Acute pyelonephritis

This is almost universal in patients with acute pyelonephritis.[33]

It may be described as pain in the lower back or under the ribs, or as loin or kidney pain.[27][33]
Note that the location of pain may be different in a patient with a kidney transplant. A kidney transplant is generally easily palpable in the left or right lower quadrant of the abdomen depending on where it has been implanted.

Palpate the costovertebral angle.

Tenderness is a key finding on examination and can help differentiate the presentation from flank pain due to renal or ureteral stones.[33][34]

A temperature >37.9°C (or ≤36°C in women aged over 65 years) can indicate pyelonephritis.[27]

Ask about other general signs of inflammation, such as chills or malaise.
Fever may be absent in early stages, in mild cases, or in older patients.[27][33]

Ask about general symptoms of infection or inflammation, such as malaise, rigors, or chills.[27][33]

Ask about the following risk factors:

History of urinary tract infections (UTIs)[8][27][34]
- Symptoms of UTI include urinary frequency, urgency, dysuria[27][34]
Stress incontinence[8]
Diabetes[8]
Presence of a catheter or renal stones
Anatomical or functional urinary abnormality
- Consider polycystic disease, enlarged prostate, vesicoureteric reflux, ureteroceles, and neurogenic bladder
Immunosuppression
- Consider use of corticosteroids
Family history of UTI[8]
Frequent sexual intercourse[8]
New sexual partner in the previous year[8]
Recent spermicide use[8]
Pregnancy
- Determine whether the patient is pregnant. Carry out a pregnancy test if the woman is unsure
- UTIs are common during pregnancy. Infections and untreated asymptomatic bacteriuria during pregnancy are associated with an increased risk of pyelonephritis, premature delivery, and fetal mortality.[40]

A general symptom of infection.[27][34]

A general symptom of infection.[27][34]

Palpate the abdomen for suprapubic tenderness.[33]

A sign of systemic illness.

A sign of systemic illness.

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History and exam