Severe unexplained loin pain (loin pain haematuria ...

Q J Med 2007; 100:369–381 Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
doi:10.1093/qjmed/hcm034

Severe unexplained loin pain (loin pain haematuria
syndrome): management and long-term outcome

C.M. BASS1, H. PARROTT1, T. JACK2, A. BARANOWSKI3 and G.H. NEILD4
1From the Department of Psychological Medicine, John Radcliffe Hospital, Oxford, 2Regional Pain
Clinic, Churchill Hospital, Oxford, 3Pain Clinic, UCL Hospitals Trust, London and 4Institute of
Urology and Nephrology, Middlesex Hospital, London, UK

Received 27 August 2006 and in revised form 2 February 2007

Summary Sixteen were receiving opiates, and none had
enduring benefit from surgery. Patients were divi-
Background: The intractable and unexplained loin sible into three groups: twelve (57%) gave a history
pain of severe ‘loin pain haematuria syndrome’ of recurrent, unexplained symptoms involving other
(LPHS) causes great psychosocial distress and parts of the body (somatoform disorder); seven had
disability. chronic loin pain; dissimulation was suspected in
Aim: To examine the psychological factors in LPHS two. At follow-up (median 42 months), eight (38%)
patients who had failed to respond to non-opiate rated their pain absent or improved. Of the
analgesia, and explore the feasibility of conservative 11 whose pain was the same or worse, all were on
management. opiates and seven had a somatoform disorder.
Design: Retrospective review of case notes, medical A further two patients had developed ‘other’
and GP records, with follow up. medical problems. Despite our advice, three
Methods: We studied 21 consecutive patients patients underwent major surgery for pain.
referred from specialist renal centres to a regional Discussion: We recommend that patients be man-
pain clinic. All records were reviewed, and patients aged in a regional pain clinic, where a multi-
received a comprehensive psychiatric and social disciplinary approach promotes self-management of
assessment. Medication with pain-coping strategies pain. Patients who were able to accept conservative
was emphasized, and surgical solutions were treatment, and taper or withdraw opiate analgesia,
discouraged. had a better prognosis.
Results: Patients’ median age was 43 years (range
21–64) and duration of symptoms 11 (1–34) years.

Introduction renal abnormalities responsible for the haematuria

Since 1967, patients with severe unexplained loin are often unexplained. Patients never develop
pain have often been described using the term
‘loin pain haematuria syndrome’ (LPHS). Because evidence of progressive renal disease such as
there is no satisfactory case definition, many
physicians doubt that this is a discrete disease, but proteinuria or hypertension. A small group
LPHS is characterized by severe unilateral loin
pain that suggests a renal origin but occurs in are severely disabled by the pain and may be
the absence of identifiable or relevant urinary tract receiving opiate analgesics.2 There is a high
disease.1 Haematuria, which can be microscopic
or macroscopic, is not always present and the prevalence of somatoform disorders in these

patients, and it has been suggested that psychosocial

factors are important causal and maintaining
factors.3

Address correspondence to Dr C.M. Bass, Department of Psychological Medicine, John Radcliffe Hospital,
Oxford OX3 9DU. email: [email protected]

! The Author 2007. Published by Oxford University Press on behalf of the Association of Physicians.
All rights reserved. For Permissions, please email: [email protected]

370 C.M. Bass et al.

Although the pain is predominantly unilateral, The first patients with LPHS were referred by Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
following renal denervation and complete relief of GHN for psychiatric assessment and advice on
the ipsilateral pain, it will commonly move to the management from 1993. After 1996, as referrals
contralateral side, and a second denervation may from London and Oxford increased, patients were
eventually be sought. Renal auto-transplantation has interviewed in a regional pain clinic, and were
been proposed to achieve a total denervation, but followed in a systematic way after the initial
this is often unsuccessful, and can result in graft loss, assessment.
or the pain may recur in the transplanted kidney.4
Rarely, patients will demand and be granted All patients had received the diagnosis of LPHS
nephrectomy, and there are patients who have after thorough renal and urological investigation had
ended up on dialysis as a consequence.5 None of failed to find an organic cause for their pain.3,10–12
these drastic surgical procedures address any of the All had reported symptoms for at least 1 year (range
psychosocial maintaining factors, which often 1–34), had failed to respond to conventional
persist. analgesics, had required or requested referral to a
tertiary pain clinic for further management of their
Many of these patients fulfil the criteria for a pain, and presented problems with pain manage-
somatoform disorder.3 Somatoform pain disorder is ment. All were assessed and examined at the
a persistent and distressing disorder characterized regional pain clinic in Oxford. Eight were referred
by pain that cannot be explained fully by a from within the region, while thirteen were referred
physiological process or a physical disorder.6 The from the Institute of Urology and Nephrology,
underlying assumption is that emotional problems or London, a national centre with a special interest in
psychosocial stressors play a key role in maintaining LPHS.3,10–12
the pain. Factors associated with somatoform
disorder include a previous history of medically Previous medical notes, including the general
unexplained physical symptoms, psychiatric comor- practitioner (GP) notes, were obtained and exam-
bidity (e.g. depressive illness, anxiety disorder or ined in all patients. Investigations undertaken for
substance misuse), and characteristic childhood risk evidence of renal and other pathology were
factors. These include experience of relevant child- documented, and details of previous and current
hood or parental illness, or an abusive childhood medication were noted, especially use of opiates.
(physical, sexual or emotional).7,8
All medical and surgical procedures (including
Although a wide range of psychiatric disorders renal biopsy, renal denervation, nephrectomy and
has been described in LPHS, including fabricated renal auto-transplantation) were documented, and a
illness,3 there has been no systematic description of comprehensive history of drug and alcohol use was
attempts to treat these patients conservatively using obtained. Of the 21 patients, five have been
psychological techniques.5,9 Conservative treatment described in another case series of patients
has proved difficult in the past, because surgical who underwent renal denervation for their
intervention was seen by patients as the short-term chronic pain.12
answer to their pain, and this surgical option may
dissuade them from seriously exploring and using All patients had a full psychiatric examination,
the facilities and therapies available in a multi- with details of previous psychiatric history, includ-
disciplinary pain clinic.2 ing episodes of deliberate self-harm and substance
misuse. Details were supplemented by examination
In this retrospective observational review we of both the GP and past hospital records, which
describe 21 consecutive patients with severe unex- were summarized on a proforma. All patients were
plained loin pain referred to a regional pain clinic. interviewed by a psychiatrist, who assigned a
Our primary aims were to examine the psychologi- psychiatric diagnosis according to ICD-10 criteria
cal factors and the feasibility of conservative (1992),13 and details of current drug use were
management without surgical intervention. documented. We wished to establish how many of
the patients had a somatoform disorder and the
Methods prevalence of dissimulation, as these disorders had
been reported in recent studies.3,14 The main feature
We investigated 21 consecutive patients with severe of somatoform disorders is ’repeated presentation of
unexplained loin pain referred from two specialist physical symptoms, together with persistent requests
renal units to a regional pain clinic between the for medical investigations, in spite of repeated
years 1993 and 2004. Since 1980, the combined negative findings and reassurances by doctors that
units have been referred over 145 patients the symptoms have no physical basis. If any physical
considered to have LPHS.4 disorders are present, they do not explain
the symptoms, distress or preoccupation of
the patient’.13 For the purposes of this study,

Severe unexplained loin pain 371

patients who reported at least two episodes of renal disorder to which the pain was attributed, but Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
medically unexplained symptoms requiring investi- in none of them were these features deemed
gation (e.g. fatigue, constipation, facial pain) were relevant to the pain. Five patients had had renal
described as having a somatoform disorder.13 biopsies that had all been reported in different
Seventeen of the 21 patients completed the centres as essentially normal. One patient with no
Hospital Anxiety and Depression Scale, and were proteinuria and normal function was reported to
considered depressed if their score was 511.15 have mesangial deposits of IgA antibody, which
would account for her microscopic haematuria.
Management in the multidisciplinary clinic
In five patients, renal denervation had failed to
Patients were seen in a joint pain clinic with a pain provide relief for longer than 2 years. Four patients
specialist and psychiatrist. After initial assessment, had undergone unilateral nephrectomy, and three
each patient was reassured that there was no sinister had received intra-ureteric capsaicin without benefit
or serious underlying damage or disease to account in another centre. In six patients the pain had moved
for the pain. We emphasized continuity of care to the contralateral side (in five after a denervation
(seeing the same doctor at consecutive visits). had been performed) (Table 2).
Patients were encouraged not to seek surgical
solutions to their pain and not to expect ‘a cure’. Sixteen patients (76%) were receiving opiate
Instead, medications and pain-coping strategies medications at the initial assessment, but in only
were discussed. two was there evidence that these drugs were being
misused. At least 11 patients had received renal
Shared care with GP nerve blocks in local pain clinics (Table 2).
Antidepressant drugs were being taken by nine
To obtain a consistent approach we communicated patients; tricyclics were prescribed for their analge-
our plan to each patient’s GP.16 After we wrote to sic effect in seven of these nine (Tables 1 and 2).
each GP, we followed-up with a telephone call
outlining the principles of treatment: (a) avoid Psychosocial characteristics (Table 3)
surgery for pain; (b) reduce unnecessary medication
if possible; (c) reduce the number of doctors Mean depression scores on the HAD Scale were 8.7
managing the patient; (d) emphasize continuity of (SD 5.0, range 1–19), and in only six (35%) of the 17
care with GP; (e) reduce referrals to other specialists patients that completed the scale was the score
(whenever possible). This approach has been shown above the depression threshold score of 10. Twelve
to improve physical functioning whilst also reducing (57%) of the 21 patients met the criteria for a
health-care costs.16 This was particularly important somatoform disorder, all of whom had been
for the 13 patients who could not be followed-up investigated on at least two previous occasions
locally for geographical reasons, as they lived at (before the onset of loin pain) for other physical
least 70 miles from Oxford, and we recommended symptoms without an organic basis (Table 3).
that management be co-ordinated with their local
pain clinic. A further three developed severe problems with
opiate misuse during the follow-up period (Tables 1
Results and 2). Twelve (57%) had a previous history of
treatment for a psychiatric illness (most often
Clinical and demographic characteristics depression), but none had evidence of previous
at initial assessment (Tables 1 and 2) substance misuse before the onset of loin pain. Nine
patients (43%) had a previous history of deliberate
Fourteen (67%) of the 21 patients were women. self-harm.
Median age at onset of loin pain was 30 years (range
14–53 years), and the median duration of symptoms We subsequently divided the 21 patients into
before referral for psychiatric assessment was 10 three groups, based on our approach to manage-
years (range 1–34 years, Table 1). Only 11 were in ment during the follow-up period.
employment at the time of assessment and eight
received long-term disability benefits (one of whom Twelve patients (57%) had a history of repeated
had retired because of ill health). Five (24%) had medically-unexplained physical symptoms (MUPS)
worked in health-care settings. Seven had evidence involving other organ systems: in six patients
of a pre-existing renal problem, such as renal previous negative investigations had involved three
scarring, and 11 reported a previous history of a separate organ systems and a further six involved
two systems (see legend in Table 3). These
12 patients all satisfied ICD-10 (1992) diagnostic
criteria13 for a ‘current somatoform disorder’
(Table 3). Two had undergone surgical procedures
for chronic constipation.

372 C.M. Bass et al.

Table 1 Clinical and demographic characteristics at presentation

Patient Age at Current Gender Duration of Co-morbid physical Occupation Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
onset age follow–up disease
1 (years) F (months) Nurse
36 Atopy; ulcerative colitis
2 31 F 70 of sigmoid colon; asthma LTD
44 Back pain, chronic
3 33 F 42 constipation Runs Bed &
64 Breakfast
4 53 F 86 Asthma Nurse
5 51 M Reiter’s disease, shingles, Factory
38 36 136 PH of migraine worker
6 32 F 77 Cashier
7 31 F Coarctation of aorta (op. Secretary
8 22 50 M 48 age 5 mths) LTD
16 48 35 Peptic ulceration
9 38 M 34 Manager
10 40 F Aortic stenosis, Absent Health-care student
11 28 28 F 40 L kidney LTD
14 38 65 Mild asthma
12 31 F 32 Endometriosis, epilepsy, Nurse (currently LTD)
13 38 F spinal problems LTD
34 46 45
14 38 M 27 Congenital absence left Unemployed 2 years
15 34 F forearm; asthma LTD (never worked)
32 38 88
16 28 F 26 Cervical dystonia LTD
17 29 F (remitted) House-person
18 14 36 M 22 Retired (ill health)
19 18 53 F 18 Care worker
20 22 21 M 24 Scientist
21 20 32 F 14 Clerical worker
30 35 18
24 132

LTD, long-term disability.

A second group of seven patients (33%) reported investigations, they had understandably formed the
chronic, persistent loin pain in the absence of a view that the pain was related to some kind of renal
documented history of previous repeated physical disease. They expressed views such as: ‘whenever I
complaints (one of these developed substance get the pain I know that my kidneys are burning up
misuse problems). inside‘; others had been told for example that . . .‘if
the pain gets too bad then we can always do an
In the remaining two patients, there was evidence auto-transplantation’.
of dissimulation. One of these patients was con-
fronted after the initial assessment and her pethidine Fifteen of the 21 patients accepted that surgery
abuse was subsequently managed jointly by her GP would not form part of the management plan, but in
and pain clinic. Another admitted her deception six there were persistent demands for a surgical
after the psychiatric assessment and was subse- solution (Table 3). For them management proved
quently referred to the local psychiatric services. more difficult, especially when the patient lived far
from the clinic or the GP, because of their increasing
Specific problems in management demands, was not able to implement the manage-
ment plan.
Expectations
Reducing patient expectations of ‘a surgical cure or Two-thirds of the patients accepted referral to
solution’ proved a formidable therapeutic problem. a pain clinic for management of their
Because all patients had received renal chronic pain, but only two engaged with a
clinical psychologist with the explicit goal of

Table 2 Principal complaints, investigations and drug use

Patient Principal complaint Attributed pathology Renal Surgical proceduresb Other medical Opiate/analgesic use
investigationsa – procedures at initial assessment
Pethidine (history
1 Bilateral loin pain ‘Classical renal colic’ Cystoscopy –
of opiate abuse)
in 1996; Bilateral
Morphine sulphate
passing small ureterograms Pethidine
Distalgesic
fragments of gravel Venogram Imipramine

Urine biochemistry Pethidine
Methadone
2 R loin pain Pyelonephritis Cystoscopy Hysterectomy (age 25) Intra-pelvic Tramadol
Chemical sympathectomy capsaicin Amitriptyline
Ureterograms
Cholecystectomy (age 36) Intravenous Morphine sulphate
Renography Laparotomy (age 40, 41) lignocaine Amitriptyline
Laparoscopy
Renal biopsy – (continued)
(age 38,40, 42)
3 L loin pain ‘Claimed to have Cystoscopy  3 Tubal sterilization Epidural
anaesthetics
haematuria passed a stone’ DPTA scan and oophorectomy (Â5) Severe unexplained loin pain

Ureterograms (age 40) [hysterectomy –
and rectopexy]
Renal angiogram L double J stenting
(age 55)
Retrograde Hysterectomy (age 30)

urethrogram –

CT scan abdomen

Micturating

cystogram

4 Cystitis IVU age 5–8 Cystoscopy Laparoscopy –
Loin pain Cystitis during Renal angiogram R denervation
Haematuria MRI kidneys R nephrectomy Self catheterizes
adolescence Cystoscopy Nerve blocks
5 Dysuria Pyelonephritis MRI spine (age 28) [L renal
Loin pain Renal biopsy auto-transplantation every 3–6
Haematuria ’Told severe CT abdomen (age 33)—failed] months
kidney infection’ On dialysis at follow-up
6 R loin pain (normal cultures) cystogram R J-J stent (age 41)
R denervation (age 43)
7 R loin pain (age 12 Uncertain Cystoscopy  3 L denervation (age 45)
Ureterograms
and 16) stone
ureteroscopy
Haematuria

(age 35) Bilateral

loin pain (38) 373

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Table 2 Continued 374 C.M. Bass et al.

Patient Principal complaint Attributed pathology Renal Surgical proceduresb Other medical Opiate/analgesic use
investigationsa procedures at initial assessment
8 Incontinent (age 36) Uncertain Clam-ileocystoplasty
Dysplastic L kidney Cystoscopy L nephrectomy (age 42) Renal nerve block Intrathecal morphine
R loin pain after L Told ’infection or Renography R retrograde insertion Intrathecal pump since age 45
nephrectomy kidney stones and
(requested papillary necrosis’ Cystoscopy of J splint morphine
removal) CT kidney
Uncertain Ureterograms R denervation (age 35) – Pethidine
9 L loin pain GFR renogram L denervation (age 36) Methadone
Operation on R Renography [R nephrectomy (age 38)] Diazepam
kidney Renal angiogram
10 R loin pain (age 14) age 16 Renography Capsaicin in renal pelvis Lumbar Pethidine
haematuria Ultrasound x3 Nephrostomy sympathectomy Ibuprofen
Absent L kidney DMSA scan R J-J stent
11 R loin pain Uncertain Renal biopsy Nerve blocks
Uncertain
12 L loin pain Renal biopsy Dilatation of R urethra – Tramadol
13 R loin pain Cystoscopy Injection of –
Ureterograms Buprenorphine
Microplastique – Diclofenac
14 R loin pain Uncertain Cystoscopy Mitrofanoff procedure Carbamazepine
– Amitriptyline
Hysterectomy (age 26) Amitriptyline
Ileostomy for constipation

(age 36)

J-J stent R ureter

Ureteroscopy

X-ray abdomen

15 Bilateral loin pain Bilateral loin pain Renal biopsy (IgA) – Regular nerve Dihydrocodeine
blocks Prothiaden
Pain moved L–R in since tonsillitis Lithotripsy for
nephrocalcinosis Tens machine Dipipanone
2000 age 28 Oramorph
R denervation (age 26) Prochloperazine
16 R loin pain, moved Pain since age 14 Cystoscopy R nephrectomy (age 27) Diazepam

to L after R. Medullary sponge

nephrectomy kidney

Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010

17 L loin pain Pain began during Cystoscopy – Tens machine Amitriptyline

Moved to R after first pregnancy Micturating Paroxetine

10 years age 18 cystogram Tramadol

Told she

has IgA

18 Bilateral loin pain Uncertain Lying and standing Capsaicin infusion into Renal nerve Morphine sulphate

isotope scans both ureters (age 47) blocks Diazepam

Bilateral denervation Subcutaneous Oxycontin

(age 48) lignocaine Fluoxetine

19 R loin pain Reflux Cystoscopy Reflux surgery (Teflon – Oramorph

nephropathy as Bilateral retrograde graft age 10) Morphine sulphate

child ureterograms Gabapentin

History Micturating Sertraline

of UTIs since cystogram

age 10, and PH of

surgery for Severe unexplained loin pain

vesico-ureteric

reflux

20 L loin pain Uncertain Cystoscopy Insertion of L J-J stent – Tramadol

Renography Dihydrocodeine

Ureteroscopy Nefopam

MRI spine

21 R loin pain Uncertain Cystoscopy Insertion of R stent Lignocaine Coproxamol

haematuria infusion

Tens machine

aAll 21 patients had at least normal abdominal X-ray, ultrasound of the kidney and bladder, IVP, urine culture (MSU) and cytology. bSurgical procedures: all procedures were

performed in an attempt to reduce loin pain. Three patients (numbers 3, 6 and 9) had surgery during the period of follow-up, which is shown in square brackets [ ]. DMSA,
99mTc-dimercaptosuccinic acid renography; J-J stent, double-J ureteric stent.

375

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Table 3 Psychosocial characteristics at presentation 376 C.M. Bass et al.

Patient Past psychiatric Deliberate Current substance Current Factitious Past history of Somatoform Seeking
history self harma disorder medically disorderc surgery
misuseà depressionb unexplained
Confronted symptoms þ
1 Bulimia nervosa þ Prescribed Â
pethidine No – þ
addiction
2 Depression; þ Pelvic pain; S
– multiple S
neurological S
chronic fatigue symptoms;
constipation, S
syndrome hemiparesis

3 None – – No Abdominal
pain,
4 Depression – Opiate No headache,
limb pains,
dependence; chest pains,
fatigue
reviewed in
Back pain,
substance misuse abdominal
pain,
service headaches,
intercostal
5 None – –Â pain
6 None –
– Yes Unexplained
joint pains

Bilateral knee
pains;
dysmenorrhoea

7 Hysterical þ – No

hemiparesis;

depression;

alcohol use

8 Depression þ – Yes Chest pains; S þ
hyperventilation;
bilateral knee
pains

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9 None þ Pethidine misuse; No Abdominal pains; S þ
epilepsy from unexplained þ
pethidine use haematemesis
and melaena þ

10 None þ Alcohol misuse; Â
prescribed
11 Depression – pethidine, multiple Chest pains; S
self-harm

– No

abdominal pain

12 Infrequent – – No Acknowledged
by patient
panic attacks

13 Depression – – No Menorrhagia; S

pseudoseizures;

chronic back pain;

constipation Severe unexplained loin pain

(ileostomy)

14 Depression þ Opiate misuse  Limb pain; facial S

and oral pain;

abdominal pain;

headaches

15 None – – Yes Headaches; left S

– Yes knee pain
– No
16 None –

17 Agoraphobia; –

depression;

obsessive

compulsive

disorder

18 None þ – Yes
– Yes
19 Depression þ – No Headaches
Bilateral knee
20 None – – No S
pains; abdominal S
21 Depression – pain
Headaches,
neck pain

aþ, yes; –, no. bYes, HAD score 511 (see reference 15); No, HADS score 410; Â, not formally tested. cTwo or more organ systems investigated with normal findings e.g.
endoscopy. *Patients 4, 9 and 14 developed problems with substance misuse during follow-up (see text).

377

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378 C.M. Bass et al.

pain management. The management plan was to clinic (five in Oxford and nine elsewhere). Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
engage the patient in long-term outpatient pain Significantly, three of the seven who defaulted
management, with a goal of containment and no from the clinic persistently sought surgical solutions
recourse to surgery. In those patients who were to their pain. The reasons for defaulting were diverse
unable to visit the clinic because they lived too far and included: clinic too far away, lack of transport,
away, management was monitored with the unwilling to see a psychiatrist or psychologist in the
patient’s GP. A case vignette illustrating the complex clinic, and one moved away.
medical histories and management problems is
shown in the Appendix (published with the patient’s Continuing pain
consent).
Pain outcome was categorized according to
Opiate use patient’s complaints of pain over the last 3 months.
Pain was rated on a four-point scale in 19 patients as
In five patients (24%) there were major problems either (i) absent or improved (in terms of reported
with opiate misuse during the follow-up period frequency and severity) or (ii) same or worse than at
(three of these had histories of MUPS, one had the initial assessment. Eight patients rated their pain
chronic pain and the other was a dissimulator) as improved (n ¼ 7) or absent (n ¼ 1), whereas in 11
(Table 3). This was accompanied by either self-harm it was rated as either the same (n ¼ 10) or worse
or abuse of other substances, and was a conse- (n ¼ 1). In the remaining two patients, one was on
quence of the ‘removal’ of the surgical solution. One haemodialysis with new symptoms, and one with
patient required a brief planned admission to a pain dissimulation did not report renal pain but had
clinic bed, while another, who increased his developed unexplained breathlessness, accompa-
pethidine use to 2.5 g/day, developed drug-induced nied by repeated admissions to hospital.
epilepsy. He subsequently underwent renal dener-
vation for his pain. Two further patients were Of the 16 patients on opiates at the outset, five
referred to psychiatric services for management of had stopped them at follow-up, but three other
their opiate misuse. In all five, management of their patients had commenced opiates since the initial
opiate use became the major focus of treatment. assessment. Thus fourteen patients (67%) at follow-
up were prescribed opiate analgesia. The six opiate
Further surgery users who rated their pain improved had had
symptoms before referral a median of 12 years
In the three patients who persuaded a surgeon to (mean 14), and their follow-up (management period
operate during the period of follow-up, one had a with us) was 31 months (mean 40).
stormy post-operative course after a second
nephrectomy and subsequent dialysis, and devel- We found an association between opiate use and
oped a set of new unexplained symptoms. Although pain severity: of the eight who reported less pain at
the loin pain disappeared, she developed unex- follow up, only two were taking opiates (compared
plained syncopal episodes. Another patient had a with seven at start), six were in gainful employment
second renal denervation (despite a previous dener- and four had a somatoform disorder. In contrast, all
vation leading only temporarily to relief from pain). of the 11 with ongoing or worse pain were on
At one-year follow-up, he remained pain free. opiates, only one was working and seven had a
A third patient developed diffuse lower abdominal somatoform disorder. Five patients with continuing
pain which did not improve after a hysterectomy pain during the follow-up period required referral to
and rectopexy. Her loin pain was unchanged at a substance misuse clinic and in one of these
follow-up. pethidine withdrawal was successful.

Outcome Other physical symptoms and use of
medical resources
The median period of follow-up was 42 (14–136)
months (Table 1). In all cases the GPs were Of the 12 patients with a somatoform disorder at the
contacted, and provided clinical information about initial assessment, nine (75%) continued to report
pain, medication, health care use and functioning pains in other parts of their bodies (e.g. chest, pelvic
during the follow-up period. All but one of the or abdominal pain) and nine were on opiates at
patients was followed up either by direct interview follow-up, compared with eight at the start.
(n ¼ 9) or by telephone up to end of study period Significantly, all three of the patients who under-
(n ¼ 11). Details on the remaining patient were went further surgery (two had renal procedures)
obtained from his GP. came from this group. These nine patients who
continued to report pains had often been referred
Our efforts to engage the patients in pain manage- to other hospitals for further investigation
ment were successful in 14 who attended a pain

Severe unexplained loin pain 379

and treatment, and this resulted in surgery (hyster- antidepressants, usually for their analgesic effects, Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
ectomy and rectopexy which failed to help chronic and this may have attenuated complaints of depres-
pelvic pain) in one. Four of these nine patients had sion. Like Lucas,3 we found high rates of lifetime
visited their GP on at least 10 occasions in the depression in our patients (50–60%), and nine
previous year, and were still seeking a ‘cure’ for their reported previous episodes of self harm.
pain.
We identified three subgroups, although their
Discussion clinical characteristics were not mutually exclusive.
Firstly, there were those with chronic, persistent
We show the feasibility of managing this very unexplained symptoms in whom the loin pain
difficult group of patients conservatively. They all represented yet another symptom complex that
posed formidable management problems, largely remained ‘unexplained’. Such patients fulfil the
because their pain was not adequately controlled. criteria for a chronic somatoform disorder, and
Although we set out to manage all patients benefit more from conservative treatment involving
conservatively, three had surgery during the period regular long-term support and continuity of care
of follow-up, one of whom remains on dialysis. Our with as few practitioners as possible than from any
patients may not be typical of LPHS, but represent surgical intervention.16,23 A second, smaller group
the group with severe and intractable loin pain that had persistent loin pain without extensive previous
are ‘most difficult’ to manage. histories of pain elsewhere; and finally, there were
two patients in whom there was evidence of
We adopted conservative management in a pain dissimulation.
clinic, as there is increasing evidence that invasive
procedures such as intra-ureteric capsaicin,17 renal The most difficult challenges in treatment, how-
denervation,12 or renal auto-transplantation18 do not ever, were with the five patients who continued to
provide enduring pain relief, especially in those with misuse opiates; in all of these patients, managing the
previous histories of emotional illness. Patients were harmful and escalating use of medication became
warned not only of the possible complications of the primary focus of therapeutic activity. The
surgery but also about ‘symptom transfer’ to the remaining 11 patients who were in receipt of
contralateral side, and ‘symptom substitution’ which opiates at the initial assessment did not abuse
is the development of further non-organic symptoms these drugs.
after the surgical procedure.19 This had already
occurred in six of our patients at the time of the We believe that our management strategy should
initial assessment and resembles those with idio- be equally valid and appropriate even if such a
pathic, slow-transit colon who request colectomy patient had biopsy-proven IgA nephropathy or
for their constipation; the results of such surgery are evidence of nephrolithiasis which nevertheless did
disappointing and lead to further iatrogenic not explain the pain. In fact one of our patients had a
illness.20,21 renal biopsy that showed mesangial IgA and one had
renal stones (medullary sponge kidney) (Table 2)
Despite high rates of opiate use and past histories
of unexplained symptoms, most of our patients did In conclusion, we would make the following
not have serious psychiatric morbidity at interview. recommendations for the management of these
We were surprised by the low rates of current difficult patients.
depression in our patients, especially as there is an
important association between pain and mental Assessment should be made in a designated pain
disorder.6 Our relatively low rate of 35% is however clinic where it is possible to perform both detailed
consistent with the findings of Lucas and his psychosocial assessment as well as a review of
colleagues,3 who found even lower mean scores analgesic medication and needs. The initial assess-
for depression, with only 13% of their patients with ment must include a search and documented review
LPHS scoring above threshold for depression on the of the primary-care medical records, with a sum-
HAD15 scale. How can these relatively low levels of mary placed in the hospital record. This may reveal
reported depression in patients with chronic pain be a long past history of medically unexplained
explained? Diagnosis of mood and anxiety disorders symptoms or surgical procedures that have failed
may be difficult to establish in some patients owing to benefit the patient.
to the process of somatization, particularly where
patients attribute their depressed mood to an One must reduce the patient’s expectation of a
underlying physical condition (whether present or surgical ‘cure’. This can initially create further
not) and invite their doctors to share this belief.22 problems, when frustration and anger may lead to
Furthermore, 43% of our patients were taking increased self harm or escalating use of opiates. We
suggest that medical staff do not discuss surgery as a
therapeutic option. If patients do enquire about it
then they should be made aware that the research

380 C.M. Bass et al.

evidence does not support its use in intractable support. The main difficulties emerged as addiction Downloaded from http://qjmed.oxfordjournals.org at Columbia University Health Sciences Library on July 25, 2010
loin pain.4 problems, with the loin pain being an integral part of
drug-seeking behaviour. She found it hard to
Removal of the prospect of surgery as a potential relinquish the idea that surgery for her loin pain
cure forces the patient to cope using his or her own would be a panacea to help her cope with
resources. One must encourage self-management of loneliness and the strains within her close family.
pain, with ongoing support from the pain clinic. In Requests for surgery emerged at different times,
our patients, those who were able to accept a and finding a physical solution to life problems
conservative approach to pain management and to remained attractive to her. Careful management of
taper or avoid the use of opiates had the best her pethidine requirements involved out-patient
outcome. A subgroup finds it difficult to cope management at a pain clinic, working closely with
however, and may place increasing demands on the psychiatrist and general practitioner, as well as
pain clinic and renal personnel. a brief admission to a pain clinic to attempt
withdrawal of pethidine. This was very difficult
Evidence of factitious illness or dissimulation is for her emotionally, and there were at least two
uncommon in this patient group, but should be episodes of self-harm. Residential rehabilitation
identified and confronted. This should be carried out placements helped her address emotional problems
in a supportive way, with the promise of providing and explore alternatives to pethidine and alcohol
regular ongoing psychological support after as coping strategies. She remains in pain (in 2006),
exposure.24 but has been working full time for 4 years, and
recently acquired a degree. She remains off all
Appendix: Case vignette opiates, and continues to be followed-up in the pain
clinic every 3 months by the pain specialist and
A 32-year-old single woman reported an 18-year psychiatrist. Her current medication is gabapentin
history of pain in the right loin that had begun 5.7 g/day.
suddenly at the age of 14 (1988) after a brief illness
characterized by lethargy and headache. Paediatric References
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