From the Guidelines
Flank pain management should prioritize identifying and treating the underlying cause, with noncontrast CT (NCCT) being the imaging study of choice for initial evaluation of patients with acute onset of flank pain and suspicion of stone disease, as recommended by the American College of Radiology 1.
Initial Evaluation and Treatment
For immediate relief, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg initially, then 250mg every 6-8 hours) can reduce inflammation and pain. Acetaminophen (500-1000mg every 6 hours, maximum 4000mg daily) is an alternative for those who cannot take NSAIDs. Some key points to consider in flank pain management include:
- Staying hydrated with 2-3 liters of water daily is crucial, especially if kidney stones are suspected.
- Gentle stretching exercises targeting the back and abdomen can help relieve muscle tension.
- Applying heat therapy with a heating pad for 15-20 minutes several times daily can relax muscles and improve blood flow.
Underlying Causes and Specific Treatments
It's essential to identify and treat the underlying cause, which could include:
- Kidney stones: NCCT is the preferred imaging method for diagnosis, as it can reliably characterize the location and size of an offending ureteral calculus and identify complications 1.
- Urinary tract infections: The European Association of Urology guidelines recommend prompt differentiation between uncomplicated and potentially obstructive pyelonephritis, with fluoroquinolones and cephalosporins being the only antimicrobial agents recommended for oral empiric treatment of uncomplicated pyelonephritis 1.
- Musculoskeletal issues or more serious conditions: Immediate medical attention is necessary if flank pain is severe, accompanied by fever, nausea, vomiting, blood in urine, or persists beyond a few days, as these symptoms may indicate a serious condition requiring specific treatment.
Severe or Complicated Cases
In cases of severe or complicated flank pain, such as staghorn calculi, open surgical removal may be necessary, with anatrophic nephrolithotomy being the most appropriate procedure for patients requiring open surgical stone removal 1. However, this approach is typically reserved for extreme cases, and less invasive methods are preferred whenever possible.
From the FDA Drug Label
If ibuprofen tablets therapy must be initiated, close monitoring of the patients renal function is advisable. The FDA drug label does not answer the question.
From the Research
Flank Pain Management
- Flank pain is a common and complex clinical problem that can be caused by various urinary and extraurinary abnormalities, with ureterolithiasis being the most frequent cause 2.
- The management of acute flank pain has evolved over the years, with imaging modalities such as plain abdominal radiographs, intravenous urography (IVU), ultrasonography (US), and unenhanced helical CT (UHCT) being used for diagnosis and evaluation 2, 3.
- UHCT has been shown to be superior to other imaging modalities due to its high sensitivity and specificity, ability to detect ureteral stones regardless of size, location, and chemical composition, and its ability to identify extraurinary causes of flank pain 2, 3.
Chronic Flank Pain Management
- Chronic flank pain can be a therapeutic challenge, and current management often centers on visceral pathology affecting the renal system 4.
- Abdominal myofascial pain syndrome is a poorly recognized cause of chronic flank pain, and an interventional management pathway including quadratus lumborum block with steroid and pulsed radiofrequency treatment may be an effective solution 4.
- A study of 45 patients with refractory chronic flank pain found that 66% of patients reported durable benefit at 6 months, and opioid consumption and emergency admissions were reduced post-intervention 4.
Pharmacological Management
- The combination of oxycodone and paracetamol has been shown to be effective in the treatment of moderate-to-severe pain, including chronic musculoskeletal pain and cancer-related pain 5.
- A randomized controlled trial found that oxycodone/acetaminophen resulted in slightly greater pain relief than acetaminophen alone in patients with acute musculoskeletal pain refractory to ibuprofen, but was associated with more medication-related adverse events 6.
- The use of oral opioids such as oxycodone/acetaminophen should be carefully considered, taking into account the potential benefits and risks, including the risk of medication-related adverse events 6.