I congratulate the authors and am confident that their gallant efforts will serve to better educate physicians and ultimately improve patient care.
Noel A. Armenakas, M.D., FACS
Clinical Associate Professor of Urology Weill Cornell Medical School
Attending Physician, Lenox Hill Hospital and New York Presbyterian Hospital
Presenting Symptoms of Urological Emergencies
Hashim Hashim and John Reynard
Flank pain is regarded as a classic symptom of renal or ureteric pathology. Indeed, it is often immediately assumed that a patient who presents with flank pain has a stone in the ureter or kidney. However, only 50% of patients who present with flank pain have a ureteric stone confirmed on imaging studies (Smith et al. 1996, Thompson et al. 2001). The other 50% have non-stone-related disease (and more often than not nonurological disease), the differential diagnosis of which is long and dependent on the age, the side of the pain, and the sex of the patient.
The multiple causes of flank pain, to an extent, reflect the fact that the nerve roots subserving pain sensation from the kidney also subserve pain sensation from other organs. Pain sensation from the kidney primarily is transmitted via preganglionic sympathetic nerves that reach spinal cord levels T11 to L2 through the dorsal nerve roots. These same nerve roots supply pain fibres to other intraabdominal organs. Similarly, pain derived from the T10 to T12 costal nerves can also be confused with renal colic.
This list of causes of flank pain is not exhaustive. Some of these alternative causes may seem bizarre, but we have seen examples of all of these conditions, which were initially referred to us as 'ureteric stone pain,' but where the final diagnosis was some other cause.
Pain on either side
Urological causes: ureteric stones, renal stones, renal or ureteric tumours, renal infection (pyelonephritis, per-inephric abscess, pyonephrosis), pelviureteric junction obstruction.
Medical causes of flank pain: myocardial infarction, pneumonia, rib fracture, malaria, pulmonary embolus.