Treatment and Management of Loin Pain Hematuria Syndrome.

PURPOSE OF REVIEW: Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS: LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.

Nutcracker syndrome: A rare cause of left flank pain that can also manifest as unexplained pelvic pain.

Nutcracker syndrome (NCS) is symptomatic unilateral renal venous hypertension due to compression of the left renal vein between the superior mesenteric artery and aorta (anterior NCS) or between the aorta and spine (posterior NCS). The left ovarian or spermatic vein empties into the left renal vein and is an additional site of venostasis in about half the cases of NCS. The presenting symptom of NCS in about half the cases is atypical left flank pain suggesting a disorder of the lower ribs or thoracolumbar spinal junction, particularly as the pain worsens with standing and increased lumbar lordosis. NCS may be suggested by any combination of the following manifestations: hematuria, which is often only microscopic; orthostatic proteinuria; varicocele and infertility; dyspareunia and other gynecological symptoms; varicose veins in the pelvis, buttocks, or upper thighs; orthostatic hypotension and fatigue; and abdominal pain. Narrowing of the left renal vein on imaging studies is required but far from sufficient to establish the diagnosis. Several converging clinical findings and a marked pressure gradient between the left renal vein and inferior vena cava must be present also. Urological procedures and vascular surgery are being superseded by endovascular stenting with or without simultaneous treatment of the acquired gonadal vein insufficiency by embolization.

Clinical variables and stone detection in patients with flank pain.

INTRODUCTION: Non-contrast CT (NCT) is commonly used to evaluate flank pain (FP). We sought to evaluate incidence of ureteral calculi on NCT in patients with FP, and to determine if clinical variables are associated with higher detection rates. MATERIALS AND METHODS: Retrospective review identified 613 patients undergoing NCT for FP. Patient clinical data, NCT findings, and intervention were analyzed. Focus was placed on variables commonly associated with urolithiasis (Vstone), comprising hematuria, nausea/vomiting, and prior stone history. Statistical analysis was performed to identify risk of ureteral stones based on number and type of Vstone. RESULTS: No stone disease was identified on NCT in 175 patients (28.5%). NCT demonstrated 214 (35%), 72 (12%), and 152 (25%) patients with stones located in the kidney, ureter, or both, respectively. Only 33 (5%) patients had FP as their sole Vstone, with ureteral calculi identified in 6% of this cohort. The rate of ureteral calculi increased with more Vstone. Patients having all four Vstone were found to have the highest rate of ureteral stones (59%). Statistical analysis demonstrated a statistically significantly increased relative risk of stone formation given three or four Vstone when compared with FP alone. CONCLUSIONS: Whereas isolated FP is associated with a lower rate of ureteral calculus detection, a significant increased relative risk of ureteral calculus is seen in patients with additional clinical variables associated with stone disease. Accordingly, it may be possible to improve detection rates of ureteral stones through the use of additional clinical variables to guide NCT selection.

A case of renal cell carcinoma and angiomyolipoma in an adolescent girl.

We describe a case of renal cell carcinoma in the right kidney together with an angiomyolipoma in the left kidney, encountered in an adolescent girl at Potchefstroom Provincial Hospital, North West Province, South Africa.

Infarto renal derecho. Presentación de un nuevo caso / Right renal infarction: a new case report

OBJETIVO: Presentar un nuevo caso de infarto renal. MÉTODOS: Se presenta el caso de una mujer de 84 años con dolor cólico en flanco derecho de 24 horas de evolución y con antecedente de infarto agudo de miocardio cuatro meses antes. CONCLUSIÓN: El infarto renal es una patología rara, dando lugar en la mayoría de los casos a una sintomatología inespecífica y solapable a otros procesos urológicos más frecuentes, lo que implica un retraso en su diagnóstico y en su tratamiento. Las pruebas de imagen más concluyentes son la Tc con contraste o la Eco-Doppler pero el diagnóstico de certeza es por angiografía o angio-Tc. Su tratamiento es conservador, anticoagulación parenteral y oral, el manejo invasivo es infrecuente (AU)

OBJECTIVE: To present a new case of renal infarction. METHODS: We report the case of an 84-year-old woman presenting with right flank colic pain of 24 hours of evolution and past history of acute myocardial infarction four months before. CONCLUSION: Renal infarction is a rare condition; in most of the cases it does not show specific symptoms and usually overlap with other more common urologic procedures, which results in a delay in diagnosis and treatment. The most conclusive imaging tests are i.v contrast CT scan or Doppler ultrasound but definitive diagnosis is achieved by angiography or CT angiography. Treatment is conservative, with parenteral and oral anticoagulation; invasive management is rare (AU)

Apendicitis aguda sin dolor o El paraíso de los tontos: caso clínico / Painless acule appendicitis: The fools´ paradise: report of two cases

The diagnosis of acute appendicitis has been based on the presence of ríght lower quadrant pain and guarding. Occasionally, the pain disappears, even in the presence of a continuing appendicular process. This phenomenon is called "the fools' paradise". We report two male patients aged 19 and 17 years with an acute appendicitis confirmed by an abdominal ultrasound in one and an abdominal CAT sean in the other, in whom the abdominal pain disappeared during the evolution. Despite of the absence of pain, both were operated, based on imaging and laboratory studies, confirming the presence of an inflamed appendix.

[Painless acute appendicitis: "The fools'paradise": report of two cases]. / Apendicitis aguda sin dolor o "El paraíso de los tontos": Caso clínico.

The diagnosis of acute appendicitis has been based on the presence of right lower quadrant pain and guarding. Occasionally, the pain disappears, even in the presence of a continuing appendicular process. This phenomenon is called "the fools' paradise". We report two male patients aged 19 and 17 years with an acute appendicitis confirmed by an abdominal ultrasound in one and an abdominal CAT scan in the other, in whom the abdominal pain disappeared during the evolution. Despite of the absence of pain, both were operated, based on imaging and laboratory studies, confirming the presence of an inflamed appendix.

Central/diffuse abdominal perception of urological pain in children.

AIM: In children with recurrent abdominal pain (RAP), the location of pain to the flank may suggest the involvement of the urinary apparatus. We aimed to evaluate the location of pain in different age groups of children with idiopathic hypercalciuria (HC) and/or hyperuricosuria (HU) and RAP. METHODS: Location of pain was assessed in 180 consecutive HC/HU children with RAP, aged 3-17.6 y, presenting to a single centre. RESULTS: Considering four age groups, central/diffuse was more prevalent than lateral location of pain in youngsters, with a progressive and significant (p<0.0001, chi2 test for trend) decrease of the prevalence of central/diffuse location with rising age, and with the most relevant drop after age 8 y. Location of pain was central/diffuse in 81% of patients under and lateral in 79% of those over 8 y of age (p<0.0001). The location of pain changed from central/diffuse to lateral in 16/18 children followed at least 1 y, within 1 to 2 y by age 8. CONCLUSION: Only after 8 y of age did the lateral location of abdominal pain become the rule in children with HC/HU and RAP. This has to be kept in mind in order to avoid overlooking the urologic origin of pain.

[Prevalence and associated factors with pain in professional dancers]. / Prevalência e fatores associados a dor em bailarinos profissionais.

PURPOSE: To investigate factors associated to pain in ballet dancers as well its prevalence. METHODS: We conducted an analytical cross-sectional study among 141 professional ballet dancers from the main capitals of Northeastern Brazil. In order to evaluate the symptoms of pain we used Portuguese official versions of the McGill Protocol and the Pain Inventory of Wisconsin. For statistical analysis of the results we performed a descriptive assessment, followed by T-Student and Pearson's Correlation tests (taking a value of p < 0.05). RESULTS: We observed high levels of pain tolerance in 70.2% of the subjects, in which the intensity varied from moderate to severe. The lumbar region was the most affected (85.8%). We observed positive correlations concerning the intensity degree of pain with activities such as dancing (60.3%), sleeping (28.4%), marching (20.6%), general activities (32.6%), mood (27.7%), and personal relations (16.3%). CONCLUSION: We observed a high prevalence of pain in professional ballet dancers from the main Northeastern capitals, attacking mostly the lumbar region, followed by knees, neck, hip and feet, with substantial interference of pain symptoms in several activities of the personal and professional lives of these people.

Prevalência e fatores associados a dor em bailarinos profissionais / Prevalence and associated factors with pain in professional dancers

PURPOSE: To investigate factors associated to pain in ballet dancers as well its prevalence. METHODS: We conducted an analytical cross-sectional study among 141 professional ballet dancers from the main capitals of Northeastern Brazil. In order to evaluate the symptoms of pain we used Portuguese official versions of the McGill Protocol and the Pain Inventory of Wisconsin. For statistical analysis of the results we performed a descriptive assessment, followed by T-Student and Pearson's Correlation tests (taking a value of p < 0.05). RESULTS: We observed high levels of pain tolerance in 70.2% of the subjects, in which the intensity varied from moderate to severe. The lumbar region was the most affected (85.8%). We observed positive correlations concerning the intensity degree of pain with activities such as dancing (60.3%), sleeping (28.4%), marching (20.6%), general activities (32.6%), mood (27.7%), and personal relations (16.3%). CONCLUSION: We observed a high prevalence of pain in professional ballet dancers from the main Northeastern capitals, attacking mostly the lumbar region, followed by knees, neck, hip and feet, with substantial interference of pain symptoms in several activities of the personal and professional lives of these people.

Loin pain hematuria syndrome: case series.

Loin pain hematuria syndrome (LPHS) is a rare condition manifested by flank pain, hematuria, and occasional low-grade fevers. Usually there are no physical findings other than hematuria. Although numerous etiological theories exist, the pathophysiology of LPHS is unknown and diagnosis remains one of exclusion. Renal autotransplantation has been suggested as an effective procedure to control the severe and debilitating pain. However, pain often recurs in the long term. This paper reviews our experiences with the diagnosis and management of this condition.