Abdominal Pain and Flank Pain
Mechanisms of Pain Caused by the Urinary Tract
Pain from the urogenital tract may be severe and is usually triggered by sudden obstruction of urinary flow or by inflammation. In contrast, gradually emerging urinary tract obstruction without inflammation is often painless.
Mechanisms of Kidney Pain and Renal Colic:
Kidney pain is caused by acute stretching of the renal capsule and is perceived in the costovertebral angle lateral to the erector spinae muscle. Infection causes continuous pain, whereas undulating pain (renal colic) speaks for a (variable) upper urinary tract obstruction, e.g. by ureteral stones.
Kidney pain may be associated with gastrointestinal symptoms due to autonomic reflexes, this may obscure correct diagnosis. Furthermore, other abdominal organs may cause pain in costovertebral angle. Signs of intraperitoneal diseases are guarding, shoulder pain, and patients who avoid carefully any type of movement to prevent the worsening of abdominal pain. For the differential diagnosis of acute abdominal pain, please see below.
Renal pain may be confused with irritation of the spine or the costal nerves. Typical signs of acute low back pain are motion-dependent pain and lack of colic.
Mechanisms of Ureteral Pain:
Ureteral pain is triggered by a sudden obstruction of the ureteral lumen, this causes strain and hyperperistalsis of the ureter. The pain is usually undulating (renal colic). Obstruction of the proximal ureter is perceived as renal pain in the costovertebral angle (see above). Pain caused by the middle ureter is projecting into the lower abdomen and to the scrotum or labia. Diseases of the distal ureter additionally may cause urinary frequency and dysuria.
Mechanisms of Bladder Pain:
Bladder pain is caused by distension in urinary retention (constant pain) or inflammation of the bladder (pain related to urination). Bladder pain is perceived suprapubic in the lower abdomen, with radiation to the penis. A constant suprapubic pain with normal micturition is usually not causes by bladder diseases.
Mechanisms of Prostate Pain:
Prostate pain is triggered by distension of the prostate capsule, but the pain is hard to localize. The patient reports perineal pain, abdominal pain or rectal pain. Furthermore, dysuria, urinary frequency or urinary retention are present. The most common cause of prostate pain are infections.
Differential Diagnosis of Abdominal pain and Flank Pain
Abdominal pain or flank pain due to urological disorders:
- Ureteral stone
- Pyelonephritis
- Rena abscess
- Retroperitoneal bleeding or hematoma
- Kidney infarction
- Renal vein thrombosis
- Urinary retention
- Acute prostatitis
- Testicular torsion
- Congenital disorders of the upper urinary tract
Abdominal pain due to liver disease:
- Cholelithiasis
- Cholecystitis
- Cholangitis
- Hepatitis
Abdominal pain due to intestinal diseases:
- Gastric ulcer or duodenal ulcer
- Appendicitis
- Ileus
- Diverticulitis
- Mesenteric infarction
- Crohn's disease
Pancreatic diseases:
- Pancreatitis
Spleen diseases:
- Splenic infarction
- Spontaneous splenic rupture
Abdominal pain or flank pain due to diseases of the great arteries:
- Aortic aneurysm
- Renal artery aneurysm
- Mesenteric artery occlusion/stenosis
Abdominal pain due to gynecological diseases:
- Pelvic inflammatory disease
- Ectopic pregnancy
- Ovarian torsion
- (Ruptured) ovarian cyst
- Mittelschmerz
Diseases of the abdominal wall:
- Incarcerated hernia
- Rectus sheath or abdominal wall hematoma
Abdominal pain or flank pain due to thoracic diseases:
- Pneumonia
- Pulmonary embolism
- Pleurisy
- Myocardial ischemia
- Esophageal rupture
- Esophageal spasm
- Gastro-esophageal reflux disease (GERD)
Abdominal pain due to metabolic diseases:
- Porphyria
- Ketoacidosis in diabetes mellitus
- Hemochromatosis
- Hyperparathyroidism
- Acute hemolysis
- Uremia
Abdominal pain or flank pain due to diseases of the nervous system:
- Back pain
- Herpes zoster
- Herniated disc
- Neuralgia
Diagnostic Work-Up of sudden Abdominal Pain or Flank Pain
- Medical history and physical examination
- Urine sediment
- Laboratory tests: blood count, GOT, GPT, gamma-GT, CK, CRP, electrolytes, creatinine, urea, lipase
- ECG
- Imaging: depending on the symptoms and severity: ultrasound, abdomen X-ray, chest X-ray and/or abdominal CT (with or without contrast media)
- Laparoscopy / laparotomy if acute intestinal or vascular disease is suspected
- Gastroscopy if melena or blood vomiting is present
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Deutsche Version: Differentialdiagnose von Bauchschmerzen und Flankenschmerzen
Last update
Dr. med. Dirk Manski
man...@urologielehrbuch.de