Tumors on the adrenal glands can absolutely cause pain, though the way they do so varies widely depending on the type, size, and hormonal activity of the growth. Many adrenal tumors are discovered incidentally on imaging done for unrelated reasons and never cause discomfort at all. But when pain does occur, it can range from a dull, persistent ache in the flank or abdomen to sudden, severe pain from a hemorrhage or rupture. The mechanisms behind adrenal tumor pain are more varied than most people expect, and the pain itself is frequently misattributed to other conditions before the true source is identified.
How an Adrenal Tumor Causes Pain Directly
The adrenal glands sit on top of each kidney, deep in the back of the abdominal cavity in the area known as the retroperitoneum. Each gland is enclosed in a fibrous capsule. When a tumor grows large enough to stretch that capsule or press on surrounding structures, the result is pain, typically felt in the flank, upper abdomen, or back on the affected side. A case report of bilateral pheochromocytomas described persistent flank pain radiating to the back, and the researchers attributed it to mass effect and capsular distension; the pain resolved completely after surgical removal of both tumors.1AACE Endocrinology and Diabetes. A Rare Presentation of Bilateral Pheochromocytoma With a Flank Pain Radiating to the Back: A Case Report and Narrative Review
Non-functioning tumors, meaning those that do not secrete excess hormones, tend to go unnoticed until they reach a size where physical compression becomes unavoidable. At that point, symptoms can include abdominal pain, a palpable mass, nausea, weight loss, and fatigue.2Elsevier / International Journal of Surgery Case Reports. The case series of functional adrenal tumors: Experience of two tertiary hospitals in Yaoundé, Cameroon – Section: Discussion The larger the tumor, the more likely it is to cause discomfort. Adrenocortical carcinomas, which are rare malignant tumors of the adrenal cortex, often grow substantially before diagnosis. Their nonspecific symptoms include abdominal or flank pain, early satiety, and a sense of abdominal fullness.3PubMed Central. Adrenocortical carcinoma: a literature review – Section: Clinical presentation One reported case of a giant adrenocortical carcinoma described the patient’s initial symptoms simply as abdominal pain and discomfort.4PubMed Central. Giant Adrenocortical Carcinoma: A Case Report and Review of the Relevant Literature – Section: Case Report
Sudden, Severe Pain From Hemorrhage or Rupture
Some of the most dramatic presentations of adrenal tumor pain happen when a tumor bleeds or ruptures. This is uncommon but serious. Adrenal myelolipomas, for instance, are benign fatty tumors that are usually silent and managed without surgery. But if one ruptures, the bleeding can extend into the retroperitoneal space and cause intense, sudden-onset pain that sends a person to the emergency room.5PubMed Central. Spontaneous rupture of adrenal myelolipoma as a cause of acute flank pain: A case report – Section: Abstract Case reviews describe these ruptures as potentially life-threatening because the bleeding can be significant.6PubMed Central. Spontaneous Rupture of Adrenal Myelolipoma: A Case Report With Review of the Literature – Section: Discussion
A similar scenario can happen with adrenal hemangiomas, which are benign vascular tumors. One case involved a 31-year-old woman who came to the emergency department with sudden right upper quadrant and flank pain along with nausea. Imaging revealed a large retroperitoneal hemorrhage from a ruptured adrenal hemangioma measuring roughly 7 by 8 centimeters.7PubMed Central. Sudden onset flank pain: a case report of retroperitoneal hemorrhage secondary to a ruptured adrenal hemangioma – Section: Case presentation From the outside, these acute events look a lot like kidney stones, a ruptured cyst, or even appendicitis, which makes them easy to misidentify on first assessment.
Pain Caused by Hormone Overproduction
Adrenal tumors that actively produce hormones can cause pain through indirect pathways that have nothing to do with the tumor physically pressing on anything. The hormonal excess itself triggers symptoms that the patient experiences as pain, even though the source is biochemical rather than mechanical.
Pheochromocytomas and Headache
Pheochromocytomas are tumors that produce catecholamines, the fight-or-flight hormones like adrenaline and noradrenaline. These surges cause episodes of dangerously high blood pressure, often accompanied by pounding headaches, a racing heart, heavy sweating, and tremor.8PubMed Central. Pheochromocytoma Presenting With Paroxysmal Hypertensive Crises in a Previously Healthy Woman: A Case Report – Section: Discussion The classic triad of sudden headache, sweating, and palpitations should raise suspicion for pheochromocytoma, particularly when hypertension is present, though fewer than one in four patients actually have all three symptoms at the same time.9Journal of Neurosonology and Neuroimaging. Pheochromocytoma-related Headache and Symptoms that Should Not be Overlooked: A Case Report – Section: Discussion The headaches tend to coincide with abrupt spikes in blood pressure and can be severe enough to be the patient’s most prominent complaint.
Cortisol-Producing Tumors and Bone Pain
Adrenal tumors that overproduce cortisol cause Cushing’s syndrome, a condition with wide-reaching effects throughout the body. One underappreciated consequence is rapid bone loss. A case report described a 20-year-old man with eight months of low back pain who turned out to have bilateral cortisol-secreting adrenal tumors. His bone density was devastatingly low, and he had already developed fragility fractures in his spine.10PubMed Central. Severe osteoporosis in a young man with bilateral Cushing’s syndrome: a case report – Section: CASE PRESENTATION The pain in cases like this comes not from the tumor itself but from bones weakened to the point of breaking under normal daily stress. In a young man, severe osteoporosis is unusual enough that it prompted the investigation that uncovered the adrenal tumors.
Aldosterone-Producing Tumors and Muscle Cramps
Conn’s adenomas produce excess aldosterone, which drives up blood pressure and depletes potassium. The low potassium leads to muscle cramps, weakness, and excessive urination, particularly at night.11Arquivos Brasileiros de Cardiologia. Conn’s adenoma: a cause of hypertension and hypokalemia – Section: Discussion The cramping can be painful and persistent, and because it feels like a musculoskeletal issue, the connection to an adrenal tumor is rarely the first thing anyone suspects.
When Cancer Spreads to the Adrenal Glands
The adrenal glands are a common destination for metastatic cancer, particularly from lung, kidney, breast, and melanoma primaries. When a metastasis grows large enough, it can produce the same type of flank and abdominal pain as a primary adrenal tumor. A distinct pain syndrome has been described in lung cancer patients with large adrenal metastases, characterized by unilateral flank pain that may extend into the abdomen, and it has only been reported with metastases at least 5 centimeters across.12Journal of Pain and Symptom Management. A pain syndrome associated with large adrenal metastases in patients with lung cancer – Section: Abstract
These metastases can also bleed. One case involved a lung cancer patient who developed sudden left flank pain four days after the metastasis was identified. CT imaging showed bleeding around the left adrenal gland, with no history of trauma to explain it.13PubMed Central. Acute flank abdominal pain as the chief complaint of spontaneous adrenal hemorrhage secondary to metastatic lung cancer – Section: Case presentation For patients with a known cancer history, new flank pain should prompt consideration of adrenal involvement. For patients whose cancer has not yet been diagnosed, the adrenal pain can sometimes be the symptom that leads to the discovery of the underlying malignancy.
Surgical removal of painful adrenal metastases can provide real relief. In a study of patients who underwent adrenalectomy for metastatic disease, pain improved in the large majority of those who had been symptomatic beforehand.14PubMed. Adrenalectomy for metastatic disease to the adrenal glands
Why Adrenal Tumor Pain Gets Misdiagnosed
The retroperitoneal location of the adrenal glands means their pain mimics conditions that are far more common. Flank pain is more often attributed to kidney stones, musculoskeletal strain, or gastrointestinal problems. Upper abdominal pain triggers workups for gallbladder disease, pancreatitis, or peptic ulcers. Unless imaging happens to capture the adrenal glands, the true source can go unrecognized for months or longer.
A striking example involved a 51-year-old woman who sought chiropractic care for what appeared to be ordinary low back pain. Four days after her initial visit, she collapsed in cardiogenic shock with heart failure and low blood pressure. CT of her abdomen revealed a right-sided adrenal mass, and lab work confirmed a pheochromocytoma. Her back pain resolved after the tumor was surgically removed.15PubMed Central. A case of pheochromocytoma presenting as low back pain – Section: CLINICAL FEATURES The case underscores that adrenal tumors can present with pain patterns that look perfectly routine to clinicians who see musculoskeletal complaints all day. Red flags that might prompt earlier suspicion include pain that does not respond to typical treatments, accompanying symptoms like unexplained blood pressure swings or weight changes, or pain that wakes you from sleep consistently.
The diagnostic challenge is compounded by the fact that most adrenal tumors are discovered incidentally on imaging ordered for some other reason. These so-called incidentalomas are common, found in a meaningful percentage of abdominal CT scans performed in adults. The overwhelming majority are small, benign, and painless. So even when an adrenal mass is found alongside a patient’s pain complaint, clinicians may not immediately connect the two, especially if the tumor appears small or inactive on initial review.
Pain That Lingers After Surgery
For patients who do undergo adrenalectomy, whether for a primary tumor or a metastasis, the surgery itself can leave behind chronic pain. Even with minimally invasive (laparoscopic) techniques, a study of over 300 patients found that roughly 15% reported chronic postsurgical pain afterward. About a third of those patients also experienced numbness or reduced sensation in the surgical area.16PubMed Central. Chronic postsurgical pain after minimally invasive adrenalectomy: prevalence and impact on quality of life – Section: Results The onset of that pain was sudden in some patients and gradual in others, suggesting that the causes include both direct nerve injury during the procedure and longer-term changes in how the surgical area heals.
This is worth knowing because a patient might interpret persistent pain after adrenalectomy as a sign that the tumor has returned or that something went wrong, when in fact chronic postsurgical pain is a recognized and not uncommon outcome of abdominal surgery in general. Laparoscopic adrenalectomy has generally reduced complications compared to open surgery, but it does not eliminate the possibility of long-term discomfort.17PubMed. The positive impact of laparoscopic adrenalectomy on complications of adrenal surgery – Section: RESULTS
When to Take Adrenal-Area Pain Seriously
Most flank or upper abdominal pain will turn out to be something other than an adrenal tumor. Kidney stones, muscle strain, and gastrointestinal issues are vastly more common causes. But certain patterns warrant a closer look with your doctor:
- Persistent flank pain: Pain in the side or upper back that does not improve with rest, anti-inflammatory medications, or physical therapy, and that has no clear musculoskeletal explanation.
- Accompanying hormonal symptoms: Episodes of sudden high blood pressure, racing heart, flushing, or drenching sweats alongside the pain point toward a pheochromocytoma. Unexplained weight gain, easy bruising, and muscle weakness suggest Cushing’s syndrome.
- Sudden severe onset: Abrupt, intense flank pain with nausea, particularly without a history of kidney stones, could reflect hemorrhage from an adrenal lesion that has ruptured.
- Known cancer history: New flank pain in someone with a current or past cancer diagnosis, especially lung, kidney, or breast cancer, should raise the question of adrenal metastasis.
- Young adults with fractures: Unexplained osteoporosis or fragility fractures in a young person, particularly with back pain, deserve an endocrine workup.
Imaging is the most straightforward path to detecting an adrenal mass. CT and MRI can identify tumors, and hormonal blood and urine tests can determine whether the tumor is secreting anything. The combination of imaging and biochemical workup usually clarifies whether an adrenal tumor is the pain’s source. For tumors that are causing pain through mass effect or hormonal excess, surgery is the most reliable path to resolution. The relationship between tumor removal and pain relief has been documented across multiple tumor types, from pheochromocytomas whose flank pain disappeared after bilateral adrenalectomy to metastatic deposits where surgery relieved symptoms in most patients who were symptomatic before the operation.
The Size Question
One practical question people often have is how big an adrenal tumor needs to be before it starts causing pain. There is no universal threshold, because the answer depends on the tumor type, its location within the gland, and whether it is hormonally active. A small pheochromocytoma can cause debilitating headaches and cardiovascular crises through hormone release alone, regardless of whether it is large enough to physically compress anything. On the other hand, a non-functioning tumor may grow to several centimeters before the patient notices any discomfort at all.
The pain syndrome described in adrenal metastases from lung cancer was specifically associated with tumors at least 5 centimeters across.12Journal of Pain and Symptom Management. A pain syndrome associated with large adrenal metastases in patients with lung cancer – Section: Abstract Adrenal cortical carcinomas, which tend to be diagnosed at larger sizes because they often grow silently, frequently present with pain as one of the initial complaints. The general pattern is intuitive: the larger the tumor, the more likely it is to stretch the capsule, press on nearby organs, or outgrow its own blood supply and bleed. But the exceptions created by hormone-secreting tumors mean that size alone is an unreliable predictor of whether someone will experience pain.