This document discusses the principle of management for right flank pain in men. It begins with definitions and anatomy then discusses various causes of right flank pain including ureteric calculi, pyelonephritis, renal abscess, renal tumor, and more. It outlines the steps for management including thorough history taking, examination, investigations like urinalysis and imaging, and definitive treatments depending on the underlying cause. These may include drainage, antibiotics, surgery, or stenting. The conclusion emphasizes the importance of fully evaluating patients with flank pain due to multiple potential causes.

1. Principle of Management of
Right flank pain in a Man
by
Dr Badmus A. M

2. Outline
• Introduction/Definition
• Anatomy
• Causes of right flank pain
• Management
history taking
Examination
Investigation
Definitive management
• Conclusion

3. Introduction
Flank pain is a common complaints in Urology outpatient
clinics and emergencies. Conditions from other specialty
can also present with flank pain.
Its usually unilateral but can also be bilateral.
It results from the stimulation of specific nerve endings
upon stretching of the renal capsule or vessels.

4. Anatomy

5. Causes of Right flank pain
• Ureteric calculi
• Pyelonephritis
• Renal abscess
• Renal tumor
• Nephrolithiasis
• Renal papillary necrosis
• Ureteric blood clot
• Muscle pain
• Acute renal infarction

6. • Radiculitis
• Muscle pain
• Appendicitis
• Gastrointestinal diseases eg pancreatitis
• Adrenal tumors
• Gall bladder disease
• Liver disease

7. Management
• Adequate history taking, characterising
the flank pain, associated symptoms.
• Examination should be thorough to rule
out possible causes of flank pain and not
just limiting to Urology causes alone

8. Investigation
• urinalysis+mcs
• plain abdominal xray
• Abdominal ultrasound scan
• Abdominal CT scan
• IVP
• Serum uric acid
• Lumbosacral xray

9. Plain abdominal X-ray

11. CT scan

13. Ureteral Calculi
• Classic presenting symptoms is flank pain.
• Prominent cause of flank pain in the absence of
fever
• Might radiates to the groin, anterior
abdomen,testicle
• Microscopic or gross hematuria
• Nausea and vomiting

14. Pyelonephritis
• Common cause of flank pain
• Relatively described as dull ache pain
• Associated fever, chills ,nausea and vomiting.
• Flank and costovertebral angle tenderness are
present.
• Patient tend to be very still when compared to
patient with renal colic

15. Abdominal Aortic Aneurysm(AAA)
• Present with flank pain, mimicking renal colic.
• Occurs in 10% of patients initially being
investigated for renal cause.
• Aneurysm caused by injury or stretching of
nerve plexus around celiac axis.
• The aneurysm can lie adjacent to the ureter

16. Renal abscess
• More intense pain than pyelonephritis
• There might be flank mass palpable
• Fever and chills are common.
• Diaphragmatic irritation may cause rales and
decreased breath sound on the affected side.
• Diabetes mellitus is a risk factor

17. • Consider renal abscess in a patient with
pyelonephritis, not improving with antibiotics
therapy.
There are of two types:
• Corticomedullary type
Ascending UTI, Urinary tract abnormality, E.coli
most common
• Cortical type
hematogenous spread,S.aureus

18. Blood clots
• Cause acute renal colic attack when they form
ureteral obstruction.
• Can be iatrogenic such as percutaneous renal
biopsy
• Underlying medical pathology such as blood
dyscrasias, renal pelvis or parenchymal tumors,
angiomyolipomas, hemophilia, sickle cell
disease, glomerulonephritis

19. Papillary Necrosis
• Can cause acute ureteral obstruction from the
sloughed papilla.
• The ring sign in the renal calyx on IVP is
characteristic of this disorder.
• Women more affected than men
• Underlying pathologies:
Analgesic abuse, liver cirrhosis, recurrent pyelonephritis,
tuberculosis, Sickle cell disease, systemic vasculitis

20. Renal Tumors
• Renal tumor causes flank pain directly or
indirectly.
• Renal tumor cause renal capsular stretching and
pain as well as hematuria with possible ureteral
obstruction from the blood clot

21. UreteroPelvic Junction (UPJ) Obstruction
• UPJ obstruction is one of the more common cause
of renal pain.
• Usually an incidental finding
• Pain usually follows ingestion of large amount of
fluid, causing a brisk diuresis resulting in renal pelvis
distension.
• Diagnosis confirmed by a diuretic-enhanced renal
nuclear scan

22. Retroperitoneal fibrosis
• Idiopathic disease.
• When it involves the ureters, it causes ureteral
midline deviation, hydronephrosis and even
renal failure.
• Pain usually located in lower flank, but
abdominal, testicular or periumbilical pain
develops later.

23. Ureteral strictures
• Resulting from trauma, surgical intervention,
radiation, stone passage, infection.
• Commonly affect UPJ,ureterovesical junction
and overlying the bifurcation of the iliac vessels.

24. Acute renal infarction
• Affect both kidneys and sexes equally.
• Risk factors include age > 50yrs,patient with
increased risk of thromboembolism e.g chronic
atrial fibrillation with inadequate anticoagulation
• Usually unilateral flank pain and hematuria

25. Other causes
• Muscle pain: arising from strain or other injury
of the back or flank
• Dull aching pain.
• Herpes zoster: moderately severe burning
pain around the flank corresponding to a
dermatone

26. • Radiculitis: When a lumbar or lower thoracic
nerve root are injured
• When the pain affects the 10th
,11th
or 12th
rib, the
discomfort mimic renal colics.
• Fungal bezoars: Most commonly are candida or
Aspergiluus.
• Usually in immunocomprosed men

27. Treatment
Renal abscess
• Drainage of the abscess either by open surgery
or percutaneous methods.
•Culture specific antibiotics
•Analgesic
Blood clots
Ureteral stent or percutaneous nephrostomy

28. Pyelonephritis
• Culture specific antibiotics
• Analgesic
Renal tumors
• Optimise patient
• Radical nephrectomy

29. Retroperitoneal fibrosis
• Analgesic
• Ureterolysis
Papillary Necrosis
•Resuscitation
•Treatment of the underlying pathology
•Bypassing the obstruction with a nephrostomy or
stent

30. Ureteral calculi
•Analgesic
•Liberal fluid intake/IV hydration
•Antiemetics
•Antibiotics
•Alkalinizing agents(e,g potassium citrate,sodium
bicarbonate) for uric acid and cysteine calculi
•Calcium channel blocker (e.g nifedipine)
•Alpha blockers (e.g tamsulosin)

31. Stones that are 7mm and more are unlikely to
pass spontaneously and require some forms of
surgical procedure.
•Stent placement
•Percutaneous nephrostomy
•Extracorporeal shockwave lithotripsy
•Ureteroscopy
•Percutaneous nephrostolithotomy
•Open nephrostomy

32. Conclusion
A patient presenting with flank pain should be
thoroughly clerked, examined and appropriately
investigated because there are several causes of
flank pain aside urinary calculi

33. Thank you for listening