatment of the underlying pathology

•Bypassing the obstruction with a nephrostomy or

stent

Ureteral calculi•Analgesic

•Liberal fluid intake/IV hydration

•Antiemetics

•Antibiotics

•Alkalinizing agents(e,g potassium citrate,sodium

bicarbonate) for uric acid and cysteine calculi

•Calcium channel blocker (e.g nifedipine)

•Alpha blockers (e.g tamsulosin)

Stones that are 7mm and more are unlikely to

pass spontaneously and require some forms of

surgical procedure.

•Stent placement

•Percutaneous nephrostomy

•Extracorporeal shockwave lithotripsy

•Ureteroscopy

•Percutaneous nephrostolithotomy

•Open nephrostomy

Conclusion A patient presenting with flank pain should be

thoroughly clerked, examined and appropriately

investigated because there are several causes of

flank pain aside urinary calculi

Thank you for listening