Severe unexplained loin pain (loin pain haematuria syndrome): management and long-term outcome
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
Address correspondence to Dr C.M. Bass, Department of Psychological Medicine, John Radcliffe Hospital, Oxford OX3 9DU. email: christopher.bass{at}obmh.nhs.uk
Received 27 August 2006 and in revised form 2 February 2007
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Summary |
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Background: The intractable and unexplained loin pain of severe ‘loin pain haematuria syndrome’ (LPHS) causes great psychosocial distress and disability.
Aim: To examine the psychological factors in LPHS patients who had failed to respond to non-opiate analgesia, and explore the feasibility of conservative management.
Design: Retrospective review of case notes, medical and GP records, with follow up.
Methods: We studied 21 consecutive patients referred from specialist renal centres to a regional pain clinic. All records were reviewed, and patients received a comprehensive psychiatric and social assessment. Medication with pain-coping strategies was emphasized, and surgical solutions were discouraged.
Results: Patients' median age was 43 years (range 21–64) and duration of symptoms 11 (1–34) years. Sixteen were receiving opiates, and none had enduring benefit from surgery. Patients were divisible into three groups: twelve (57%) gave a history of recurrent, unexplained symptoms involving other parts of the body (somatoform disorder); seven had chronic loin pain; dissimulation was suspected in two. At follow-up (median 42 months), eight (38%) rated their pain absent or improved. Of the 11 whose pain was the same or worse, all were on opiates and seven had a somatoform disorder. A further two patients had developed ‘other’ medical problems. Despite our advice, three patients underwent major surgery for pain.
Discussion: We recommend that patients be managed in a regional pain clinic, where a multidisciplinary approach promotes self-management of pain. Patients who were able to accept conservative treatment, and taper or withdraw opiate analgesia, had a better prognosis.
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Introduction |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix: Case vignetteReferences |
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Since 1967, patients with severe unexplained loin pain have often been described using the term ‘loin pain haematuria syndrome’ (LPHS). Because there is no satisfactory case definition, many physicians doubt that this is a discrete disease, but LPHS is characterized by severe unilateral loin pain that suggests a renal origin but occurs in the absence of identifiable or relevant urinary tract disease.1 Haematuria, which can be microscopic or macroscopic, is not always present and the renal abnormalities responsible for the haematuria are often unexplained. Patients never develop evidence of progressive renal disease such as proteinuria or hypertension. A small group are severely disabled by the pain and may be receiving opiate analgesics.2 There is a high prevalence of somatoform disorders in these patients, and it has been suggested that psychosocial factors are important causal and maintaining factors.3
Although the pain is predominantly unilateral, following renal denervation and complete relief of the ipsilateral pain, it will commonly move to the contralateral side, and a second denervation may eventually be sought. Renal auto-transplantation has been proposed to achieve a total denervation, but this is often unsuccessful, and can result in graft loss, or the pain may recur in the transplanted kidney.4 Rarely, patients will demand and be granted nephrectomy, and there are patients who have ended up on dialysis as a consequence.5 None of these drastic surgical procedures address any of the psychosocial maintaining factors, which often persist.
Many of these patients fulfil the criteria for a somatoform disorder.3 Somatoform pain disorder is a persistent and distressing disorder characterized by pain that cannot be explained fully by a physiological process or a physical disorder.6 The underlying assumption is that emotional problems or psychosocial stressors play a key role in maintaining the pain. Factors associated with somatoform disorder include a previous history of medically unexplained physical symptoms, psychiatric comorbidity (e.g. depressive illness, anxiety disorder or substance misuse), and characteristic childhood risk factors. These include experience of relevant childhood or parental illness, or an abusive childhood (physical, sexual or emotional).7,8
Although a wide range of psychiatric disorders has been described in LPHS, including fabricated illness,3 there has been no systematic description of attempts to treat these patients conservatively using psychological techniques.5,9 Conservative treatment has proved difficult in the past, because surgical intervention was seen by patients as the short-term answer to their pain, and this surgical option may dissuade them from seriously exploring and using the facilities and therapies available in a multi-disciplinary pain clinic.2
In this retrospective observational review we describe 21 consecutive patients with severe unexplained loin pain referred to a regional pain clinic. Our primary aims were to examine the psychological factors and the feasibility of conservative management without surgical intervention.
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Methods |
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We investigated 21 consecutive patients with severe unexplained loin pain referred from two specialist renal units to a regional pain clinic between the years 1993 and 2004. Since 1980, the combined units have been referred over 145 patients considered to have LPHS.4
The first patients with LPHS were referred by GHN for psychiatric assessment and advice on management from 1993. After 1996, as referrals from London and Oxford increased, patients were interviewed in a regional pain clinic, and were followed in a systematic way after the initial assessment.
All patients had received the diagnosis of LPHS after thorough renal and urological investigation had failed to find an organic cause for their pain.3,10–12 All had reported symptoms for at least 1 year (range 1–34), had failed to respond to conventional analgesics, had required or requested referral to a tertiary pain clinic for further management of their pain, and presented problems with pain management. All were assessed and examined at the regional pain clinic in Oxford. Eight were referred from within the region, while thirteen were referred from the Institute of Urology and Nephrology, London, a national centre with a special interest in LPHS.3,10–12
Previous medical notes, including the general practitioner (GP) notes, were obtained and examined in all patients. Investigations undertaken for evidence of renal and other pathology were documented, and details of previous and current medication were noted, especially use of opiates.
All medical and surgical procedures (including renal biopsy, renal denervation, nephrectomy and renal auto-transplantation) were documented, and a comprehensive history of drug and alcohol use was obtained. Of the 21 patients, five have been described in another case series of patients who underwent renal denervation for their chronic pain.12
All patients had a full psychiatric examination, with details of previous psychiatric history, including episodes of deliberate self-harm and substance misuse. Details were supplemented by examination of both the GP and past hospital records, which were summarized on a proforma. All patients were interviewed by a psychiatrist, who assigned a psychiatric diagnosis according to ICD-10 criteria (1992),13 and details of current drug use were documented. We wished to establish how many of the patients had a somatoform disorder and the prevalence of dissimulation, as these disorders had been reported in recent studies.3,14 The main feature of somatoform disorders is 'repeated presentation of physical symptoms, together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. If any physical disorders are present, they do not explain the symptoms, distress or preoccupation of the patient'.13 For the purposes of this study, patients who reported at least two episodes of medically unexplained symptoms requiring investigation (e.g. fatigue, constipation, facial pain) were described as having a somatoform disorder.13 Seventeen of the 21 patients completed the Hospital Anxiety and Depression Scale, and were considered depressed if their score was 
11.15
Management in the multidisciplinary clinic
Patients were seen in a joint pain clinic with a pain specialist and psychiatrist. After initial assessment, each patient was reassured that there was no sinister or serious underlying damage or disease to account for the pain. We emphasized continuity of care (seeing the same doctor at consecutive visits). Patients were encouraged not to seek surgical solutions to their pain and not to expect ‘a cure’. Instead, medications and pain-coping strategies were discussed.
Shared care with GP
To obtain a consistent approach we communicated our plan to each patient's GP.16 After we wrote to each GP, we followed-up with a telephone call outlining the principles of treatment: (a) avoid surgery for pain; (b) reduce unnecessary medication if possible; (c) reduce the number of doctors managing the patient; (d) emphasize continuity of care with GP; (e) reduce referrals to other specialists (whenever possible). This approach has been shown to improve physical functioning whilst also reducing health-care costs.16 This was particularly important for the 13 patients who could not be followed-up locally for geographical reasons, as they lived at least 70 miles from Oxford, and we recommended that management be co-ordinated with their local pain clinic.
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Results |
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Clinical and demographic characteristics at initial assessment (Tables 1 and 2)
Fourteen (67%) of the 21 patients were women. Median age at onset of loin pain was 30 years (range 14–53 years), and the median duration of symptoms before referral for psychiatric assessment was 10 years (range 1–34 years, Table 1). Only 11 were in employment at the time of assessment and eight received long-term disability benefits (one of whom had retired because of ill health). Five (24%) had worked in health-care settings. Seven had evidence of a pre-existing renal problem, such as renal scarring, and 11 reported a previous history of a renal disorder to which the pain was attributed, but in none of them were these features deemed relevant to the pain. Five patients had had renal biopsies that had all been reported in different centres as essentially normal. One patient with no proteinuria and normal function was reported to have mesangial deposits of IgA antibody, which would account for her microscopic haematuria.
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In five patients, renal denervation had failed to provide relief for longer than 2 years. Four patients had undergone unilateral nephrectomy, and three had received intra-ureteric capsaicin without benefit in another centre. In six patients the pain had moved to the contralateral side (in five after a denervation had been performed) (Table 2).
Sixteen patients (76%) were receiving opiate medications at the initial assessment, but in only two was there evidence that these drugs were being misused. At least 11 patients had received renal nerve blocks in local pain clinics (Table 2). Antidepressant drugs were being taken by nine patients; tricyclics were prescribed for their analgesic effect in seven of these nine (Tables 1 and 2).
Psychosocial characteristics (Table 3)
Mean depression scores on the HAD Scale were 8.7 (SD 5.0, range 1–19), and in only six (35%) of the 17 patients that completed the scale was the score above the depression threshold score of 10. Twelve (57%) of the 21 patients met the criteria for a somatoform disorder, all of whom had been investigated on at least two previous occasions (before the onset of loin pain) for other physical symptoms without an organic basis (Table 3).
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A further three developed severe problems with opiate misuse during the follow-up period (Tables 1 and 2). Twelve (57%) had a previous history of treatment for a psychiatric illness (most often depression), but none had evidence of previous substance misuse before the onset of loin pain. Nine patients (43%) had a previous history of deliberate self-harm.
We subsequently divided the 21 patients into three groups, based on our approach to management during the follow-up period.
Twelve patients (57%) had a history of repeated medically-unexplained physical symptoms (MUPS) involving other organ systems: in six patients previous negative investigations had involved three 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.
A second group of seven patients (33%) reported chronic, persistent loin pain in the absence of a documented history of previous repeated physical complaints (one of these developed substance misuse problems).
In the remaining two patients, there was evidence of dissimulation. One of these patients was confronted after the initial assessment and her pethidine abuse was subsequently managed jointly by her GP and pain clinic. Another admitted her deception after the psychiatric assessment and was subsequently referred to the local psychiatric services.
Specific problems in management
Expectations
Reducing patient expectations of ‘a surgical cure or solution’ proved a formidable therapeutic problem. Because all patients had received renal investigations, they had understandably formed the view that the pain was related to some kind of renal disease. They expressed views such as: ‘whenever I get the pain I know that my kidneys are burning up inside‘; others had been told for example that ...‘if the pain gets too bad then we can always do an auto-transplantation’.
Fifteen of the 21 patients accepted that surgery would not form part of the management plan, but in six there were persistent demands for a surgical solution (Table 3). For them management proved more difficult, especially when the patient lived far from the clinic or the GP, because of their increasing demands, was not able to implement the management plan.
Two-thirds of the patients accepted referral to a pain clinic for management of their chronic pain, but only two engaged with a clinical psychologist with the explicit goal of pain management. The management plan was to engage the patient in long-term outpatient pain management, with a goal of containment and no recourse to surgery. In those patients who were unable to visit the clinic because they lived too far away, management was monitored with the patient's GP. A case vignette illustrating the complex medical histories and management problems is shown in the Appendix (published with the patient's consent).
Opiate use
In five patients (24%) there were major problems with opiate misuse during the follow-up period (three of these had histories of MUPS, one had chronic pain and the other was a dissimulator) (Table 3). This was accompanied by either self-harm or abuse of other substances, and was a consequence of the ‘removal’ of the surgical solution. One patient required a brief planned admission to a pain clinic bed, while another, who increased his pethidine use to 2.5 g/day, developed drug-induced epilepsy. He subsequently underwent renal denervation for his pain. Two further patients were referred to psychiatric services for management of their opiate misuse. In all five, management of their opiate use became the major focus of treatment.
Further surgery
In the three patients who persuaded a surgeon to operate during the period of follow-up, one had a stormy post-operative course after a second nephrectomy and subsequent dialysis, and developed a set of new unexplained symptoms. Although the loin pain disappeared, she developed unexplained syncopal episodes. Another patient had a second renal denervation (despite a previous denervation leading only temporarily to relief from pain). At one-year follow-up, he remained pain free. A third patient developed diffuse lower abdominal pain which did not improve after a hysterectomy and rectopexy. Her loin pain was unchanged at follow-up.
Outcome
The median period of follow-up was 42 (14–136) months (Table 1). In all cases the GPs were contacted, and provided clinical information about pain, medication, health care use and functioning during the follow-up period. All but one of the patients was followed up either by direct interview (n = 9) or by telephone up to end of study period (n = 11). Details on the remaining patient were obtained from his GP.
Our efforts to engage the patients in pain management were successful in 14 who attended a pain clinic (five in Oxford and nine elsewhere). Significantly, three of the seven who defaulted from the clinic persistently sought surgical solutions to their pain. The reasons for defaulting were diverse and included: clinic too far away, lack of transport, unwilling to see a psychiatrist or psychologist in the clinic, and one moved away.
Continuing pain
Pain outcome was categorized according to patient's complaints of pain over the last 3 months. Pain was rated on a four-point scale in 19 patients as either (i) absent or improved (in terms of reported frequency and severity) or (ii) same or worse than at the initial assessment. Eight patients rated their pain as improved (n = 7) or absent (n = 1), whereas in 11 it was rated as either the same (n = 10) or worse (n = 1). In the remaining two patients, one was on haemodialysis with new symptoms, and one with dissimulation did not report renal pain but had developed unexplained breathlessness, accompanied by repeated admissions to hospital.
Of the 16 patients on opiates at the outset, five had stopped them at follow-up, but three other patients had commenced opiates since the initial assessment. Thus fourteen patients (67%) at follow-up were prescribed opiate analgesia. The six opiate users who rated their pain improved had had symptoms before referral a median of 12 years (mean 14), and their follow-up (management period with us) was 31 months (mean 40).
We found an association between opiate use and pain severity: of the eight who reported less pain at follow up, only two were taking opiates (compared with seven at start), six were in gainful employment and four had a somatoform disorder. In contrast, all of the 11 with ongoing or worse pain were on opiates, only one was working and seven had a somatoform disorder. Five patients with continuing pain during the follow-up period required referral to a substance misuse clinic and in one of these pethidine withdrawal was successful.
Other physical symptoms and use of medical resources
Of the 12 patients with a somatoform disorder at the initial assessment, nine (75%) continued to report pains in other parts of their bodies (e.g. chest, pelvic or abdominal pain) and nine were on opiates at follow-up, compared with eight at the start. Significantly, all three of the patients who underwent further surgery (two had renal procedures) came from this group. These nine patients who continued to report pains had often been referred to other hospitals for further investigation and treatment, and this resulted in surgery (hysterectomy and rectopexy which failed to help chronic pelvic pain) in one. Four of these nine patients had visited their GP on at least 10 occasions in the previous year, and were still seeking a ‘cure’ for their pain.
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Discussion |
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We show the feasibility of managing this very difficult group of patients conservatively. They all posed formidable management problems, largely because their pain was not adequately controlled. Although we set out to manage all patients conservatively, three had surgery during the period of follow-up, one of whom remains on dialysis. Our patients may not be typical of LPHS, but represent the group with severe and intractable loin pain that are ‘most difficult’ to manage.
We adopted conservative management in a pain clinic, as there is increasing evidence that invasive procedures such as intra-ureteric capsaicin,17 renal denervation,12 or renal auto-transplantation18 do not provide enduring pain relief, especially in those with previous histories of emotional illness. Patients were warned not only of the possible complications of surgery but also about ‘symptom transfer’ to the contralateral side, and ‘symptom substitution’ which is the development of further non-organic symptoms after the surgical procedure.19 This had already occurred in six of our patients at the time of the initial assessment and resembles those with idiopathic, slow-transit colon who request colectomy for their constipation; the results of such surgery are disappointing and lead to further iatrogenic illness.20,21
Despite high rates of opiate use and past histories of unexplained symptoms, most of our patients did not have serious psychiatric morbidity at interview. We were surprised by the low rates of current depression in our patients, especially as there is an important association between pain and mental disorder.6 Our relatively low rate of 35% is however consistent with the findings of Lucas and his colleagues,3 who found even lower mean scores for depression, with only 13% of their patients with LPHS scoring above threshold for depression on the HAD15 scale. How can these relatively low levels of reported depression in patients with chronic pain be explained? Diagnosis of mood and anxiety disorders may be difficult to establish in some patients owing to the process of somatization, particularly where patients attribute their depressed mood to an underlying physical condition (whether present or not) and invite their doctors to share this belief.22 Furthermore, 43% of our patients were taking antidepressants, usually for their analgesic effects, and this may have attenuated complaints of depression. Like Lucas,3 we found high rates of lifetime depression in our patients (50–60%), and nine reported previous episodes of self harm.
We identified three subgroups, although their clinical characteristics were not mutually exclusive. Firstly, there were those with chronic, persistent unexplained symptoms in whom the loin pain represented yet another symptom complex that remained ‘unexplained’. Such patients fulfil the criteria for a chronic somatoform disorder, and benefit more from conservative treatment involving regular long-term support and continuity of care with as few practitioners as possible than from any surgical intervention.16,23 A second, smaller group had persistent loin pain without extensive previous histories of pain elsewhere; and finally, there were two patients in whom there was evidence of dissimulation.
The most difficult challenges in treatment, however, were with the five patients who continued to misuse opiates; in all of these patients, managing the harmful and escalating use of medication became the primary focus of therapeutic activity. The remaining 11 patients who were in receipt of opiates at the initial assessment did not abuse these drugs.
We believe that our management strategy should be equally valid and appropriate even if such a patient had biopsy-proven IgA nephropathy or evidence of nephrolithiasis which nevertheless did not explain the pain. In fact one of our patients had a renal biopsy that showed mesangial IgA and one had renal stones (medullary sponge kidney) (Table 2)
In conclusion, we would make the following recommendations for the management of these difficult patients.
Assessment should be made in a designated pain clinic where it is possible to perform both detailed psychosocial assessment as well as a review of analgesic medication and needs. The initial assessment must include a search and documented review of the primary-care medical records, with a summary placed in the hospital record. This may reveal a long past history of medically unexplained symptoms or surgical procedures that have failed to benefit the patient.
One must reduce the patient's expectation of a surgical ‘cure’. This can initially create further problems, when frustration and anger may lead to 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 evidence does not support its use in intractable loin pain.4
Removal of the prospect of surgery as a potential cure forces the patient to cope using his or her own resources. One must encourage self-management of pain, with ongoing support from the pain clinic. In our patients, those who were able to accept a conservative approach to pain management and to taper or avoid the use of opiates had the best outcome. A subgroup finds it difficult to cope however, and may place increasing demands on pain clinic and renal personnel.
Evidence of factitious illness or dissimulation is uncommon in this patient group, but should be identified and confronted. This should be carried out in a supportive way, with the promise of providing regular ongoing psychological support after exposure.24
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Appendix: Case vignette |
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TopSummaryIntroductionMethodsResultsDiscussionAppendix: Case vignetteReferences |
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A 32-year-old single woman reported an 18-year history of pain in the right loin that had begun suddenly at the age of 14 (1988) after a brief illness characterized by lethargy and headache. Paediatric investigations included a renal ultrasound scan that suggested minimal right hydronephrosis, but repeatedly sterile urine and a normal intravenous urogram (IVU). Microscopic haematuria was documented on two occasions. The pain persisted, and over the next 10 years, repeated tests included a normal static renogram (DMSA scan), a normal renal biopsy (1997), and many ultrasound scans. Treatments included three local anaesthetic lumbar sympathetic nerve blocks, none of which helped. She was given three intra-ureteric capsaicin installations as well as instillations of lignocaine into the renal pelvis in the early 1990s, but they provided only temporary relief. Oral pethidine was prescribed early on in the clinical history but she became tolerant to it and was using up to 800 mg/day by 1998. A course of amitriptyline and the application of a Tens machine were not helpful, and insertion of a JJ stent gave no benefit. In 1998, she began intermittent alcohol abuse. Attempts to help her with counselling and psychological support failed initially, as she was unable to engage with treatment.
Both she and her mother had trained in paramedical fields, although she was not able to sit her final degree. The home atmosphere was affected by her long and continuing ill health, and family communication with health personnel resulted in frequent frustration and anger.
From 1999 her management focused on helping her identify her difficulties while offering continuing support. The main difficulties emerged as addiction problems, with the loin pain being an integral part of drug-seeking behaviour. She found it hard to relinquish the idea that surgery for her loin pain would be a panacea to help her cope with loneliness and the strains within her close family. Requests for surgery emerged at different times, and finding a physical solution to life problems remained attractive to her. Careful management of her pethidine requirements involved out-patient management at a pain clinic, working closely with the psychiatrist and general practitioner, as well as a brief admission to a pain clinic to attempt withdrawal of pethidine. This was very difficult for her emotionally, and there were at least two episodes of self-harm. Residential rehabilitation placements helped her address emotional problems and explore alternatives to pethidine and alcohol as coping strategies. She remains in pain (in 2006), but has been working full time for 4 years, and recently acquired a degree. She remains off all opiates, and continues to be followed-up in the pain clinic every 3 months by the pain specialist and psychiatrist. Her current medication is gabapentin 5.7 g/day.
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References |
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1. Little PJ, Sloper JS, de Wardener HE. A syndrome of loin pain and haematuria associated with disease of peripheral renal arteries. Q J Med (1967) 36:253–9.[Web of Science][Medline]
2. Burke JR, Hardie IR. Loin pain haematuria syndrome. Pediatr Nephrol (1996) 10:216–20.[Web of Science][Medline]
3. Lucas PA, Leaker BR, Murphy M, Neild GH. Loin pain and haematuria syndrome: a somatoform disorder. Q J Med (1995) 88:703–9.
4. Neild GH, Bass CM. Loin pain haematuria syndrome. In: Urogenital Pain in Clinical Practice—Baranowski AP, Abrams P, Fall M, eds. (2007) New York: Taylor & Francis.
5. Winearls CG, Bass C. The loin pain haematuria syndrome. Nephrol Dial Transplant (1994) 9:1537–9.
6. Benjamin S, Morris S, McBeth J, Macfarlane GJ, Silman AJ. The association between chronic widespread pain and mental disorder: a population-based study. Arthritis Rheum (2000) 43:561–7.[CrossRef][Web of Science][Medline]
7. McBeth J, Macfarlane GJ, Benjamin S, Morris S, Silman AJ. The association between tender points, psychological distress, and adverse childhood experiences: a community-based study. Arthritis Rheum (1999) 42:1397–404.[CrossRef][Web of Science][Medline]
8. McBeth J, Morris S, Benjamin S, Silman AJ, Macfarlane GJ. Associations between adverse events in childhood and chronic widespread pain in adulthood: are they explained by differential recall? J Rheumatol (2001) 28:2305–9.
9. Kelly B. Psychiatric issues in the ‘loin pain and haematuria syndrome’. Aust NZ J Psychiatry (1994) 28:302–6.[Web of Science][Medline]
10. Leaker BR, Gordge MP, Patel A, Neild GH. Haemostatic changes in the loin pain and haematuria syndrome: secondary to renal vasospasm? Q J Med (1990) 76:969–79.[Web of Science][Medline]
11. Woolfson RG, Lewis CA, Hilson AJ, Hill PD, Neild GH. Ureteric peristalsis studies in loin pain and haematuria syndrome—another diagnostic disappointment. Br J Urol (1993) 72:291–2.[Web of Science][Medline]
12. Greenwell TJ, Peters JL, Neild GH, Shah PJ. The outcome of renal denervation for managing loin pain haematuria syndrome. BJU Int (2004) 93:818–21.[CrossRef][Web of Science][Medline]
13. International Classification of Mental and Behavioural Disorders. In: International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10), Version for 2007 (2007) Geneva: WHO. [http://www.who.int/classifications/apps/icd/icd10online/].
14. Haddad E, Lapeyraque AL, de Pontual L, Landthaler G, Bocquet N, Baudouin V, Dorgeret S, Abbou H, Broux F, Loirat C. Clinical quiz. Loin pain haematuria syndrome. Pediatr Nephrol (2002) 17:217–19.[CrossRef][Web of Science][Medline]
15. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand (1983) 67:361–70.[Web of Science][Medline]
16. Smith GR Jr, Rost K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry (1995) 52:238–43.
17. Playford D, Kulkarni H, Thomas M, Vivian J, Low A, Mander J, Perlman D, Finch P. Intra-ureteric capsaicin in loin pain haematuria syndrome: efficacy and complications. BJU Int (2002) 90:518–21.[CrossRef][Web of Science][Medline]
18. Harney J, Rodgers E, Campbell E, Hickey DP. Loin pain-hematuria syndrome: how effective is renal autotransplantation in its treatment? Urology (1994) 44:493–6.[CrossRef][Web of Science][Medline]
19. DeVaul RA, Faillace LA. Persistent pain and illness insistence. A medical profile of proneness to surgery. Am J Surg (1978) 135:828–33.[CrossRef][Web of Science][Medline]
20. Dykes S, Smilgin-Humphreys S, Bass C. Chronic idiopathic constipation: a psychological enquiry. Eur J Gastroenterol Hepatol (2001) 13:39–44.[CrossRef][Web of Science][Medline]
21. Kamm MA. Constipation and its management. Br Med J (2003) 327:459–60.
22. Benjamin S, Main C. Psychiatric and psychological approached to the treatment of chronic pain: concepts and individual treatment. In: Mayou R, Bass C, Sharpe M, eds. In: Treatment of Functional Somatic Symptoms (1995) Oxford: OUP. 188–213.
23. Bass C, May S. Chronic multiple functional somatic symptoms. Br Med J (2002) 325:323–6.
24. Bass C. Factitious Disorders and Malingering. In: Halligan P, Bass C, Marshall J, eds. In: Contemporary approaches to the study of hysteria. Clinical and theoretical perspectives (2001) Oxford: OUP. 126–42.
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