What is the appropriate workup for an elderly female with flank pain and hematuria, who is afebrile and has no history of kidney stones?

Workup for Elderly Female with Flank Pain and Hematuria

This patient requires urgent imaging with CT abdomen/pelvis with IV contrast to evaluate for renal malignancy, as the combination of flank pain and hematuria in an elderly patient without fever or stone history raises significant concern for renal cell carcinoma or urothelial malignancy. 1

Initial Diagnostic Approach

Laboratory Evaluation

• Complete blood count (CBC) and comprehensive metabolic panel including serum creatinine, liver function tests, serum-corrected calcium, and urinalysis 1
• Urine cytology is strongly recommended given the patient's age and risk factors for transitional cell carcinoma 1
• Serum alkaline phosphatase to screen for bone metastases if malignancy is suspected 1

Imaging Strategy

Primary imaging: CT abdomen/pelvis with IV contrast 1, 2, 3

• This is the gold standard for evaluating both malignancy and alternative diagnoses 2, 3
• Non-contrast CT alone (typically used for stones) would miss critical details about renal masses and vascular involvement 1
• Contrast-enhanced CT is essential because it characterizes renal masses, evaluates for tumor thrombus in the inferior vena cava, and assesses for metastatic disease 1

Chest imaging is mandatory as part of metastatic evaluation - chest CT is more accurate than plain radiography for staging 1

Critical Differential Considerations

Why Malignancy Must Be Ruled Out First

• The classic triad of hematuria, flank mass, and flank pain suggests renal cell carcinoma, though fewer patients present with all three symptoms 1
• Elderly patients with new-onset hematuria and flank pain without stone history have significant risk for urothelial or renal malignancy 1
• A central renal mass may indicate urothelial carcinoma, requiring ureteroscopy and biopsy 1

Alternative Diagnoses to Consider

• Renal subcapsular hematoma (Page kidney) can present identically to nephrolithiasis with flank pain and hematuria 4
• Urothelial masses may be detected on excretory phase imaging 2
• Hydronephrosis from obstruction (non-stone causes) 2

Common Pitfalls to Avoid

Do not assume nephrolithiasis despite the classic presentation of flank pain and hematuria 4

• While stones are the most common cause of acute flank pain (19% lifetime risk in men, 9% in women), the absence of stone history and elderly age shift probability toward malignancy 2
• Approximately one-third of patients with flank pain have extraurinary causes identified on CT 2, 3

Do not order non-contrast CT as initial imaging in this clinical scenario 1, 2

• Non-contrast CT is appropriate for suspected nephrolithiasis with typical presentation 1, 3
• This patient needs contrast to evaluate soft tissue masses and vascular structures 1

Do not delay imaging for ultrasound first 1, 3

• While ultrasound is appropriate for pregnant patients or recurrent stone formers, it has only 45% sensitivity for stones and would miss important details about renal masses 1
• CT provides comprehensive evaluation in a single study 3

When to Involve Specialists

Urology consultation should be obtained if imaging reveals:

• Any renal mass or suspicious lesion 1
• Urothelial abnormalities requiring cystoscopy 1
• Complex hydronephrosis without clear stone etiology 1

Nephrology evaluation is indicated if there is evidence of:

• Glomerular bleeding (dysmorphic RBCs, red cell casts) 1
• Significant proteinuria or renal insufficiency 1

Follow-up Based on Initial Findings

If malignancy is identified: proceed with staging CT chest, consider brain MRI if clinically indicated, and obtain tissue diagnosis if needed before definitive treatment 1

If imaging is negative: cystoscopy should still be performed given age and hematuria to exclude bladder pathology 1

If isolated hematuria persists with negative urologic evaluation: monitor for development of proteinuria, hypertension, or renal insufficiency 1