29 International Journal of Scientific Study | January 2015 | Vol 2 | Issue 10

Clinical Spectrum of Flank Pain and ITS Association with UrolithiasisNaveen Kumar Singh1, Abhijat Kumar2, Sadhna Singh3

1Professor, Department Of General Surgery, SGGRR Institute of Medical Sciences, Patel Nagar, Dehradun, Uttarakhand, India 2Post Graduate Student, Department of General Surgeon, Himalayan Institute of Medical Sciences Jolly Grant, Dehradun, Uttarakhand, India, 3Assistant Professor, Department of Community Medicine, SGRR Institute Of Medical Sciences, Patel Nagar, Dehradun, Uttarakhand, India

the emergency, because of time-consuming laboratory examinations. Furthermore, requesting advanced tests and imaging for non-complicated renal colic in the emergency may not be cost-effective. Simple ultrasonography (USG) in emergency has a high yield. The incidence of renal disease appears to be gradually increasing hence the present study was taken up. 12% of men and 5% of women will suffer from renal stones by the age of 70 years. Patients with a history of stones have 50% risk of developing another stone within 5-10 years.2

Aims and ObjectivesTo determine the clinical spectrum of flank pain and its association with urolithiasis. To find appropriate diagnostic modality for flank pain to exclude extra urinary causes requiring emergency interventions.

INTRODUCTION

Flank pain is one of the most painful and it is one of the most common presentation in surgical outpatient department (OPD) inpatient of pain abdomen, its incidence has increased considerably during 20th century.1 It is estimated that approximately 12% of the population will have a renal stone at some point in their lives. Management of patients suspected for renal colic is often delayed in

Original Article

AbstractIntroduction: Flank pain is one of the most painful and it is one of the most common presentation in surgical outpatient department (OPD) inpatient of pain abdomen, its incidence has increased considerably during century Management of patients suspected for renal colic is often delayed in the emergency, because of time consuming laboratory examinations.

Aims and Objectives: The aim was to determine the clinical spectrum of flank pain and its association with urolithiasis, to find appropriate diagnostic modality for flank pain to exclude extra urinary causes requiring emergency interventions.

Methodology: A total of hundred patients of flank pain were studied prospectively. Patients are suffering from flank pain, coming to the OPD of general surgery, Orthopedics and obstetrics and gynecology over a period 12 months.

Result: 54 patients presented with renal pathology in hundred patients of flank pain out of which 47 had urolithiasis and seven had renal problems such as renal abscess, renal tuberculosis and pelvic-ureteric junction obstruction. By chi-square test application, statistically highly significant association (P = 0.0000) was seen between flank pain and urolithiasis. Main renal pathology causing flank pain was renal calculi 47% in my study. Among the urinary complaints most common complaints were of burning micturition. In my study second most common cause of flank pain, was spinal pathology 32%. X-ray showed a sensitivity of 83% in diagnosing urolithiasis in patients of flank pain. Ultrasonography showed a sensitivity of 91% in diagnosing urolithiasis while intravenous urogram was sensitive in 100% cases. Computed tomography was shown to have a sensitivity of 94-100%.

Conclusion: Urolithiasis constituted maximum number of flank pain patients, most patients presented with burning micturition which shows the presence of infection. Second most common cause of flank pain was spinal pathology while other pathology like related with abdominal, ovarian and other also contributes in few patients.

Key words: Diagnostic modalities, Flank pain, Urolithiasis

DOI: 10.17354/ijss/2015/07

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Month of Submission : 11-2014 Month of Peer Review : 12-2014 Month of Acceptance : 12-2014 Month of Publishing : 01-2015

Corresponding Author: Dr. Naveen Kumar Singh, Professor, Department of Surgery, SGRRIM & HS, Patel Nagar, Dehradun - 248 001, Uttarakhand, India. Mobile: +91-9359937074. E-mail: dr.naveen.s@gmail.com

Singh, et al.: Clinical Spectrum of Flank Pain and ITS Association with Urolithiasis

30International Journal of Scientific Study | January 2015 | Vol 2 | Issue 10

To find out the sensitivity of different diagnostic procedure for cause of flank pain.

To find out the specificity of different investigations in cause of flank pain.

METHODOLOGY

Inclusion criteria: All patients of flank pain were included in the study.

Exclusion criteria:1) Patients of trauma.2) Patients operated for renal diseases.

A total of hundred patients of flank pain were studied prospectively.

Study Design: A hospital-based study, Follow Up study.

Study Area: Patients attending Surgery, Orthopedics and Gynae OPD.

Study Period: For the period of 1 year.

Study Subjects: Patients with flank pain.

Selection of study subjects: All the patients suffering from flank pain, coming to the OPD of general surgery, Orthopedics and obstetrics and gynecology over a period 12 months.

OBSERVATIONS AND RESULTS

Among the radiology modalities X-ray shows the sensitivity of 83% and specificity is 100% USG had 91% sensitivity and intravenous urography (IVU) 100% sensitivity in diagnosing urolithiasis.

By chi-square test application, statistically high significant association was seen between flank pain and urolithiasis.

Fifty-four patients presented with renal pathology in hundred patients of flank pain out of which 47 had urolithiasis and 7 had renal problems such as renal abscess, renal tuberculosis and pelvic-ureteric junction obstruction (Table 1).

A total of 100 patients of flank pain were studied prospectively. Flank pain is more common in male patients (59%). Most common urinary complaints in patients of flank pain was burning micturition 70.9%, followed by gross hematuria (12.7%) in patients of flank pain. Renal Pathology was most common cause of flank pain 54%,

followed by spinal causes 32%. Urolithiasis was most common cause of flank pain in the study, 47% patient had urolithiasis as a cause of flank pain with a P = 0.000000. Second common cause of flank pain was spinal pathology. Spinal cord compression and degenerative diseases of the spine were most common among spinal pathology. Other less common causes of flank pain include, ovarian diseases and pelvic inflammatory diseases which were seen in few female patients of flank pain. And also acute appendicitis and psoas abscess were found in few patients of flank pain. X-ray showed a sensitivity of 83% in diagnosing urolithiasis in patients of flank pain. USG showed a sensitivity of 91% in diagnosing urolithiasis while Intravenous urogram was sensitive in 100% cases. In my study X-ray kidneys, ureters, bladder (KUB) after bowel preparation was used as primary radiological modality to diagnose urolithiasis in patients of flank pain. X-ray KUB helped in making diagnosis of 83% patients of calculi, which is much higher as compared to recent studies which shows a sensitivity of only 77%. Therefore, in this study X-ray KUB is an important modality for diagnosing cause of flank pain on OPD basis. USG KUB region was done in patients with flank pain where renal calculi was strongly suspected which shows a sensitivity of 91%. Middleton et al. showed that US has a sensitivity of 96% for renal calculi and a sensitivity of nearly 100% when calculi are larger than 5 mm. IVU was also done in patients with flank pain which shows a sensitivity of 100% for diagnosing. In studies comparing non-enhanced computed tomography (CT) with IVU, CT was shown to have a sensitivity of 94-100% and a specificity of 92-100%, while IVU was shown to have a sensitivity of 64-97% and a specificity of 92-94%. CT scan helps to diagnose flank pain in a better way but the cost factor is confounding factor in developing countries (Tables 2-4).

DISCUSSION

As urolithiasis constituted maximum number of flank pain patients, Pearle et al. also observed renal disease typically affects adult men more commonly than adult women has been attributed to the protective effect of estrogen against stone formation in premenopausal women.3 Most common associated complaints in patients of flank pain were fever 50% of patients. Urolithiasis has a strong association with

Table 1: Pathology in patients of flank pain (n=100)Pathology Number of patientsRenal 54Spinal 32Ovarian 3Abdominal 1Others 10Total 100

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infection. About 10-15% of renal calculi are associated with urinary tract infection and main bacteria isolated Escherichia coli (32%) followed by Pseudomonas (22%).1 In my study flank pain patients urinary complaints was a common association, most patients presented with burning micturition 39 patients, burning micturation shows presence of infection, Hizbullah et al. also shows infection in 19% of patients of renal calculi.1 Main renal pathology causing flank pain was renal calculi 47% in my study. In my study X-ray KUB after bowel preparation was used as primary radiological modality to diagnose urolithiasis in patients of flank pain, X-ray KUB helped in making diagnosis of 83% patients of calculi, which is much higher as compared to recent studies which shows a sensitivity of only 77%. Therefore in this study X-ray KUB is an important modality for diagnosing cause of flank on OPD basis.

USG KUB region was done in patients with flank pain where renal calculi was strongly suspected, which shows a sensitivity of 91%. Middleton et al. showed that US has a sensitivity of 96% for renal calculi and a sensitivity of nearly 100% when calculi are larger than 5 mm. IVU was also done in patients with flank pain which shows a sensitivity of 100% for diagnosing urolithiasis as an etiological factor for flank pain, it also helped to access renal function. In studies comparing non-enhanced CT with IVU, CT was shown to have a sensitivity of 94-100% and a specificity of 92-100%, while IVU was shown to have a sensitivity of 64-97% and a specificity of 92-94%. CT the scan helps to diagnose flank pain in a better way as renal, and extra-renal pathology are

better visualized, but the cost factor is confounding factor in developing countries. In my study, urinary complaints were was main associated complaints along with flank pain in patients of urolithiasis, 70% of patients of renal calculi had urinary complaints. Among the urinary complaints most common complaints were of burning micturition. In other studies, urolithiasis was associated with urinary complaints in 6% patients. Higher urinary complaints in my study may be due to late presentation of patients in the hilly region, leading to development of renal infection and increased urinary complaints in study group.2 In my study, microscopic hematuria was present in only 12% patients of urolithiasis. In a study done at Chicago by Elaine. Worcester shows that hematuria is always present in patient of urolithiasis, but may be microscopic.4 In my study, 7% of patients had renal cause other than urolithiasis as a cause of flank pain. Most of them were of renal abscess and renal tuberculosis. In my study second most common cause of flank pain, was spinal pathology 32%. Flank pain may also be confused with pain resulting from irritation of the costal nerves, most commonly T10-T12. Such pain has a similar distribution from the cost vertebral angle across the flank toward the umbilicus. However, the pain is not colicky in nature in my study most of the patients of flank pain were heaving urolithiasis as a cause of pain, 47% patients of flank pain had urolithiasis (P = 0.0000).

Statistically high significant association between flank pain and urolithiasis is seen. A study was done by Kartal et al. shows a high association between flank pain and urolithiasis 49% (P = 0.024). Flank pain of urolithiasis origin has a colicky character, with radiation along the course of ureter.5

CONCLUSION

Urolithiasis constituted maximum number of flank pain patients, most patients presented with burning micturition that shows the presence of infection. Second most common cause of flank pain was spinal pathology while other pathology like related with abdominal, ovarian and other also contributes in few patients. After proper bowel preparation X-ray KUB is still an important modality for diagnosing cause of flank on OPD basis, USG shows high sensitivity in differential diagnosis of flank pain beside urolithiasis as far as IVU is concerned shows 100% sensitivity in diagnosing urolithiasis along with renal function while CT scan helps

Table 2: Radiological modality used for diagnosis of urolithiasis (n=47)Investigations Number of patients Sensitivity (%) Specificity PPV NPV NLR PLRX-ray 39 83 100 32.7 86.8 1.19 0.84USG 43 91 100 100 92.98 1.08 0.9IVU 47 100 100 100 - 0.99 1.01PPV: Positive predictive value, NPV: Negative predictive value, NLR: Negative likelihood ratio, PLR: Positive likelihood ratio, USG: Ultrasonography, IVU: Intra venous urography

Table 3: Association of urinary symptoms with urolithiasisSymptoms Urolithiasis present Urolithiasis absentBurning micturition 26 21Hematuria 4 43Urgency of micturition 2 45Chi‑square=43.01, P=0.00000000

Table 4: Renal pathology in patients of flank pain (n=54)Renal pathology Number of patientsUrolithiasis 47Others 7Total 54

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to diagnose flank pain in better way as renal and extra renal pathology are better visualized.

REFERENCES

1. Jan H, Akbar I, Kamran H, Khan J. Frequency of renal stone disease in patients with urinary tract infection. J Ayub Med Coll Abbottabad 2008;20:60-2.

2. Serinken M, Karcioglu O, Turkcuer I, Ozkan HI, Keysan MK, Bukiran A. Analysis of clinical and demographic characteristics of patients presenting with renal colic in the emergency department. BMC Res Notes 2008;1:79.

3. Kartal M, Eray O, Erdogru T, Yilmaz S. Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic. Emerg Med J 2006;23:341-4.

4. Worcester EM, Coe FL. Nephrolithiasis. Prim Care 2008;35:369-91.5. Pearle MS, Calhoun EA, Curhan GC, Urologic Diseases of America Project.

Urologic diseases in America project: Urolithiasis. J Urol 2005;173:848-57.

How to cite this article: Singh NK, Kumar A, Singh S. Clinical Spectrum of Flank Pain and ITS Association with Urolithiasis. Int J Sci Stud 2015;2(10):29-32.

Source of Support: Nil, Conflict of Interest: None declared.