Back and Loin Pain

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FieldsPyelonephritis Constipation Mechanical Back Pain Cauda Equina Syndrome GI Bleed Renal Stones Renal Cell Carcinoma Transitional Cell Carcinoma (TCC) Sciatica 
Age Increases with age Usually in Elderly Teenagers and adults Increases with age Increases with age Increases with age Typically 65+ >60 years Increases with age 
Gender F>M F>M M>F M=F M > F M:F 3:1 M:F 2:1 M:F 4:1 M=F 
Typical Presentation A 40 y/o woman with Type 2 Diabetes presents to her GP with abdominal pain radiating to her back and loin, which began about 6 hours ago. On examination, she has tenderness at her left renal angle, and a temperature of 38.5’. An 80 y/o woman with known dementia is brought to A&E by her son after she had been complaining of abdominal pains. She has become more agitated and confused, and has also not passed any urine for over 24 hours. A 32 y/o man presents to his GP with intermittent lumbosacral back pain which was exacerbated by movement and relieved by rest. He is systemically well, but has been feeling depressed for the past 3 months due to problems at work. A 70 y/o woman with known osteoarthritis in her spine attends A&E with a 3 hr history of lower back pain and numbness in her buttocks and groin. She has developed urinary and faecal incontinenceA 65 year old man with a history of peptic ulcer disease visited his GP complaining of several episodes of vomiting blood. He said he felt tired all of the time, and on examination he had pale mucous membranes and was tachycardic and hypotensive A 40 y/o man developed intermittent waves of excruciating abdominal pain which radiated to his hypochondrium and groin. He is rolling around on the floor in pain. On examination he was febrile with a temperature of 39’C, and tachycardic with a HR of 110. A 70 y/o man with a 40 pack-year smoking HX presents to his GP with fatigue, haematuria, loin pain and weight loss. On examination, he has a palpable mass in his abdomen. A 75 y/o man with a 20 pack-year smoking history presented to his GP with weight loss, haematuria and flank pain. He complained of having to urinate much more frequently than usual. A 60 y/o woman visits her GP with an intermittent, shooting lower back and left leg pain and pins and needles. A left leg raise reveals positive Lasegue’s sign. 
Other Symptoms ● Fever ● Oliguria ● Frequent micturition (day and night) ● Pain on voiding (dysuria) ●Smelly urine ● Pyuria ● Vomiting ● Fatigue ● Tenesmus ● Nausea ● Patient generally well (no fevers/ weight loss) ● Sciatica ● Saddle anaesthesia ● Incontinence of bladder and bowels ● Sexual dysfunction ● Tired all the time (if chronic - see Iron Deficiency Anaemia). ● Medical emergency if acute ● Nausea/ vomiting ● Haematuria ● Dysuria ●Sepsis Haematuria in 60% ● Weight loss ● Flank pain ● Painless haematuria ● Flank pain ● Pain on voiding (dysuria) ● Frequent micturition ● Weight loss ● Pins and needles sensation ● Difficulty moving/ controlling the leg ● Typically unilateral 
Pain Constant abdominal pain radiating to the back and loin. Cramping/ aching abdominal pain radiating to the lower back. Cyclical lower back pain/ muscle spasm worse on movement. Acute onset lower back/ groin pain +/- saddle anaesthesia. Acute or sub-acute Quick onset waves of agonising colicky loin pain. Slow onset constant loin and flank pain Slow onset constant loin and flank pain. Acute onset shooting pain in the lower back, buttocks and the posterior and lower leg. 
Signs ● Tenderness at the renal angle on affected side ● Tachycardia ● Tachypnea ● Hypotension ● Shivering ●Delirium ● Abdominal bloating/ distension ● Palpable mass/ scybala in Left lower quadrant ● Visible haemorrhoids/ anal fissure ● Examination may reveal restricted movement/ tenderness in affected area. ● Decreased anal tone ● LMN signs in lower limbs ● Muscle weakness of lower extremities/ paraplegia ● Detrusor weakness: urinary retention and post-voidal incontinence ● Signs of hypovolaemia/ shock ● Orthostatic hypotension ● Haematemesis/ malaena/ bloody stools ● Pale mucous membranes ● Tachycardia ● Tachypnoea ● Patient my writhe around in pain ● Loin pain radiates down and round in L1-L2 nerve routes ● Signs of sepsis: fever >38 ● Tachycardia ● Hypotension ● Palpable mass in 25% ● Polycythaemia ● Hypertension ● Anaemia ● Pyrexia of unknown origin ●Varicocoele – seen in makes as an enlargement of tissue at the testicle. ● Altered sensation ● Motor weakness ● Altered reflexes ● Straight leg raise: Lasegue’s sign positive 
Past Medical History Catheterisation ● Diabetes ● Anatomical abnormality of the urinary tract ● Proceeding sexual intercourse ● Exposure to spermicide in females ● Pregnancy ● Menopause ● Immunosuppression ● Constipation ● Psychological stress/ depression ● Lack of fibre/ fluid intake ● Sedentary lifestyle ● IBS ● DH: opiates, iron supplements, anti-cholinergics, calcium antagonists, ● Neurological: MS, Parkinson’s, a CVA, spinal cord lesions ● Pregnancy ● Diabetes ● Hypercalcaemia ● Hypothyroidism ● Hirschprung’s disease ● Colonic carcinoma ● Diverticular disease ● Obstruction ● Crohn’s ● Fissures/ haemorrhoids ● Luteal phase of menstrual cycle. ● Pregnancy ● Smoking ● Poor working conditions ● Low socioeconomic status ● Cardiorespiratory disease ● Large number of children ● Anxiety/depression ● HX disc herniation ● Tumour ● Trauma ● Lumbar spinal stenosis ● Osteoarthritis ● Spondylolisthesis ● Paget disease ● Neurosarcoidosis ● Ankylosing spondylitis ● DH NSAIDs/ aspirin ● H. Pylori infection ● Hx PUD ● Haemorrhoids ● Ulcerative colitis ● Crohn’s disease ● Dyspepsia ● Liver disease ● Alcoholism ● Hypercalcaemia ● Hyperparathyroidism ● FH ● Diet high in tea/ coffee/ coke/ rhubarb/ radishes/ strawberries ● ● FH ● Von-Hippel-Lindau disease ● Polycystic kidney disease ●Exposure to irradiation ●Exposure to oestrogens ●Hypertension ● Smoking ●Exposure to cadmium ● Obesity ● Hysterectomy ● Smoking ● FH ● Exposure to industrial chemical carcinogens, e.g. chemical/ cable/ rubber/ leather/ painting and dye industry work ● DH: phenacetin, cyclophosphamide ● Hx chronic inflammation ● HX disc herniation ● Lumbar spinal stenosis ● Spondylolisthesis ● Piriformis syndrome ● Pregnancy 
Bloods ● FBC, U&£, CRP: signs of inflammation ● High urea ● None specific ● None specific ● None specific ● Blood film: normocytic anaemia ● FBC, U&E, Ca2+, phosphate, glucose, bicarbonate, urate ● High ESR ● Anaemia ● Hypercalcaemia if bone metastases ● FBC ●CBC test ● LFT: high ALT/ AST ● None specific ● None specific 
Imaging ● CT: wedge-shaped areas of inflammation in acute pyelonephritis; irregular, small kidneys in chronic reflux nephropathy. ● X-ray: impacted faecal matter in colon ● X-ray: may show osteophytes/ loss of joint space ● CT ● MRI ● MRI to see disc prolapse ● CT to confirm diagnosis ● Endoscopy/ colonoscopy will reveal bleed ● CT angiography: reveals exact location of bleed ● X-ray of kidneys, ureter and bladder: 85% stones visible (uric acid stones not visible) ● CT ● Intravenous Urogram demonstrates location of stone (but IV contrast carries risk) ● US to detect mass: solid renal lesion disturbs renal contour ● CT for staging ● MRI is an alternative for staging ● Intravenous pyelography ● USS ● CT ● Cytoscopy ● MRI to see disc prolapse ● CT to confirm diagnosis 
Additional Investigations ● MSU dipstick: nitrites and leukocytes esterase ● Urinalysis: bacteriuria ●Biopsy: infiltration with leucocytes, renal abscess with streaks of pus in renal medulla ● PR: impaired sensation/ rectal mass/ prolapse/ reduced anal sphincter function ● Barium enema (not often used) ● Colonoscopy may be considered if a sinister cause is suspected● None specific ● None specific As above ● Urinalysis: haematuria if accompanying sepsis ● Urinalysis: haematuria and presence of sugar/ protein/ bacteria ● Urinalysis: malignant cells and haematuria ● Biopsy ● None specific 
Full Article UTIConstipationMechanical Back PainSpinal Cord CompressionUpper GI bleedRenal StonesRenal Cell CarcinomaTCCSciatica




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