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Nontraumatic Renal Emergencies
ACUTE FLANK PAIN—URETERIC OR RENAL COLIC
Sudden onset of severe pain in the flank is most often due to the passage of a stone formed in the kidney, down through the ureter. The pain is characteristically of very sudden onset, is colicky in nature (waves of increasing severity are followed by a reduction in severity, but it seldom goes away completely), and it radiates to the groin as the stone passes into the lower ureter. The pain may change in location, from the flank to the groin, but the location of the pain does not provide a good indication of the position of the stone, except in those cases where the patient has pain or discomfort in the penis and a strong desire to void, which suggest that the stone may have moved into the intramural part of the ureter. The patient cannot get comfortable, and may roll around in agony. Indeed, the majority of women we have seen with radiologically confirmed ureteric stones and who have also had children, describe the pain of a ureteric stone as being worse than the pain of labour.
The problem with these classic symptoms of ureteric colic is that approximately 50% of patients with the symptoms we have just described do not have a stone confirmed on subsequent imaging studies, nor do they physically ever pass a stone (Smith et al. 1996, Thomson et al. 2001). They have some other cause for their pain. The list of differential diagnoses is very long. A sample of those that we have personally seen include leaking abdominal aortic aneurysms, pneumonia, myocardial infarction, ovarian pathology (e.g., twisted ovarian cyst), acute appendicitis, testicular torsion, inflammatory bowel disease (Crohn's, ulcera-tive colitis), diverticulitis, ectopic pregnancy, burst peptic ulcer, bowel obstruction, and malaria (presenting as bilateral loin pain and dark haematuria—black water fever)!