What is the diagnosis and treatment for right flank pain, and what tests should be performed?

From the Guidelines

For right flank pain, the recommended diagnostic approach is to start with a noncontrast CT (NCCT) scan of the abdomen and pelvis, as it is the imaging study of choice for initial evaluation of patients with acute onset of flank pain and suspicion of stone disease, according to the most recent guidelines 1. The diagnostic approach for right flank pain should include:

• Urinalysis and urine culture to check for signs of infection
• Complete blood count (CBC) and comprehensive metabolic panel (CMP) to evaluate for underlying conditions
• NCCT scan of the abdomen and pelvis, which is the most appropriate initial imaging test for suspected stone disease, as it can reliably characterize the location and size of an offending ureteral calculus, identify complications, and diagnose alternative etiologies of abdominal pain 1 The treatment for right flank pain depends on the underlying cause, but may include:
• Pain management: Acetaminophen 500-1000 mg every 6 hours or ibuprofen 400-600 mg every 6-8 hours
• Antibiotics if infection is present: e.g., Ciprofloxacin 500 mg twice daily for 7 days for urinary tract infection, as recommended by the European Association of Urology guidelines 1
• Hydration: Increase fluid intake to 2-3 liters per day to help flush out small stones and prevent new ones from forming It's essential to note that the choice of imaging test may vary depending on the patient's specific situation, such as pregnancy or known current stone disease, and that other tests like ultrasound or MRI may be appropriate in certain cases, as suggested by the ACR Appropriateness Criteria 1.

From the Research

Diagnosis of Right Flank Pain

• The diagnosis of right flank pain can be challenging, and several tests can be performed to determine the underlying cause, including:
  • Unenhanced helical CT scan of the abdomen and pelvis, which is considered the optimal diagnostic test to confirm a urinary stone in a patient with flank pain 2
  • Point of care ultrasound (PoCUS), which can play an important role in the diagnostic algorithm and risk stratification of acute flank pain, but has its benefits and drawbacks 3
  • Urine analysis, which can help diagnose urolithiasis, but the absence of microhematuria does not exclude the possibility of urolithiasis 4
  • Blood analysis, including hemogram, coagulation tests, and serum ions, which can help diagnose other causes of flank pain, such as segmental renal infarction 5

Treatment of Right Flank Pain

• The treatment of right flank pain depends on the underlying cause, and can include:
  • Pain management with NSAIDs, opioids, or a combination of both for patients with nephrolithiasis 2
  • Low molecular weight heparin for patients with segmental renal infarction 5
  • Temporary ureteric stent and antibiotics for patients with obstructing ureteric calculus 6
• Emergent urology evaluation may be warranted in certain cases, such as large renal calculi, persistence of colic pain, impaired renal function, and signs of infection 2

Tests to be Performed

• The following tests can be performed to diagnose the cause of right flank pain:
  • Noncontrast-enhanced CT scan, which is the gold standard diagnostic test for urolithiasis 4
  • PoCUS, which can help diagnose hydronephrosis and other causes of flank pain 3
  • Urine analysis, including hematuria, which can help diagnose urolithiasis, but has limited sensitivity and specificity 4
  • Blood analysis, including hemogram, coagulation tests, and serum ions, which can help diagnose other causes of flank pain, such as segmental renal infarction 5