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Forum Name: Urology Topics

Question: Multiple bilateral renal cysts- implications?


 mickapoo - Fri Jul 15, 2005 12:08 pm

First of all, thank you for taking the time to read my posting.

I am a 35 y/o female in good health. About two months ago I started having back and flank pain, along with nausea. The pain is between the bottom of my rib cage and my navel, but in my back and flanks on both sides. It's a dull ache, intermittent, that sometimes feels like a burning sensation, and other times like pressure. I have no pain when urinating, or other symptoms. Just the flank and back pain, and nausea.

I went to a walk in clinic, where they did a urinalysis- found no evidence of a UTI, but did find a small amount of blood, along with a trace amount of ketones and protein. He gave me a 3-day antibiotic regiment of Factive-7 telling me he didn't think it was a UTI, but wanted to give it to me just in case.

The symptoms did not go away after the 3 days, so I went to my regular primary care physician. He did blood work, and said all came back normal, but pointed out my BUN/Creatinine ratio was 21. He also did a urinalysis, which again showed a small amount of blood, but no ketones or protein as before.

He sent me for an abdominal, pelvic, and transvaginal u/s. The results showed a cyst in my right ovary of about 2.5 cm, and a cyst in my right kidney of about 2 cm.

After the u/s, he followed up with an abdominal and pelvic CT scan, both with and without contrast. Multiple hypodensities were found in both kidneys. There were 6 total: two of them were about 2cm, and the other 4 were less than 1 cm. The radiologists report stated that the larger hypodensities were fluid filled cysts, but that the other 4 were to small to characterize, but said more than likely represented cysts as well.

My primary care physician had me for a follow up, and wasn't sure what could be the cause of my flank pain and nausea. He prescribed Protonix, which helped somewhat with the nausea, but has not helped the flank and back pain. He mentioned PKD, but I am not sure of any family history (it's unknown on my father's side). My doctor phoned a urologist colleague of his while I was there, who advised him to refer me to a nephrologist.

I wasn't able to get in for a while, because he's going on vacation. I found a nephrologist about 50 miles away, who I went to see yesterday. He did another urinalysis, and found my specific gravity to be 1.0005, and urobilin to be 2mg. Also found a trace of blood and a small amount of white blood cells. Other than that, the urinalysis was within normal ranges.

Even though I told him my PCP prescribed Factive-7 two months ago, he prescribed a 10 day regimen of Bactrim and suspects it might be a UTI.

My questions are these:
Can I have a UTI without pain in urinating, frequent urination, etc...?
Are my symptoms (flank and back pain, nausea) consistent with a UTI?
Given my situation and findings above, do you have any ideas what might be possible cause(s) of my symptoms?

Provided this current antibiotic does not relieve me of my symptoms, should I visit a urologist or nephrologist, or both? My PCP said urologists basically do surgery, while nephrologists specialize in treatment.

Thank you again for your time.
 Dr. Anthony Solomon - Sat Jul 16, 2005 5:09 am

No mention is made of a urine culture, in spite of indications for it. Was it an information you missed in your post? Your PCP is right about having the opinion of a nephrologist for the kidney cysts. Was the gall bladder reported in the abdominal CT scan?

Simple renal cysts are common and harmless unless they become enlarged and press on other organs or become infected and painful. For more information on kidney cysts, please read this recent post :
http://www.doctorslounge.com/forums/vie ... highlight=

Dr Anthony Solomon
Consultant Physician, Tropical & Genitourinary Medicine
 mickapoo - Sat Jul 16, 2005 6:36 am

medicare wrote:No mention is made of a urine culture, in spite of indications for it. Was it an information you missed in your post?


A urine culture has never been performed. The physician at the walk in clinic mentioned it, but because I did not have insurance at the time, he then said it really was not necessary. Neither my primary care physician nor the nephrologist mentioned a urine culture.
medicare wrote:Was the gall bladder reported in the abdominal CT scan?

Yes, the radiologist's report stated that the 'gallbladder was grossly unremarkable'.

Do you have any thoughts as to what might be possible causes of my symptoms? Are the symptoms consistent with those of a UTI?

With multiple bilateral renal cysts, combined with my other symptoms, would a diagnosis of PKD be considered? And if family history is unknown, how can PKD be confirmed? My PCP mentioned PKD, given that I also have cysts in other organs (ovary) and that he could not find other causes of my symptoms.

Thank you very much for your time.
 Dr. Anthony Solomon - Tue Jul 19, 2005 11:44 am

The kidneys are situated at the back of the abdomen, below the diaphragm, one on each side of the spine. Therefore, the site of your pain coincides with the anatomical location of your kidneys and unless proved otherwise, the kidneys are the source of your pain.

Adult polycystic kidney disease (PKD) is an inherited condition in which multiple cysts develop throughout the kidneys. These cysts increase in size with advancing age and lead to kidney enlargement, progressive destruction of normal kidney tissue and gradual loss of kidney function. One third of patients with PKD will also develop cysts elsewhere, such as in the liver, pancreas, spleen or ovary.

The classical features of PKD include:
Acute loin pain and/or blood in urine
Abdominal discomfort caused by enlargement of the kidneys
Development of hypertension or kidney malfunction.
Presence of multiple cysts in the kidneys detected by a renal ultrasound or CT scan.

It appears you have most of these features, but that does not confirm the diagnosis. It is common to find multiple simple renal cysts in persons who do not have PKD.

UTI may present in different ways depending on the location of infection. In upper UTI, acute infection of the kidneys (pyelonephritis) may present as loin pain and tenderness with fever and systemic upset. Lower UTI may present as frequency of urination, burning on micturition, lower abdominal pain and tenderness, and the findings of pus cells and red blood cells on urine analysis. A culture in both types of UTI confirms the diagnosis. In answer to one of your questions, yes, you can have a kidney infection without the features of frequency and dysuria.

You did not state if your blood pressure was measured and if it is normal. What are the individual results of BUN and Creatinine? Your BUN/Creatinine ratio is elevated at 21 (normal range is 10-20).

It is worthwhile waiting for the results of treatment which the nephrologist has initiated. Yes, I agree with your PCP that the nephrologist is the right specialist for your problem.


Dr Anthony Solomon
Consultant Physician, Tropical & Genitourinary Medicine
 mickapoo - Tue Jul 19, 2005 5:12 pm

Thank you very much, Dr. Solomon, for the reply.

Yes, I have had my blood pressure checked- it has been within normal limits.

What are the individual results of BUN and Creatinine? Your BUN/Creatinine ratio is elevated at 21 (normal range is 10-20).


BUN/Creatinine Ratio: 21
BUN: 17 mg/dl
Creatinine, serum: .8 mg/dl

Being that this ratio is elevated according to the values you presented above, would this be indicative of anything, given my other symptoms?

Thank you again.
 Dr. Anthony Solomon - Tue Jul 19, 2005 6:14 pm

The individual BUN and Creatinine results are perfect, and exclude kidney malfunction. Your blood pressure is also normal. I do not attach too much importance to the ratio if the individual tests are within normal ranges. I would say the ratio is at the upper limit of normal range. What must be further investigated is the finding of blood in the urine, if it is persistent after treatment, as well as renal angle pain which disturbs you.

Dr Anthony Solomon
 mickapoo - Mon Jul 25, 2005 3:38 pm

Hello Doctor,
I just wanted to follow up with you. My antibiotic regimen was finished yesterday. I went to the nephrologist today, who conducted a urinalysis and said the results were normal.

However, my symptoms have not improved- I still have the nausea and flank pain. He gave me Celebrex for the pain and sent me on my way. Is there nothing further that can be done to possibly find the cause of my discomfort?

Thank you again.
 Dr. Anthony Solomon - Tue Jul 26, 2005 5:09 pm

I would have expected urine culture tests as the next line of investigation, since your symptoms have not improved. You have now been prescribed an anti-inflammatory medication - it is reasonable to await the results and be reviewed again if symptoms persist.

We are an educational and advisory forum and cannot offer diagnosis and treatment, or interfere with a specialist's opinion.


Dr Anthony Solomon
 mickapoo - Tue Jul 26, 2005 7:31 pm

I feel that by just taking pain medicine we are just medicating me instead of trying to find out what is actually causing the pain. Two questions:

1. If the pain and nausea were caused by a UTI, is it reasonable to assume that there is a possibility of the pain taking a few months to subside even though the infection has cleared up?

2. Other than a urine culture, are there any other means to determine the cause of my pain?

(and just one more, sorry)
3. Is there any definitive way to distinguish between true back pain that's occuring in the back muscles or spine, versus pain that is felt through the back, but is actually coming from an organ or other internal source?

Thank you again.
 Dr. Anthony Solomon - Thu Jul 28, 2005 9:19 am

Imaging procedures of the lumbar and sacral spine may be necessary to exclude a musculoskeletal cause of your pain. An orthopaedic surgeon will be of further assistance in this respect. Another imaging procedure for the kidneys is an intravenous pyelography, which is a more invasive procedure. Again, this must be requested by a nephrologist or urologist.

Dr Anthony Solomon

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