Received: 27 June 2022 | Revised: 23 August 2022 | Accepted: 30 August 2022

DOI: 10.1002/jgf2.581

PRELIMINARY REPORT

Evaluation of the usefulness of costovertebral angle tenderness

in patients with suspected ureteral stone

Hiroyasu Higuchi MD1 | Taku Harada MD1,2 | Juichi Hiroshige MD1

1
Division of General Medicine, Showa
University Koto Toyosu Hospital, Tokyo, Abstract
Japan
Background: The usefulness of costovertebral angle (CVA) tenderness for the diagno-
2
Division of Diagnostic and Generalist
Medicine, Dokkyo Medical University
sis of a suspected ureteral stone remains controversial.
Hospital, Tochigi, Japan Methods: This single-­center, retrospective, observational study included patients

Correspondence
Taku Harada, MD, Division of General
Medicine, Showa University Koto Toyosu
Hospital, 5-­1-­38 Toyosu Koto-­ku, Tokyo
135-­8577, Japan.
Email: hrdtaku@gmail.com
aged 16–­6 4 years with acute-­onset unilateral lower back pain or abdominal pain. The
diagnostic accuracy of CVA tenderness was investigated.
Results: In total, 132 patients met the criteria; 80 were diagnosed with ureteral stones.
The sensitivity and specificity of CVA tenderness were 0.65 and 0.50, respectively;
positive and negative likelihood ratios were 1.3 and 0.7, respectively.
Conclusions: CVA tenderness cannot be used as a single diagnostic indicator to con-
firm or exclude ureteral stone diagnosis.

KEYWORDS
costovertebral angle tenderness, physical examination, ureteral stone

1 | I NTRO D U C TI O N
1
Ureteral stone is one of the most common diseases in primary care,
and accurate timely diagnosis is considered important. Diagnosis
is based on medical history, physical examination, urinalysis, ultra-
sonography, kidney–­ureter-­bladder radiography, and computed to-
mography (CT). However, although plain film radiography is useful
for determining the course of known stones, it is not useful for diag-
nosis in the acute phase. 2 Noncontrast CT is recommended for first-­
episode ureteral stone, 2 and pretest probability should be increased
based on history, physical examination, and simple tests to avoid CT
scan overuse.
When a ureteral stone is suspected in a patient with acute onset
unilateral abdominal or back pain, costovertebral angle (CVA) ten-
3
derness is often noted. Eskelinen et al. reported that lateral loin
tenderness has a sensitivity of 15%, specificity of 99%, and LR+ 30.3
On this basis, Japanese guidelines for acute abdomen recommend
CVA tenderness for the diagnostic clue of ureteral stones.4 However,
Moore et al. reported a cohort odds ratio of 0.4 for lumbar or back
tenderness for ureteral stones,5 while Kartal et al. reported a di-
agnostic odds ratio of 2.0 for CVA tenderness.6 Additionally, CVA
tenderness is associated with several diseases.3,6 Therefore, the use-
fulness of CVA tenderness for ureteral stone diagnosis is controver-
sial. Accordingly, we evaluated its usefulness for diagnosing ureteral
stone in this study.
2 | M E TH O D S
This single-­center retrospective observational study was based in
a 400-­bed acute-­care university hospital in an urban area. It was
conducted over 12 months, from April 1, 2020, to March 31, 2021.
Inclusion criteria were patients aged 16–­6 4 years who visited the
emergency department for acute-­
onset unilateral back pain or

This study was presented orally at the 12th Annual Meeting of the Japanese Primary Care Association.

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association.

J Gen Fam Med. 2022;00:1–3.  wileyonlinelibrary.com/journal/jgf2 | 1

2 | HIGUCHI et al.

TA B L E 1 Results of costovertebral angle tenderness TA B L E 2 Diagnoses of the patients with each group

Positive Negative Costovertebral Costovertebral

angle angle
Ureteral stone 52 28
Diagnosis Tenderness(+) Tenderness(−) Total
Other disease 26 26
Ureteral stone 52 28 80
Undiagnosed 7 13 19
abdominal pain. CT imaging was performed in all cases where the Acute appendicitis 2 3 5
examining physician judged that the pretest probability of ureteral Constipation 5 0 5
stone was high, whereas the decision to perform CT imaging when Acute back pain 3 0 3
the pretest probability of ureteral stone suspicion was low was made Peristaltic pain 1 2 3
by the physician responsible for each case. The reference stand- Acute cholecystitis 1 1 2
ard of ureteral stone was the presence of a ureteral stone at a site
Ovarian tumor 1 1 2
concordant to the symptoms on CT in a patient with acute-­onset torsion
unilateral abdominal or low back pain. Exclusion criteria were fever Acute pancreatitis 1 1 2
over 37.5°C, diarrhea, trauma, pregnancy, and no documented CVA Choletithiasis 1 0 1
tenderness.
Acute cholangitis 1 0 1
Age, gender, clinical course, CVA tenderness, and diagnosis were
Pneumonia 0 1 1
investigated. To test for CVA tenderness, the examiner placed one
Ischemic colitis 1 0 1
hand over the region inside the CVA and tapped that hand gently
Adnexitis 0 1 1
with the closed first of the other hand. Tapping intensity was at the
Ovarian tumor 0 1 1
discretion of each physician. Positive CVA tenderness was defined
as an exacerbation of pain and a left–­right difference. Positive and Acute diverticulitis 0 1 1

negative likelihood ratios (LR+, LR-­) were calculated for usefulness Ruptured liver 0 1 1
tumor
of CVA tenderness. Statistical analyses were performed using EZR
(Easy R) software7 and was calculated using the chi-­square test. Renal infarction 1 0 1

This research was approved by the ethical review board of Small bowel 1 0 1
obstruction
Showa university and conducted according to the Declaration of
Helsinki. The requirement for written informed consent was waived Total 78 54 132

by the ethical review board of Showa University owing to the retro-

spective design. An opt-­out method was used so that patients could
refuse to participate in the study. The collected data was converted 0.58–­0.72), specificity was 0.5 (95% CI: 0.40–­0.60), positive likeli-
to deidentified data. hood ratio was 1.3 (95% CI: 0.97–­1.79), and negative likelihood ratio
was 0.7 (95% CI: 0.48–­1.05). The chi-­square test showed no signifi-
cant difference between the two groups with positive and negative
3 | R E S U LT CVA tenderness (p = 0.10).

Of 4249 patients who visited the emergency department, 132 met

the inclusion criteria and were included. Ninety-­nine patients (75%)
were men, with a median age of 46 (37–­53) years, and 80 (60.1%)
were diagnosed with ureteral stone. Diagnoses of the 52 patients
without ureteral stones were as follows: undiagnosed (n = 20), acute
appendicitis (n = 5), constipation (n = 5), acute back pain (n = 3), peri-
staltic pain (n = 3), acute cholecystitis (n = 2), ovarian tumor torsion
(n = 2), acute pancreatitis (n = 2), cholelithiasis (n = 1), acute chol-
angitis (n = 1), pneumonia (n = 1), ischemic colitis (n = 1), adnexitis
(n = 1), ovarian tumor (n = 1), acute diverticulitis (n = 1), ruptured
liver tumor (n = 1), renal infarction (n = 1), and small bowel obstruc-
tion (n = 1).
Of the 80 patients with ureteral stones, 52 were positive for CVA
tenderness. Of the 52 patients without ureteral stones, 26 were pos-
itive for CVA tenderness. The CVA tenderness results are shown in
Table 1, and the diagnoses are listed in Table 2. The sensitivity of CVA
tenderness for ureteral stone was 0.65 (95% confidence interval [CI]:
4 | DISCUSSION
In this study, we found that CVA tenderness cannot be used as a
single diagnostic indicator to confirm or exclude ureteral stone di-
agnosis. Previous studies have examined the usefulness of CVA
tenderness and back tenderness in ureteral stone diagnosis.3,5,6
Eskelinen et al. found that the sensitivity and specificity of lateral
loin tenderness were 0.15 and 0.99, respectively, but the prevalence
of ureteral stones in the overall population was very low, about 4%.3
Moore et al. reported a ureteral stone prevalence of approximately
50–­60%, with a cohort OR of 0.4 (95% CI: 0.2–­0.6) for lumbar or
back tenderness.5 Kartal et al. recorded a ureteral stone prevalence
of 77%, and a diagnostic OR of 2.07 for CVA tenderness (95% CI:
0.915–­4.660).6 Our finding that CVA tenderness is not useful during
physical examination for suspected ureteral stone in settings with a
high prevalence of ureteral stone is largely consistent with previous
HIGUCHI et al.
studies. In both the present and previous studies, CVA tenderness
was positive in several diseases other than ureteral stone. Therefore,
CVA tenderness should not be used as a single diagnostic indicator,
but rather to clarify the localization of the patient's chief complaint
of pain or assist in clinical reasoning.
The limitations of this study include the following: the setting
was an emergency room, not a general outpatient clinic; as this was a
single-­center emergency room, the study does not have external va-
lidity; reproducibility was not assessed using the kappa coefficient;
elderly patients with low prevalence and low diagnostic accuracy on
physical examination were excluded; and the failure to investigate
characteristics of patients with negative CVA tenderness or positive
CVA tenderness in nonureteral stone patients.
In conclusion, in patients presenting to the emergency depart-
ment with acute-­onset unilateral abdominal or low back pain, the
presence of CVA tenderness does not contribute significantly to the
diagnosis of ureteral stone.
AC K N OW L E D G E M E N T S
We are grateful to Editage (www.edita​ge.jp) for the English language
editing.
C O N FL I C T O F I N T E R E S T
The authors have stated explicitly that there are no conflicts of inter-
est in connection with this article.
ORCID
Taku Harada https://orcid.org/0000-0001-8794-6744
| 3
REFERENCES
1. Afsar B, Kiremit MC, Sag AA, Tarim K, Acar O, Esen T, et al. The role
of sodium intake in nephrolithiasis: epidemiology, pathogenesis,
and future directions. Eur J Intern Med. 2016;35:16–­9.
2. Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone
imaging techniques. Nat Rev Urol. 2016;13:654–­62.
3. Eskelinen M, Ikonen J, Lipponen P. Usefulness of hystory-­taking,
physical examination and diagnostic scoring in acute renal colic. Eur
Urol. 1998;34:467–­73.
4. Acute Abdomen Clinical Practice Guidelines Publication
Committee. Acute Abdomen Clinical Practice Guidelines 2015.
Tokyo: Igaku Shoin; 2015 [in Japanese].
5. Moore CL, Bomann S, Daniels B, Luty S, Molinaro A, Singh D, et al.
Derivation and validation of a clinical prediction rule for uncompli-
cated ureteral STONE—­the STONE score: retrospective and pro-
spective observational cohort studies. BMJ. 2014;348:g2191.
6. Kartal M, Eray O, Erdogru T, Yilmaz S. Prospective validation of a
current algorithm including bedside US performed by emergency
physicians for patients with acute flank pain suspected for renal
colic. Emerg Med J. 2006;23:341–­4.
7. Kanda Y. Investigation of the freely available easy-­ to-­use soft-
ware “EZR” for medical statistics. Bone Marrow Transplant.
2013;48:452–­8.
How to cite this article: Higuchi H, Harada T, Hiroshige J.
Evaluation of the usefulness of costovertebral angle
tenderness in patients with suspected ureteral stone. J Gen
Fam Med. 2022;00:1–3. https://doi.org/10.1002/jgf2.581