Flank pain

Question 1

What are the ddx for acute flank pain

Answer 1

Muscular sprain
Nephrolithiasis/ureteric colic
Spinal pathology
Leaking/ruptured AAA*
Testicular torsion
Pyelonephritis
Perforated peptic ulcer

also consider gynaecological causes in women e.g. ectopic pregnancy or ovarian torsion

Question 2

Unilateral “loin to groin” pain indicates?

Answer 2

Kidney stones

Question 3

Colicky flank pain may suggest what?

What about constant flank pain?

Answer 3

Colicky pain = ureteric stones(as periodic spasms of ureteric smooth muscle)

Constant pain = kidney stones

Question 4

What may a fever indicate?

Answer 4

Pyelonephritis

Or also psoas abscess or malignancy

Question 5

Dehydration may indicate?

Answer 5

Kidney stones

Question 6

N&V may indicate which pathologies

Answer 6

Ureteric stones, biliary colic, appendicitis

Question 7

Haematuria (unreliable) can indicate what

Answer 7

Kidney or ureteric stones but don’t rely on this. But ask

Question 8

Urinary frequency, urgency and dysuria are common in what?

Answer 8

UTI

Question 9

Hesitancy, reduced flow, dribbling and incomplete voiding are signs of?

Answer 9

Ureteric obstruction - e.g. due to enlarged prostate or less commonly stones/tumours

Question 10

Recurrent episodes of UTI predispose to what?

Answer 10

Struvite (bacterial origin) stones

Question 11

Polycystic kidney disease predisposes to?

Answer 11

Pyelonephritis

Question 12

Aciclovir, indinavir crystallise in urine. Acetazolomide can cause what?

Answer 12

Stones potentially as acetazolomide can cause diuresis and dehydration

Question 13

Patients that are unable to sit still and write in pain probably have?

Answer 13

Ureteric colic

Question 14

Flank and loin tenderness suggests what?

Answer 14

Ureteric/kidney stones

Question 15

A high temperature indicates an inflammatory process, such as?

Answer 15

Pyelonephritis

Question 16

What urine investigations should be done in someone with flank pain?

Answer 16

1. Urinalysis - haematuria, pyuria, leucocyte esterase and nitrites. Acidic urine pH indicates stones. Alkali pH suggests bacteria that predispose to stones.
2. Urine microscopy/culture/sensitivity - if urinalysis abnormal.

Question 17

What blood tests should be done in someone with flank pain

Answer 17

1. FBC and CRP
2. Urea, creatinine and electrolytes. Obstruction by renal stone can cause renal failure (medical emergency)
3. Serum calcium, phosphate and urate

Question 18

What imaging is done in someone with flank pain

Answer 18

1. Bedside US- AAA? Do CT abdomen if AAA evidence

2. Non contrast CT-KUB

Question 19

How should kidney stone be managed

Answer 19

1. Multimodal analgesia
2. Fluid intake
3. Tamsulosin or nifedipine - they relax SMC in ureter - may allow spontaneous passage of renal tract stone.
4. Consider stone removal

Question 20

How may the kidney stone be removed

Answer 20

1. Lithotriopsy
2. Ureterenoscopic removal
3. Percutaneous nephrolithotomy
4. Stenting
5. Abx cover if invasive procedure used

Question 21

Dull flank pain, high fever and urinalysis suggestive of UTI indicates what diagnosis

Answer 21

Acute pyelonephritis - most commonly caused by e coli

Treat with IV fluid, oxygen, blood cultures, VBG, Abx for 2 weeks, monitoring

Question 22

How is leaking AAA managed

Answer 22

Cross match 10 units blood
Urinary catheter
Notify senior