Pain typical of that from the diseased reno-ureteral unit can emanate from any adjacent organ or any organ with the same innervation. It may also be the result of, or be exacerbated by, mental illness. Case examples of herniated thoracic disk, T12 neuralgia and short leg syndrome, costovertebral joint arthritis, metastatic carcinoma, myofascial syndrome and pancreatitis demonstrated the need for an orderly approach to the problem. Currently, patient screening with the Cornell medical index and the urology questionnaire allows direction of the physical examination, special radiographic and laboratory studies and psychiatric evaluations. An orderly evaluation of flank pain will prove rewarding and may prevent unnecessary urologic operations.