Attention thought leaders: How is new-onset flank pain evaluated?

A few weeks ago, I received a page at about 2 am from the local emergency room. A male patient in his 50s had presented earlier with right flank pain. The pain was colicky in nature and worse than he had ever previously felt, the ER doctor explained over the phone. The usual cocktail of IV meds helped, but his pain was not well controlled. His urine was clean, he was afebrile, and his white blood cell count was normal. He had no prior history of stones.

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At this point, I was starting to get out of bed to get dressed and head in to do an early-morning ureteroscopy when the ER doctor stated, “I ordered an ultrasound that showed mild to moderate right-sided hydronephrosis…”

And then … radio silence.

I asked what the CT showed, and the ER doctor became a bit flustered. He started lecturing me on the overuse of CT scanning and the danger of radiation exposure. He even went so far as to cite a recent article in the New England Journal of Medicine on the use of ultrasound to diagnose kidney stones. At this point, my first thought was to reach through the phone, grab the ER physician by the cremaster muscle, and immediately perform a simple orchiectomy. But remembering my own advice on playing nice with others, I simply stated that I would like a CT scan ordered and to call me when it was ready. I hung up and went back to sleep.

An hour later the ER secretary called to inform me that I wasn’t needed anymore. When I looked up the CT scan later that morning, it showed mild hydro but no stones.

For those not familiar with the New England Journal article cited by the ER physician, the study randomized over 2,700 patients who presented to the ER with symptoms consistent with a kidney stone to US by the ER physician, US by a radiologist, or a CT scan. The authors found no differences in serious adverse events, return trips to the ER, or hospitalizations. The article’s conclusion stated: "Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations."

The study has been interpreted, at least by the ER doctors where I work, to mean that CT scans are not the initial imaging test in the evaluation of colicky flank pain.

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I don't know about everyone else, but as variations on this theme have become more common in my practice (eg, patients being sent from the ER to my clinic with a US showing hydronephrosis and no stones but being told they have a stone), this incident has become more bothersome to me. One of the lessons I was taught in residency is that diagnosis comes before treatment and unless things have changed, hydronephrosis with flank pain is not necessarily a surgical diagnosis. I just don't think it’s wise to assume that the cause is a kidney stone and rush the patient to the OR.

Or am I wrong? I've been wrong before, and I'm sure I’ll be wrong again. With that in mind, if I may be so bold, I would like to challenge the thought leaders in our field to offer some guidance on the proper radiographic evaluation of new-onset colicky flank pain. I will go so far as to offer to buy the first round of beers for a joint urology/emergency committee on this topic. A few beers would be a small price to pay for a reduction in the number of pages I get while on call.

Whether or not urology’s thought leaders take up my challenge, I am continuing to confirm the diagnosis of obstructing ureteral calculi before going to surgery. I am curious to know if other urologists have encountered this problem and handled it any differently than I did.

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