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Question
I recently went to the er with flank pain. I had a Physical showing a small amount of blood in my urine and the constant pain in my back lead me to believe that I probably had an infection. I'm a 53 year old female. When I was 5 years old I had surgery were, as best as I understand, they took tissue from my bladder and reconstructed my ureter and a valve that was causing back flow. I have no infection and no stones. What the ct scan showed was thickening of the wall of my bladder. I had many urinary tracked infections until puberty when the tissue finally toughened up. The er doctor doesn't think the flank pain is related to the bladder issue. If not what else could it be? the pain is on the left dull and constant. It's less painful when I'm up moving around. Pain meds don't seem to help much.

Answer
Marilyn, what you had as a child is called vesico-ureteral reflux.  The kidneys drain the urine they produce into the urinary bladder by long tubular structures called the ureters.  The ureters pass through the wall of the bladder in an oblique angle which, although not truly a valve, acts in a valve like manner.  When the filled bladder contracts, all of the urine should pass in an antegrade manner out the urethra.   Because of this local anatomy, the contraction causes the intramural portion of the ureter to be closed off,  thus preventing backward flow of urine (reflux) into the kidney.  Although reflux can be acquired, one usually is born with a predisposition to reflux due to  malformation of the ureteral insertion into the bladder.  The surgery you had corrected the reflux.  It is common for the infections to gradually resolve over time usually at or before puberty as in your case.

There are many possible causes for blood in the urine (hematuria).  The origin of the bleeding can come from the upper (kidneys or ureters) or lower (bladder, prostate, urethra) urinary tract.  Blood seen only under the microscope (microscopic hematuria) is usually of a benign nature whereas gross hematuria is potentially more serious. With gross hematuria, it is important to note the relationship of the bleeding to the urinary stream.  If at the beginning of urination (initial hematuria), the source of the blood is almost always in the urinary canal (urethra).  If at the end of urination (terminal hematuria), the source is usually the prostate gland in men or the bladder neck in men and women.  Bleeding throughout the entire stream (total hematuria) is due to bleeding that is initiated in the urinary bladder or upper urinary tract (kidneys and/or ureters).  

Some of the common causes of hematuria include infection, tumors, stones, and trauma (injury).  In order to look for the cause, it is necessary to consult a urologist.  A history, physical examination, urine cytology, and other laboratory tests are done.   Visualization of the kidneys by imaging studies (ie IVP, ultrasound, CT or MRI) and examination of the lower urinary tract with a cystoscope are usually required.  

Pain the the flank associated with microscopic hematuria can be due to infection but usually one finds pus and bacteria in the urine as well as other symptoms (burning with urination, fever, etc.).  Much more likely is that you have a kidney stone.  You need to have an imaging study to evaluate the upper urinary tract so that the etiology of your problem can be determined with certainty.  

To follow is some information I have written on kidney stones that you might find useful in understanding this condition.  Your kidney is made essentially of 2 portions:  the parenchyma and the pelvo-calyceal system. The renal parenchyma is the outer meaty portion of the kidney which is constructed mainly of millions of tiny tubules that filter waste products from the blood for excretion in the form of urine.  The interior of the kidney is a lined collecting cavity called the pelvo-calyceal into which the parenchymal tubules drain the urine.  It is here in the pelvo-calyceal system that stones form.  They usually lie free but on occasion may be attached.  Stones that are in the kidney generally are painless.  It is when they move out of the kidney causing either blockage of urine drainage or muscle spasm in the ureter (the tube that drain urine from the kidney to the bladder) that pain occurs. If the stone becomes lodged in the lower ureter, it characteristically causing irritation of the urinary bladder producing marked urinary frequency and urgency.  Typically, this pain is unilateral, starts  in the flank, radiates into the lower abdomen and then into the ipsilateral testicle.  The pain may be constant or intermittent, mild or severe but more often the latter.  As the stone scrapes the lining of the urinary tract, blood in the urine is often noted.  Movement of stones are spontaneous and may occur during activity, rest or sleep.  Passage is unrelated to physical activity.

Imaging studies (usually an IVP or MRI) are needed to definitively diagnose urinary stones.  The degree of obstruction, location and size of the stone all are factors in determining the likelihood of passage and treatment options.  The latter includes conservatism (forcing fluids and taking pain medication as needed), extracorporeal shock wave lithotripsy (ESWL), endoscopic manipulation or, less commonly, open surgical removal.  Intractable pain, severe kidney obstruction or signs of sepsis (fever, chills) are indications for prompt intervention.  Good luck.

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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