[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Kidney, genitourinary, breast and obstetric exam](https://durgical.com/en/clinical-exam/#a-renal) › Kidney palpation: bimanual palpation and ballottement [Clinical exam](https://durgical.com/en/clinical-exam/) · [Kidney, genitourinary, breast and obstetric exam](https://durgical.com/en/clinical-exam/#a-renal) # Kidney palpation: bimanual palpation and ballottement - Maneuver The kidney is felt with one hand under the back and one on the belly while the patient breathes in deeply. If it can be felt, it may be enlarged. Updated 2026-11-01 **See it in 3D:** [Kidneys](https://durgical.com/en/anatomy/kidney/) · [Renal pelvis](https://durgical.com/en/anatomy/renal-pelvis/) · [Psoas major](https://durgical.com/en/anatomy/psoas-major/) ## Key points - Bimanual palpation: back hand in the flank, front hand under the costal margin, press at the end of deep inspiration. - In a healthy adult only the lower pole of the right kidney is sometimes felt. - A kidney that ballots is enlarged: hydronephrosis, polycystic kidneys, cyst or tumour. - The kidney is resonant in front (colon); the spleen is dull and has a notch. - Costovertebral angle pain points to pyelonephritis or a stone, not to a large kidney. ## What it is Bimanual kidney palpation traps the kidney between a back hand in the flank and a front hand below the costal margin. Ballottement is the variant in which the back hand flicks the kidney forward and the front hand feels it bounce. In a healthy adult the kidney is rarely felt, except the lower pole of the right kidney in thin people, so a palpable kidney points to a mass or an enlarged kidney. ## The anatomy it tests - The kidneys are retroperitoneal, one on each side of the spine, roughly from the twelfth thoracic to the third lumbar vertebra; the eleventh and twelfth ribs shield their upper poles. - The right kidney sits slightly lower than the left because of the liver, which is why its lower pole is the one sometimes felt. - On inspiration the diaphragm descends and pushes the kidney down within reach of the hands. - The kidney differs from the spleen: it has bowel resonance in front (the colon lies over it), it ballots backward, has no notch, and fingers can get between it and the costal margin. ## How to do it - Patient supine, abdomen exposed, arms at the sides and knees slightly bent to relax the wall; the examiner stands on the right. - Right kidney: the left hand goes under the right flank, between the twelfth rib and the iliac crest, and lifts the flank forward. - The right hand rests on the right upper quadrant, lateral to the rectus muscle and below the costal margin, fingers pointing up. - Ask the patient to breathe in deeply; at the end of inspiration the front hand presses firmly and deeply toward the back hand. - Feel for the lower pole of the kidney, smooth, firm and rounded, which descends with inspiration and slips between the hands on expiration. - Ballottement: with the front hand still, the back hand gives brief forward pushes; an enlarged kidney is felt bouncing against the front hand. - Left kidney: repeat on the left, moving to the left side of the bed or reaching across to the left flank with the left hand. - To finish, with the patient sitting, add gentle fist percussion over each costovertebral angle and ask whether it hurts. ## What a positive result means - Positive: a palpable kidney that ballots. It suggests enlargement: hydronephrosis, polycystic kidneys (often both sides and irregular), a large cyst or a renal tumour. - In a child, a ballotable flank mass that does not cross the midline suggests Wilms tumour or hydronephrosis. - Pain on palpation or on fist percussion of the costovertebral angle suggests pyelonephritis or an obstructing stone, not an enlarged kidney. - A negative result does not rule out kidney disease: the small kidney of chronic disease and many early tumours cannot be felt. ## Usefulness and limits - Low sensitivity: obesity, guarding and examiner experience limit the maneuver a great deal. - Renal ultrasound confirms size, cysts, hydronephrosis or masses, and is the test of choice for a palpable kidney. ## Memory aid The kidney plays ping-pong between your two hands: if it bounces back, it is big. ## Test yourself Think of the answer, then tap the question to see it. ## At what point in the breathing cycle does the front hand press during kidney palpation? At the end of a deep inspiration, when the diaphragm has pushed the kidney down. ## Which kidney is felt most often in a thin, healthy adult, and why? The right, because the liver pushes it down and its lower pole is easier to reach. ## What does bilateral positive ballottement with irregular kidneys suggest? Polycystic kidney disease. ## How does percussion separate a large left kidney from an enlarged spleen? The colon in front of the kidney is resonant; an enlarged spleen is dull and has a notch. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/kidney-palpation-bimanual-palpation-and-ballottement/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Kidneys](https://durgical.com/en/anatomy/kidney/) - [Renal pelvis](https://durgical.com/en/anatomy/renal-pelvis/) - [Psoas major](https://durgical.com/en/anatomy/psoas-major/) ## Related - [Costovertebral angle tenderness (fist percussion)](https://durgical.com/en/clinical-exam/costovertebral-angle-tenderness/) - [Abdominal palpation: light and deep, guarding and masses](https://durgical.com/en/clinical-exam/abdominal-palpation-light-and-deep-guarding-and-masses/) - [Palpation of the liver and spleen](https://durgical.com/en/clinical-exam/palpation-of-the-liver-and-spleen/) - [Urinary symptoms: dysuria, frequency, oliguria and hematuria](https://durgical.com/en/clinical-exam/urinary-symptoms-dysuria-frequency-oliguria-and-hematuria/) - [Uremic syndrome and the signs of chronic kidney disease](https://durgical.com/en/clinical-exam/uremic-syndrome-and-the-signs-of-chronic-kidney-disease/) ## Related conditions - [Autosomal dominant polycystic kidney disease](https://durgical.com/en/conditions/autosomal-dominant-polycystic-kidney-disease/) - [Hydronephrosis and obstructive uropathy](https://durgical.com/en/conditions/hydronephrosis-and-obstructive-uropathy/) - [Renal cell carcinoma](https://durgical.com/en/conditions/renal-cell-carcinoma/) - [Wilms tumour (nephroblastoma)](https://durgical.com/en/conditions/wilms-tumour/) - [Acute pyelonephritis](https://durgical.com/en/conditions/acute-pyelonephritis/) - [Kidney stones (urolithiasis)](https://durgical.com/en/conditions/kidney-stones/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [25.3 Gross Anatomy of the Kidney - Anatomy and Physiology 2e | OpenStax](https://openstax.org/books/anatomy-and-physiology-2e/pages/25-3-gross-anatomy-of-the-kidney) (OpenStax, 2022); [Polycystic kidney disease: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000502.htm) (MedlinePlus (U.S. National Library of Medicine), 2024). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/kidney-palpation-bimanual-palpation-and-ballottement/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/kidney-palpation-bimanual-palpation-and-ballottement/