Does nephrolithiasis pain worsen with pressure on the flank area?

Nephrolithiasis Pain and Flank Pressure

Nephrolithiasis pain typically does not worsen with external pressure on the flank area. 1

Clinical Presentation of Nephrolithiasis Pain

• Nephrolithiasis presents as acute flank or abdominal pain, often accompanied by nausea and vomiting 2
• The pain of kidney stones is typically caused by obstruction and distension of the collecting system, not by external pressure 1
• Hematuria is present in approximately 90% of nephrolithiasis cases, though its absence does not rule out kidney stones 2

Differentiating Features of Nephrolithiasis Pain

• Kidney stone pain is characteristically colicky in nature, with waves of severe pain followed by periods of less intense discomfort 1
• The pain is caused by internal pressure from obstruction rather than external compression 1
• Pain that significantly worsens with external pressure (costovertebral angle tenderness) is more suggestive of conditions such as:
  • Pyelonephritis or kidney infection 1
  • Perinephric abscess 1
  • Renal subcapsular hematoma (as in Page kidney) 3

Diagnostic Approach

• Non-contrast CT is the gold standard for diagnosing nephrolithiasis, with a reported sensitivity as high as 97% 1
• Ultrasound combined with radiography can be an alternative with sensitivity of 79-90%, particularly useful for detecting clinically significant stones 1
• The addition of color Doppler with assessment of twinkling artifact can improve sensitivity for small renal stones 1

Management Considerations

• Most cases can be managed expectantly as outpatients with hydration, analgesia, and possibly medications to aid passage 2
• Medical treatment of nephrolithiasis in people with autosomal dominant polycystic kidney disease (ADPKD) should be the same as that used in the general population 1
• Obstructing kidney stones should be managed by centers of expertise, particularly in patients with complex conditions like ADPKD 1
• Patients with nephrolithiasis complicated by urinary tract infection require careful consideration, as obstruction with infection can lead to severe sepsis 4

Important Clinical Pearls

• When evaluating flank pain, consider alternative diagnoses if pain significantly worsens with external pressure 3
• Flank pain with hematuria is not always due to kidney stones - other conditions like Page kidney can present similarly 3
• Nephrolithiasis patients have an increased risk of osteoporotic fractures compared to the general population 5
• Recurrent nephrolithiasis may warrant metabolic evaluation, particularly after a second episode in adults or first episode in children or those with family history 2