Acute Pelvic Pain in Women

1. See Also
   1. Chronic Pelvic Pain
   2. Chronic Pelvic Pain in Men
   3. Acute Abdominal Pain
   4. Acute Abdominal Pain Causes
   5. Suprapubic Abdominal Pain
2. Causes
   1. See Acute Pelvic Pain Causes
   2. No cause found in 8-37% of cases
   3. Most common and important causes
      1. Appendicitis
      2. Pelvic Inflammatory Disease
      3. Ovarian Cyst
      4. Ectopic Pregnancy
      5. Endometriosis
      6. Ovarian Torsion
3. History
   1. Location
      1. Bilateral Pelvis
         1. Pelvic Inflammatory Disease
      2. Unilateral Pelvis
         1. Nephrolithiasis
         2. Ruptured Ovarian Cyst
         3. Ovarian Torsion
      3. Left Pelvis
         1. Diverticulitis
      4. Right Pelvis
         1. Appendicitis
   2. Radiation
      1. From periumbilical to RLQ Abdomen
         1. Appendicitis
      2. Into inguinal region or groin
         1. Nephrolithiasis
         2. Ovarian Torsion
   3. Timing
      1. Mid-cycle pain
         1. Mittelschmerz
   4. Associated Symptoms: Miscellaneous
      1. Fever
         1. Pelvic Inflammatory Disease
         2. Urinary Tract Infection including Pyelonephritis
         3. Postpartum Endometritis
         4. Diverticulitis
      2. Nausea or Vomiting
         1. Appendicitis
         2. Ovarian Torsion
   5. Associated Symptoms: Urologic
      1. Urinary frequency, urgency, hesitancy
         1. Urinary Tract Infection
      2. Dysuria
         1. Pelvic Inflammatory Disease
         2. Urinary Tract Infection
      3. Gross Hematuria
         1. Nephrolithiasis
         2. Urinary Tract Infection
   6. Associated Symptoms: Gynecologic
      1. Dysmenorrhea
         1. Endometriosis
         2. Uterine Fibroid
      2. Dyspareunia
         1. Endometriosis
         2. Ovarian Cyst
         3. Pelvic Inflammatory Disease
      3. Vaginal Bleeding
         1. Ectopic Pregnancy
         2. Miscarriage
         3. Uterine Fibroid
      4. Vaginal Discharge (especially mucopurulent)
         1. Pelvic Inflammatory Disease
4. Exam: Focal findings
   1. Peritoneal signs
      1. Pelvic Inflammatory Disease
      2. Appendicitis
   2. Hypotension
      1. Ectopic Pregnancy
   3. Cervical motion tenderness
      1. Pelvic Inflammatory Disease
   4. Adnexal Mass
      1. Ectopic Pregnancy
      2. Pelvic Inflammatory Disease
      3. Ovarian Cyst
      4. Uterine Fibroid
   5. Vaginal purulent discharge
      1. Pelvic Inflammatory Disease (PID)
5. Labs
   1. Complete Blood Count with differential
   2. Cervical swab for Gonorrhea and Chlamydia
   3. Cervical Gram Stain
   4. Urinalysis and Urine Culture
   5. Urine Pregnancy Test
6. Imaging
   1. Transvaginal Pelvic Ultrasound
   2. Consider other imaging in non-pregnant patient
      1. Flat and upright Abdomen
      2. CT Abdomen and Pelvis
7. Diagnosis: Critical Causes of Acute Pelvic Pain and their most suggestive findings
   1. Pelvic Inflammatory Disease
      1. Purulent endocervical discharge
      2. Abdominal rebound tenderness
   2. Ectopic Pregnancy
      1. Pelvic Ultrasound with any non-cystic, extraovarian Adnexal Mass
      2. bHCG <1,000 mIU
   3. Appendicitis
      1. Right Lower Quadrant Abdominal Pain
      2. Pain location transitions from periumbilical area to right lower quadrant
      3. Fever
      4. Psoas Sign
      5. Abdominal rebound tenderness
8. Evaluation
   1. Start with History, Exam and Labs as above
   2. Pregnancy Test positive
      1. Obtain trausvaginal Ultrasound and bHCG
      2. See Ectopic Pregnancy for protocol based on:
         1. Ultrasound findings
         2. bHCG discriminatory value of 1500 mIU
   3. Urinalysis suggestive of Urinary Tract Infection
      1. Urine Culture
      2. Treat as Urinary Tract Infection or Pyelonephritis
   4. Hematuria (not due to Vaginal Bleeding)
      1. CT Abdomen and Pelvis via stone protocol to evaluate for Nephrolithiasis
   5. Right Lower Quadrant Abdominal Pain
      1. Consult with general surgery
      2. Appendectomy without imaging for classic Appendicitis symptoms and signs
      3. CT Abdomen and Pelvis with IV contrast if diagnosis unclear
   6. Transvaginal Ultrasound to evaluate other conditions
      1. Findings suggestive of Pelvic Inflammatory Disease
         1. Evaluate for tuboovarian abscess
         2. Treat for Pelvic Inflammatory Disease if clinical findings suggest regardless of Ultrasound findings
      2. Pelvic mass on examination
      3. Suspected Ovarian Torsion
      4. Pelvic Pain not explained by alternative diagnoses (see Pelvic Pain causes)
9. References
   1. Cartwright (2008) Am Fam Physician 77(7): 971-8
   2. Kruszka (2010) Am Fam Physician 82(2): 141-7
   3. Vandermeer (2009) Clin Obstet Gynecol 52(1): 2-20