Costovertebral angle (CVA) tenderness is a crucial clinical finding, often associated with renal pathology. It typically reflects sudden distention or inflammation of the renal capsule due to infectious, obstructive, or vascular conditions of the kidneys. CVA tenderness is especially important in diagnosing acute pyelonephritis, renal calculi, and other serious renal disorders.

Anatomical and physiological background

The costovertebral angle is the angle formed between the 12th rib and the vertebral column, overlying the kidney. The kidneys are innervated by sympathetic nerves originating from T11 to L2, which explains the referral of renal pain to the flank and anterior abdominal regions. The renal capsule, when inflamed or stretched, stimulates these nerves, resulting in pain that is often deep, dull, and constant.

Pathophysiology

CVA tenderness arises primarily from capsular distention due to:

• Inflammatory swelling (e.g., pyelonephritis)

• Obstructive hydronephrosis (e.g., calculi, tumors)

• Vascular congestion (e.g., renal vein thrombosis)

Capsular stretch triggers nociceptive signals transmitted to the spinal cord, resulting in localized pain over the CVA, often radiating anteriorly to the subcostal region and periumbilical area. The involvement of visceral afferent fibers explains the referred pain and associated symptoms such as nausea or vomiting.

Eliciting CVA tenderness (Examination Tip)

To assess for CVA tenderness:

• Have the patient sit upright or lie prone.

• Place the palm of one hand over the costovertebral angle.

• Tap it gently using the ulnar side of your fist.

• Repeat on both sides.

Interpretation

• Positive finding: Sharp, localized pain (suggests renal inflammation).

• Negative finding: Thudding or pressure without pain (normal).

Clinical history and physical examination

Renal & urological symptoms to explore

• Urinary frequency, urgency, hesitancy, or retention

• Dysuria (painful urination)

• Changes in urine color (hematuria, cloudy urine)

• Nocturia or polyuria

• Strangury (painful, ineffective urination)

Associated pain

• Flank or back pain—onset, severity, radiation

• Abdominal or suprapubic pain

• History of urinary tract infections, stones, congenital anomalies

Vital Signs & Systemic Signs

• Fever, chills (suggest infection)

• Hypertension or bradycardia (possible autonomic response)

• Diaphoresis and pallor in severe renal pain

Abdominal exam

• Inspect for distention or palpable masses

• Auscultate for bowel sounds (may be reduced in renal colic)

• Gently palpate for tenderness or rebound

Medical causes of CVA tenderness

Table below shows medical causes of CVA tenderness, now with an added column for Special Considerations. This column highlights diagnostic pearls, complications, or unique features to consider for each condition.

Special Populations

Pediatrics

Infants rarely exhibit CVA tenderness. Instead, they may present with:

• Fever

• Vomiting or diarrhea

• Irritability or poor feeding

• Grey or mottled skin tone

Older children may demonstrate CVA tenderness similar to adults.

Geriatrics

Elderly patients may have diminished pain perception or cognitive decline, making symptom interpretation challenging. Fever or mental status changes may be the only clues.

Investigations

• Urinalysis: pyuria, hematuria, bacteriuria

• Blood tests: CBC, renal function, inflammatory markers

• Imaging:

  • Ultrasound (first-line in many cases)

  • CT scan with contrast or spiral CT (renal colic or abscess)

  • Renal arteriography (suspected vascular causes)

Management and nursing considerations

• Administer appropriate analgesics and antibiotics promptly.

• Monitor vital signs, fluid intake/output, and signs of sepsis.

• Hydration: Encourage 2–3 L fluid intake daily unless contraindicated.

• Prepare for radiological studies as needed.

• Educate patient on:

  • Completing antibiotics

  • Recognizing signs of worsening infection

  • Dietary recommendations (e.g., stone prevention)

Patient education & counseling

• Reinforce the importance of hydration, especially in infection or stone formers.

• Teach how to monitor urine color and volume.

• Counsel on lifestyle changes, such as reducing salt and oxalate-rich foods in recurrent stone formers.

• Ensure understanding of when to seek medical help (e.g., fever, worsening pain, decreased urination).

Conclusion

CVA tenderness remains a simple yet essential bedside finding with significant diagnostic value. It provides early clues to potentially serious renal pathology and should always be evaluated within the broader clinical context through history, physical examination, and investigations.

References

1. Afhami MR, Salmasi PH. Studying analgesic effect of preincisional infiltration of lidocaine as a local anesthetic with different concentrations on postoperative pain. Pak J Med Sci. 2009;25(5):821–824.

2. Soleimanpour H, Hassanzadeh K, Aghamohammadi D, Vaezi H, Mehdizadeh EM. Parenteral lidocaine for treatment of intractable renal colic: Case series. J Med Case Rev. 2011;5:256.

3. Longo DL, Fauci AS, Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine. 20th ed. McGraw-Hill; 2018.

4. McGee S. Evidence-Based Physical Diagnosis. 4th ed. Elsevier; 2017.