Teenaged girl experiences rare cause of flank pain

Key Points

The Case

You are on call in the emergency department (ED) when a 15-year-old girl is brought in with the chief complaint of pain in the right flank. You learn that the patient attends secondary school and plays field hockey. The patient describes the pain as dull and achy rather than colicky in nature and as a 5 to 6 out of 10 in severity.

The pain first appeared 6 weeks ago and has been more or less consistent since then. It is exacerbated by defecation, urination, and menstruation and partially relieved by rest and ibuprofen. She denies any trauma to her back either while playing field hockey or at any other time. The patient reports no fever, weight loss, or fatigue and has normal appetite and bowel movements.

She was initially treated for flank pain 6 weeks by her primary care physician for a urinary tract infection (UTI) before she presented to you.

Subsequently, after moving to a different country, she was again treated with several courses of antibiotics for suspected UTI. However, despite this treatment, symptoms did not resolve, and she finished her last prescribed course of antibiotics a week ago.

Medical review

Her medical records are normal overall except for a slightly elevated blood pressure (BP) detected on a prior school physical. No complaints of headaches, dizziness, or chest pain were elicited at that time or while in the ED.

The patient attained menarche 2 years ago at age 13. Her last menstrual period was 14 days before the date of this visit. Her menses last about 6 days with moderate flow and occur at regular 28-day intervals. She has some cramping during her menses for which she uses over-the-counter pain medication. Her mother tells you that her daughter is a good student with no behavior problems.

Privately, the patient confides that she is not sexually active and denies use of alcohol, tobacco, or other drugs.