Acute Pelvic Pain


Conditions Causing Acute Pelvic Pain in Different Populations

PATIENT CATEGORY COMMON DIAGNOSES LESS COMMON DIAGNOSES RARE DIAGNOSES
Reproductive age (not pregnant)

Endometriosis (ruptured endometrioma)

Adenomyosis

Endosalpingiosis

 

Idiopathic (no cause identified)

Dysmenorrhea

Round ligament mass (lipoma, teratoma)

 

Ovarian cyst, ruptured

Endometritis (postprocedure)

Transverse vaginal septum

 

Ovarian torsion

Imperforate hymen

 
 

PID, tubo-ovarian abscess

Intrauterine device perforation

 
   

Leiomyoma (degenerating)

 
   

Mittelschmerz

 
Reproductive age (pregnancy related)

Corpus luteum cyst

Leiomyoma (degenerating)

Incarcerated gravid uterus

 

Ectopic pregnancy

Pubic symphysis separation

Ovarian vein thrombosis

 

Endometritis (postpartum)

Subchorionic hemorrhage

PID (rare after first trimester)

 

Normal labor

 

Uterine rupture

 

Ovarian torsion

   
 

PID (first trimester)

   
 

Placental abruption

   
 

Preterm labor

   
 

Spontaneous abortion

   

Reproductive age (undergoing fertility treatment)

Ectopic pregnancy

Heterotopic pregnancy

 

Ovarian follicular cyst

   
 

Ovarian hyperstimulation syndrome

   
 

Ovarian torsion

   

Postmenopausal

Malignancy

Ischemic colitis

Endometriosis

     

PID, tubo-ovarian abscess

     

Retained intrauterine device

All groups

Appendicitis

Bowel obstruction

Mesenteric adenitis

 

Diverticulitis

Inguinal hernia

 
 

Inflammatory bowel disease

Interstitial cystitis

 
 

Irritable bowel syndrome

Pelvic adhesive disease (postoperative scarring)

 
 

Musculoskeletal (abdominal wall) pain

Perirectal abscess

 
 

Urinary tract infection

Urethral diverticulum

 
 

Urolithiasis

Urinary retention

 
       

 

Historical Findings and Suggested Diagnoses and Subsequent Testing in Patients with Acute Pelvic Pain

FINDING SUGGESTED DIAGNOSES FURTHER DIAGNOSTIC CONSIDERATIONS
History of intrauterine instrumentation, multiple cesarean deliveries, or other uterine surgeriestd> Adenomyosis (endometrial tissue grown into the uterine wall) Magnetic resonance imaging
  Pelvic adhesions Consider nonurgent referral to gynecologist or general surgeon in absence of other findings
Menstrual abnormalities
  Amenorrhea Imperforate hymen Pelvic examination
  Transverse vaginal septum Pelvic ultrasonography
  Dysmenorrhea Endometriosis, ovarian cyst Pelvic ultrasonography (to assess for ovarian cyst)
Nausea and vomiting Appendicitis, ovarian torsion If appendicitis is more likely: proceed with contrast CT
    If ovarian torsion is more likely: proceed with pelvic ultrasonography with Doppler flow study
    Early urgent referral for surgical evaluation and treatment is recommended
Pain symptoms
  Bilateral pain, particularly if associated with mucopurulent vaginal discharge Pelvic inflammatory disease Testing for sexually transmitted infections
    Complete blood count to test for leukocytosis or left shift
  Dull, unilateral adnexal pain that is constant or intermittent Ovarian torsion Presence of risk factors (nausea, vomiting, pregnancy)
    Pelvic ultrasonography with Doppler flow study
    Consider urgent referral for surgical evaluation and treatment
  Right lower quadrant pain Acute appendicitis Complete blood count demonstrating leukocytosis
    Contrast CT of the abdomen and pelvis
  Ectopic pregnancy Qualitative urine β-hCG can detect a pregnancy at four weeks' gestation
    Quantitative serum β-hCG can determine if pregnancy is above the discriminatory level such that an intrauterine pregnancy should be visible on pelvic ultrasonography to rule out ectopic gestation (Figure 2)
    Blood type to determine Rh status; if bleeding and pregnant, will need Rho(D) immune globulin (RhoGam)
    Pelvic ultrasonography
  Ovarian torsion Pelvic ultrasonography with Doppler flow study
Sexually active; pregnancy possible Ectopic pregnancy, spontaneous abortion Qualitative urine β-hCG can detect a pregnancy at four weeks' gestation
    Quantitative serum β-hCG can determine if pregnancy is above the discriminatory level such that an intrauterine pregnancy should be visible on pelvic ultrasonography to rule out ectopic gestation (Figure 2)
    Blood type to determine Rh status; if bleeding and pregnant, will need Rho(D) immune globulin
    Pelvic ultrasonography
Urinary symptoms    
  Dysuria Urinary tract infection Urinalysis demonstrating white blood cells, bacteria, leukocyte esterase, or nitrites
  Gross hematuria Urolithiasis Abdominal ultrasonography

β-hCG = beta human chorionic gonadotropin; CT = computed tomography.


 

Physical Examination Findings and Suggested Diagnoses and Subsequent Testing in Patients with Acute Pelvic Pain

FINDING SUGGESTED DIAGNOSES FURTHER DIAGNOSTIC CONSIDERATIONS
Carnett sign (increased pain to palpation when the abdominal wall musculature is voluntarily contracted) Musculoskeletal (abdominal wall) pain No further testing needed in the absence of other historical or physical examination findings that might suggest intrapelvic or intra-abdominal conditions
 
Cervical motion tenderness Pelvic inflammatory disease Consider testing for sexually transmitted infections
 
Fever Appendicitis Ultrasonography or contrast CT of the abdomen and pelvis
Complete blood count demonstrating leukocytosis
 
  Pelvic inflammatory disease Consider testing for sexually transmitted infections
  Pyelonephritis Urinalysis demonstrating evidence of urinary tract infection (white blood cells, bacteria, leukocyte esterase, or nitrites)
  Complete blood count demonstrating leukocytosis, left shift
  Tubo-ovarian abscess Pelvic ultrasonography
    Complete blood count demonstrating leukocytosis, left shift
Pelvic mass Ectopic pregnancy See Table 2
  Fibroid uterus Pelvic ultrasonography
  Ovarian cancer Pelvic ultrasonography
  Consider CT of the chest, abdomen, and pelvis if metastatic disease is suspected
  Ovarian cyst Pelvic ultrasonography
  Tubo-ovarian abscess Pelvic ultrasonography
Rovsing sign (palpation in the left lower quadrant causes pain in the right lower quadrant) Appendicitis Contrast CT of the abdomen and pelvis
Complete blood count demonstrating leukocytosis
 
Tachycardia, hypotension Ruptured ectopic pregnancy Consider urgent referral to facility with immediate surgical
  Ruptured hemorrhagic cyst capability  

CT = computed tomography.