Costovertebral angle (CVA) tenderness is pain that results from touching the region inside of the

costovertebral angle The costovertebral angle ( la, arcus costovertebralis) is the acute angle formed on either side of the human back between the twelfth rib and the vertebral column. The kidney lies directly below this area, so is the place where, with percussion ...

.Bickley, Lynn S., Peter G. Szilagyi, and Richard M. Hoffman. Bates' guide to physical examination and history taking. Philadelphia: Wolters Kluwer, 2017. Print. The CVA is formed by the 12th rib and the spine. Assessing for CVA tenderness is part of the

abdominal exam The abdomen (colloquially called the belly, tummy, midriff, tucky or stomach) is the part of the body between the thorax (chest) and pelvis, in humans and in other vertebrates. The abdomen is the front part of the abdominal segment of the torso. ...

, and CVA tenderness often indicates kidney

pathology Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...

Anatomy

The CVA is an anatomic concept of the relationship of the 12th rib to the

transverse processes The spinal column, a defining synapomorphy shared by nearly all vertebrates,Hagfish are believed to have secondarily lost their spinal column is a moderately flexible series of vertebrae (singular vertebra), each constituting a characteristic i ...

of the lumbar vertebrae. There is one CVA on each side of the spine.Moore, Keith L., A. M. R. Agur, and Arthur F. Dalley. Clinically oriented anatomy. Philadelphia: Wolters Kluwer, 2018. Print. The

lateral Lateral is a geometric term of location which may refer to: Healthcare *Lateral (anatomy), an anatomical direction *Lateral cricoarytenoid muscle *Lateral release (surgery), a surgical procedure on the side of a kneecap Phonetics *Lateral cons ...

part of the CVA is formed by the lower border of the 12th rib, and the medial part of the CVA is formed by the transverse processes of the lumbar vertebrae. The CVA is distinct from the

costovertebral joints The costovertebral joints are the joints that connect the ribs to the vertebral column. The articulation of the head of the rib connects the head of the rib to the bodies of the thoracic vertebrae. Structure The costotransverse joint connects t ...

. The lower poles of the

kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blood ...

s are within the CVAs. A small amount of

pleura The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls. The inner pleura, called the visceral pleura, covers the surface of each lung and dips bet ...

extends below the ribs in the CVAs.

Physical exam

To test for CVA tenderness, the examiner first applies gentle pressure to the region inside of the CVA with their finger.LeBlond, Richard F., et al. DeGowin's diagnostic examination. New York: McGraw-Hill Education, 2020. Print. If gentle pressure does not elicit tenderness, the examiner places one hand over the region inside the CVA and taps that hand gently with the closed fist of the other hand.

Differential diagnosis

CVA tenderness often indicates kidney pathology, but it may result from other medical problems.Stone, C K., and Roger L. Humphries. Current diagnosis & treatment. New York: McGraw-Hill Education, 2017. Print. CVA tenderness is often present in acute

pyelonephritis Pyelonephritis is inflammation of the kidney, typically due to a bacterial infection. Symptoms most often include fever and flank tenderness. Other symptoms may include nausea, burning with urination, and frequent urination. Complications may ...

.Rakel, Robert E., and David Rakel. Textbook of family medicine. Philadelphia: Elsevier/Saunders, 2011. Print. CVA tenderness may be present in patients who have a

kidney stone Kidney stone disease, also known as nephrolithiasis or urolithiasis, is a crystallopathy where a solid piece of material (kidney stone) develops in the urinary tract. Kidney stones typically form in the kidney and leave the body in the urine s ...

,Doherty, Gerard M. Current diagnosis & treatment : surgery. New York: McGraw-Hill Education, 2020. Print. a stone in the

ureter The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually long and around in diameter. The ureter is lined by urothelial cells, a type of transitional epit ...

, a ureteropelvic junction obstruction, a kidney

abscess An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends b ...

, a

urinary tract infection A urinary tract infection (UTI) is an infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney ...

, and

vesicoureteral reflux Vesicoureteral reflux (VUR), also known as vesicoureteric reflux, is a condition in which urine flows retrograde, or backward, from the bladder into one or both ureters and then to the renal calyx or kidneys. Urine normally travels in one directi ...

. CVA tenderness is also present in patients who have retrocecal

appendicitis Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a rup ...

and

retroperitoneal The retroperitoneal space (retroperitoneum) is the anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum on their ...

abscesses. In patients with

sickle cell disease Sickle cell disease (SCD) is a group of blood disorders typically inherited from a person's parents. The most common type is known as sickle cell anaemia. It results in an abnormality in the oxygen-carrying protein haemoglobin found in red blo ...

, blockage of blood flow to the kidney may cause CVA tenderness. A lack of CVA tenderness in patients with low back pain supports a diagnosis other than kidney pathology.

History

This medical test was first described by the American surgeon

John Benjamin Murphy John Benjamin Murphy, born John Murphy (December 21, 1857 – August 11, 1916) was an American physician and abdominal surgeon noted for advocating early surgical intervention in appendicitis appendectomy, and several eponyms: Murphy’s button, ...

in 1884. In the

Post-Soviet states The post-Soviet states, also known as the former Soviet Union (FSU), the former Soviet Republics and in Russia as the near abroad (russian: links=no, ближнее зарубежье, blizhneye zarubezhye), are the 15 sovereign states that wer ...

and

Eastern Europe Eastern Europe is a subregion of the Europe, European continent. As a largely ambiguous term, it has a wide range of geopolitical, geographical, ethnic, cultural, and socio-economic connotations. The vast majority of the region is covered by Russ ...

it is often called Pasternacki's sign after Belorussian internist Fiodor Ignatjevich Pasternacki, who described it during his rounds in a regional hospital in

Minsk Minsk ( be, Мінск ; russian: Минск) is the capital and the largest city of Belarus, located on the Svislach and the now subterranean Niamiha rivers. As the capital, Minsk has a special administrative status in Belarus and is the admi ...

in 1888. In italian the manouvre is referred to as "Giordano's sign", after the Italian physician Davide Giordano. In Poland, it is often called Goldflam's sign after Polish neurologist

Samuel Goldflam Samuel Wulfowicz Goldflam (15 February 1852 – 26 August 1932) was a Polish-JewishIsaac Lewin & Nathan Michael Gelber, ''A History of Polish Jewry during the revival of Poland'', Shengold Publishers (1990), p. 86 neurologist best known for his b ...

, who described it in 1900.

References

{{Urinary system symptoms and signs Nephrology Abdominal pain