Urogenital pain

Renal pain is usually due to stretching of the renal capsule or renal pelvis. A chronic dull aching discomfort in the loin and renal angle may occur in renal scarring or infection and in hydronephrosis. Intermittent pain can occur in polycystic disease from infection or spontaneous bleeding into a cyst. In acute pyelonephritis, renal pain is often accompanied by dysuria, fever and sometimes rigors.

Severe pain, known as renal colic, can be caused by acute distension of the renal pelvis and ureter, resulting from obstruction by calculus or blood clot. Renal colic is not a true colic; the pain is severe, sustained and


A 49-year-old woman presented with an 8-hour history ol severe left-sided loin pain radiating into the groin and associated with vomiting. The past medical history revealed a previous light nephrectomy for 'chronic pyelonephritis' and long-standing headaches for which she had been taking ibuprofen, a non-steroidal, anti-inflammatory drug (NSAID) on a daily basis for over 20 years. Her last menstrual period had been 2 weeks ago. She had not passed urine for 6 hours.

She was restless and distressed by pain necessitating intravenous opiate therapy before clinical examination could proceed. Tenderness was noted in the left renal angle and left Iliac fossa. The bladder was not palpable. Rectal and vaginal examination were normal.

An immediate ultrasound examination of the urinary tract revealed marked dilatation of the left renal pelvicalyceal syslem. A percutaneous nephrostomy drain was inserted into the left renal pelvis, resulting in rapid restoration of urine flow via the drain. The following day she passed a large fleshy 'stone' per urethra. Pathological examination of the 'stone' revealed a necrotic renal papilla and review of the histopathology of the previous nephrectomy confirmed the diagnosis of NSAID-induced renal papillary necrosis due to analgesic nephropathy.

Learning points

• The pain ol ureteric colic is usually sustained and associated with vomiting.

• Anuria strongly suggests complete obstruction of the urinary trad

• A careful history often elicits key pointers to Ihe underlying diagnosis.

• Look first lor a single unifying diagnosis belore considering multiple unrelated diagnoses.

unremitting and the patient is restless, nauseated and often vomits. The pain may radiate from the renal angle and loin to the iliac fossa, the groin and into the genitalia. Once the stone reaches the bladder, it is often asymptomatic until it enters the urethra and causes dysuria. In patients with renal colic, specific questions should he asked to try to determine any underlying cause for stone formation (see Fig. 5.3).

Mosi conditions causing bladder pain also cause frequency and dysuria. In males, perineal and rectal pain with associated dysuria suggest prostatic inflammation or infection {prostatitis| and may be associated with symptoms of bladder neck obstruction. Testicular and epididymal pain may be felt in the groin and lower abdomen to such an extent that its testicular origin may be obscured. Its occurrence in pubertal boys and young men is most often the result of torsion of the testis and demands urgent intervention. The onset is frequently at night with pain in the iliac fossa. Tenderness and swelling of the testis may need to be distinguished from a strangulated hernia or acute epididymo-orchitis.

Ovarian pain is also felt in the iliac fossa and may be episodic and cyclical, as in endometriosis, or more constant. as in malignant tumours. Uterine pain is felt centrally in the hypogastrium and may radiate to the lumbosacral area. e.g. labour pains and dysmenorrhoea.

Boys Genital Injury
Fig. 5.3 Checklist in patients with renal colic.
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