2 H. HASHIM AND J.REYNARD
Gynaecological and obstetric disease: twisted ovarian cysts, ectopic pregnancy, salpingitis.
Other nonurological causes: pancreatitis, diverticulitis, inflammatory bowel disease, peptic ulcer disease, gastritis. Right-side flank pain
Biliary colic, cholecystitis, hepatitis, appendicitis.
When flank pain has a urological origin, it occurs as a consequence of distention of the renal capsule by inflammatory or neoplastic disease (pain of constant intensity) or as a consequence of obstruction to the kidney (pain of fluctuating intensity). In the case of ureteric obstruction by a stone, pain also arises as a consequence of obstruction to the kidney and from localised inflammation within the ureter.
Characteristics of flank pain due to ureteric stones: this pain is typically of sudden onset, located below the costovertebral angle of the 12th rib and lateral to the sacrospinalis muscle, and it radiates anteriorly to the abdomen and inferiorly to the ipsilateral groin. The intensity may increase rapidly, reaching a peak within minutes or may increase more slowly over the course of 1 to 2 hours. The patient cannot get comfortable, and tries to move in an attempt to relieve the pain. The pain is not exacerbated by movement or posture. Associated symptoms, occurring with variable frequency include nausea, vomiting, and haematuria.
Patients with pathology that irritates the peritoneum (i.e., peritonitis) usually lie motionless. Any movement, or palpation, exacerbates the pain. Patients with renal colic try to move around to find a more comfortable position. The pain may radiate to the shoulder tip or scapula if there is irritation of the diaphragm (the sensory innervation of which is by the phrenic nerve, spinal nerve root C4). Shoulder-tip pain is not a feature of urological disease.
While haematuria is only relatively rarely an emergency (presenting as clot retention, clot colic, or anaemia), it is such an alarming symptom that it may cause a patient to present to the emergency department.