What are the best next steps for a patient with uterine prolapse and possible IBS experiencing right flank pain while taking naproxen?

Right Flank Pain in a Patient with Uterine Prolapse and Possible IBS on Naproxen

The most critical next step is to obtain urgent imaging with CT urography or renal ultrasound to rule out urinary tract obstruction, nephrolithiasis, or ureteral injury, as these are life-threatening complications that can occur with pelvic organ prolapse and present with flank pain. 1

Immediate Assessment: Rule Out Urological Emergencies

High-Priority Differential Diagnoses

• Urinary tract obstruction from uterine prolapse can cause hydronephrosis and flank pain, particularly when the prolapsed uterus compresses or kinks the ureters 1, 2
• Nephrolithiasis with possible infection requires urgent evaluation if fever, leukocytosis, or signs of sepsis are present 1
• Urinary retention or recurrent UTIs are common with moderate-to-severe uterine prolapse and can manifest as flank pain 2, 3

Critical Red Flags Requiring Immediate Action

• Fever with flank pain and leukocytosis suggests obstructive pyelonephritis requiring urgent decompression via retrograde ureteral stenting or percutaneous nephrostomy 1
• Elevated creatinine or decreased urine output may indicate bilateral obstruction or acute kidney injury 1
• Hemodynamic instability with flank pain warrants immediate imaging to assess for ruptured pathology 1

Imaging Algorithm

First-Line Imaging

• Renal ultrasound is appropriate for initial evaluation if the patient is stable, to assess for hydronephrosis, stones, or structural abnormalities 1
• CT urography without contrast (if renal function permits) provides definitive evaluation of the urinary tract, stones, and degree of obstruction 1

When to Escalate

• If moderate-to-severe hydronephrosis is identified with signs of infection, proceed immediately to urological consultation for decompression 1
• Retrograde ureteral stenting or percutaneous nephrostomy are both appropriate interventions for obstructive uropathy with infection 1

Addressing the Uterine Prolapse

Symptom Correlation

• Pelvic heaviness, low back pain, or sensation of vaginal fullness that worsens with exertion are classic symptoms of moderate-to-severe uterine prolapse 2, 3
• Difficulty voiding, recurrent UTIs, or need to manually reduce prolapse to urinate ("splinting") indicate significant prolapse affecting bladder function 2, 3

Management Options

• Conservative management with pessary should be first-line if the patient desires non-surgical therapy and prolapse is symptomatic 2, 4
• Surgical repair (vaginal or abdominal approach) is indicated for second- or third-degree prolapse when patients are significantly symptomatic and conservative measures fail 2, 4
• Urgent surgical consultation is warranted if prolapse is causing urinary obstruction or if the cervix is protruding outside the introitus with ulceration 2, 3

Managing Possible IBS Symptoms

Reassess IBS Diagnosis in Context of Flank Pain

• Severe or refractory IBS symptoms should prompt review of the diagnosis with consideration of further targeted investigation, as the risk of missing organic pathology increases with severe symptoms 1
• Right-sided flank pain is NOT typical of IBS and should not be attributed to IBS without excluding urological, gynecological, or gastrointestinal pathology 1

If IBS is Confirmed

• Continue naproxen 500 mg twice daily for pain management if tolerated, as NSAIDs are appropriate for inflammatory pain but do not treat IBS-specific symptoms 5
• First-line IBS management includes soluble fiber (psyllium 3-4 g/day), antispasmodics for abdominal cramping, and loperamide if diarrhea-predominant 6, 7
• Avoid attributing all abdominal/flank pain to IBS when a patient has known structural pelvic pathology like uterine prolapse 1

Naproxen Considerations

Current Dosing and Safety

• Naproxen 500 mg twice daily is within recommended dosing for chronic pain conditions like osteoarthritis 5
• Monitor for renal toxicity, especially if imaging reveals any degree of renal impairment, as naproxen is not recommended with creatinine clearance <30 mL/min 5
• Use the lowest effective dose for the shortest duration to minimize cardiovascular and gastrointestinal risks 5

When to Discontinue or Adjust

• Stop naproxen immediately if acute kidney injury or significant renal impairment is identified on imaging 5
• Consider dose reduction in elderly patients due to increased unbound plasma fraction 5

Common Pitfalls to Avoid

• Never attribute flank pain to IBS without imaging, as this can miss life-threatening urological emergencies like obstructive pyelonephritis or ureteral injury 1
• Do not delay imaging in patients with pelvic organ prolapse and new flank pain, as urinary obstruction can progress rapidly to renal failure 1, 2
• Avoid prescribing opioids for chronic pain management in IBS or prolapse-related pain due to dependency risk and lack of efficacy 1
• Do not assume all pelvic/abdominal symptoms are from IBS when structural pathology like uterine prolapse is present 1, 3

Multidisciplinary Coordination

• Urology consultation if hydronephrosis, stones, or obstruction are identified 1
• Gynecology/urogynecology referral for definitive prolapse management once acute urological issues are addressed 2, 4, 3
• Gastroenterology referral only after organic causes are excluded and if IBS symptoms persist despite first-line therapy for 12 weeks 1, 7