Costovertebral angle tenderness
Costovertebral angle (CVA) tenderness indicates sudden distention of the renal capsule. It almost always accompanies unelicited, dull, constant flank pain in the CVA just lateral to the sacrospinal muscle and below the 12th rib. This associated pain typically travels anteriorly in the subcostal region toward the umbilicus.
Percussing the CVA elicits tenderness, if present. (See Eliciting CVA tenderness.) A patient who doesn’t have this symptom will perceive a thudding, jarring, or pressurelike sensation—but no pain—when tested. A patient with a disorder that distends the renal capsule will experience intense pain as the renal capsule stretches and stimulates the afferent nerves that emanate from the spinal cord at levels T11 through L2 and innervate the kidney.
History and physical examination
After detecting CVA tenderness, determine the possible extent of renal damage. First, find out if the patient has other symptoms of renal or urologic dysfunction. Ask about voiding habits: How frequently does he urinate and in what amounts? Has he noticed any change in intake or output? If so, when did he notice it? (Ask about fluid intake before judging his output as abnormal.) Does he have nocturia, pain or burning during urination, or difficulty starting a stream? Does the patient strain to urinate without being able to do so (tenesmus)? Ask about urine color; brown or bright red urine may contain blood.
Explore other signs and symptoms. For example, if the patient is experiencing pain in his flank, abdomen, or back, when did he first notice it? How severe is it, and where is it located? Find out if the patient or a family member has a history of urinary tract infections, congenital anomalies, calculi, or other obstructive nephropathies or uropathies. Also, ask about a history of renovascular disorders, such as occlusion of the renal arteries or veins.
Perform a brief physical examination. Begin by taking the patient’s vital signs. Fever and chills in a patient with CVA tenderness may indicate acute pyelonephritis. If the patient has hypertension and bradycardia, be alert for other autonomic effects of renal pain, such as diaphoresis and pallor. Inspect, auscultate, and gently palpate the abdomen for clues to the underlying cause of CVA tenderness. Be alert for abdominal distention, hypoactive bowel sounds, and palpable masses.
Medical causes
Calculi
Infundibular and ureteropelvic or ureteral calculi produce CVA tenderness and waves of waxing and waning flank pain that may radiate to the groin, testicles, suprapubic area, or labia. The patient may also develop nausea, vomiting, severe abdominal pain, abdominal distention, and decreased bowel sounds.
Perirenal abscess
Causing exquisite CVA tenderness, this disorder may also produce severe unilateral flank pain, dysuria, persistent high fever, chills, erythema of the skin, and sometimes a palpable abdominal mass.
Pyelonephritis (acute)
Perhaps the most common cause of CVA tenderness, acute pyelonephritis is commonly accompanied by persistent high fever, chills, flank pain, anorexia, nausea and vomiting, weakness, dysuria, hematuria, nocturia, urinary urgency and frequency, and tenesmus.
Renal artery occlusion
In this disorder, the patient experiences flank pain as well as CVA tenderness. Other findings include severe, continuous upper abdominal pain; nausea; vomiting; decreased bowel sounds; and high fever.
Renal vein occlusion
The patient with this disorder has CVA tenderness and flank pain. He may also have sudden, severe back pain; fever; oliguria; edema; and hematuria.
Special considerations
Administer pain medication, and continue to monitor the patient’s vital signs and intake and output. Collect blood and urine samples, and then prepare the patient for radiologic studies, such as excretory urography, renal arteriography, and computed tomography scan.
Pediatric pointers
An infant with a disorder that distends the renal capsule won’t exhibit CVA tenderness. Instead, he’ll display nonspecific signs and symptoms, such as vomiting, diarrhea, fever, irritability, poor skin perfusion, and yellow to gray skin color. In older children, however, CVA tenderness has the same diagnostic significance as in adults. Vaginal discharge, vulval soreness, and pruritus may occur in girls.
Geriatric pointers
Advanced age and cognitive impairment reduce an elderly patient’s ability to perceive pain or to describe its intensity.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
Other Book Chapters Related to Flank pain
Read excerpts from these other book chapters related to Flank pain:
Medical Books Excerpts
- FLANK PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
- [ read ]
- Flank pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Flank pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Abdominal Pain
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Abdominal pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Flank pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Flank pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Abdominal Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Flank pain
» Next page: Flank pain (Professional Guide to Signs & Symptoms (Fifth Edition))
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