II. Causes

III. History: General

  1. Menses
    1. Amenorrhea
      1. Pregnancy
      2. Imperforate Hymen
      3. Transverse vaginal septum
    2. Dysmenorrhea
      1. Endometriosis
      2. Ovarian Cyst
  2. Gastrointestinal and Urologic history
    1. See Acute Abdominal Pain history
    2. Multiple abdominal or pelvic surgeries
      1. Adenomyosis
      2. Pelvic adhesions
  3. Sexual History
    1. Sexually active
      1. Ectopic Pregnancy
      2. Spontaneous Abortion
    2. Sexually Transmitted Infection
      1. Pelvic Inflammatory Disease
    3. Fertility treatment
      1. Ovarian hyperstimulation syndrome
      2. Heterotopic pregnancy (rare)

V. Exam: Focal findings

  1. Fever
    1. Appendicitis
    2. Pelvic Inflammatory Disease or tubo-ovarian abscess
    3. Pyelonephritis
  2. Peritoneal signs or hemodynamic instability (surgical emergencies)
    1. Ruptured Appendicitis
    2. Ovarian Torsion
    3. Ruptured Ectopic Pregnancy
  3. Cervical motion tenderness
    1. Pelvic Inflammatory Disease
    2. Appendicitis (25% of Appendicitis cases)
    3. Ectopic Pregnancy (50% of ectopic cases)
  4. Adnexal Mass
    1. Ectopic Pregnancy
    2. Pelvic Inflammatory Disease and tubo-ovarian abscess
    3. Ovarian Cyst
    4. Uterine Fibroid
    5. Ovarian Cancer
  5. Mucopurulent Cervical Discharge
    1. Pelvic Inflammatory Disease (PID)

VI. Labs

  1. Complete Blood Count with differential
  2. Cervical swab for Gonorrhea and Chlamydia PCR
  3. Urinalysis and Urine Culture
  4. Urine Pregnancy Test
  5. C-Reactive Protein
    1. Not recommended due to non-specific, false positive which does not change management

VII. Imaging: Non-pregnant patients

  1. Transabdominal and Transvaginal Pelvic Ultrasound
    1. Ectopic Pregnancy
    2. Tubo-ovarian abscess
    3. Ruptured Ovarian Cyst
    4. Urolithiasis with Hydronephrosis
    5. Large Uterine Fibroids
    6. Ovarian Torsion
      1. Specify Ultrasound order to include doppler
      2. Positive Predictive Value of 94%, but false negatives occur due to dual arterial supply
    7. Appendicitis
      1. Variable efficacy (very operator dependent)
      2. Best in thin body habitus
      3. First-line imaging for Appendicitis in pregnancy, children and adolescents
  2. CT Abdomen and Pelvis with IV contrast (and oral water)
    1. Appendicitis
    2. Diverticulitis
    3. Urolithiasis (non-contrast CT Abdomen and Pelvis)
    4. Ischemic Colitis (or other colitis)
  3. Flat and upright Abdomen (not recommended in most cases)
    1. Minimal utility due to poor Specificity and other imaging is preferred
    2. May demonstrate a few findings that direct management
      1. Abominal free air
      2. Small Bowel Obstruction
      3. Excessive stool (non-specific and does not exclude more significant pathology)

VIII. Imaging: Pregnant patients

  1. Transabdominal and Transvaginal Pelvic Ultrasound (first-line)
    1. See above under non-pregnant patients
  2. MRI Abdomen and Pelvis (second-line)
    1. If MRI unavailable, CT Abdomen and Pelvis (low exposure technique) may be considered for serious findings
    2. Appendicitis
    3. Diverticulitis
    4. Urolithiasis
    5. Placental Abruption (if Ultrasound non-diagnostic)
    6. Large Uterine Fibroids
    7. Hemorrhagic Ovarian Cysts
    8. Inflammatory Bowel Disease

IX. Differential Diagnosis: Critical Causes of Acute Pelvic Pain and their most suggestive findings

  1. See Acute Pelvic Pain Causes
  2. Pelvic Inflammatory Disease
    1. Purulent endocervical discharge
    2. Abdominal Rebound Tenderness
    3. Cervical motion tenderness (does not distinguish PID from Appendicitis or Ectopic Pregnancy)
  3. Ectopic Pregnancy
    1. Pelvic Ultrasound with any non-cystic, extraovarian Adnexal Mass
    2. bHCG >1000 to 1500 mIU (or local discriminatory values)
  4. 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

X. 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. Consider Ultrasound for Hydronephrosis
    2. CT Abdomen and Pelvis via stone protocol to evaluate for Urolithiasis
  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 (Ultrasound or MRI if pregnant) 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)

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Ontology: Pelvic Pain (C0030794)

Definition (MSHCZE) Bolest v pánevní oblasti genitálního i negenitálního původu a organické nebo psychogenní etiologie. Častou příčinou bolesti jsou distenze nebo kontrakce dutinových vnitřních orgánů, náhlé natažení pouzdra pevného orgánu, chemické dráždění, tkáňová ischemie a neuritida jako následek zánětlivých, neoplastických nebo fibrotických procesů v okolních orgánech. (Kase, Weingold & Gershenson: Principles and Practice of Clinical Gynecology, 2. vydání, str. 479-508)
Definition (MEDLINEPLUS)

Pelvic pain occurs mostly in the lower abdomen area. The pain might be steady, or it might come and go. If the pain is severe, it might get in the way of your daily activities.

If you're a woman, you might feel a dull pain during your period. It could also happen during sex. Pelvic pain can be a sign that there is a problem with one of the organs in your pelvic area, such as the uterus, ovaries, fallopian tubes, cervix or vagina. It could also be a symptom of infection, or a problem with the urinary tract, lower intestines, rectum, muscle or bone. If you're a man, the cause is often a problem with the prostate.

You might have to undergo a lot of medical tests to find the cause of the pain. The treatment will depend on the cause, how bad the pain is and how often it occurs.

NIH: National Institute of Child Health and Human Development

Definition (NCI) Painful sensation in the pelvis.
Definition (NCI_CTCAE) A disorder characterized by marked discomfort sensation in the pelvis.
Definition (MSH) Pain in the pelvic region of genital and non-genital origin and of organic or psychogenic etiology. Frequent causes of pain are distension or contraction of hollow viscera, rapid stretching of the capsule of a solid organ, chemical irritation, tissue ischemia, and neuritis secondary to inflammatory, neoplastic, or fibrotic processes in adjacent organs. (Kase, Weingold & Gershenson: Principles and Practice of Clinical Gynecology, 2d ed, pp479-508)
Concepts Sign or Symptom (T184)
MSH D017699
SnomedCT 30473006, 207222001
English Pelvic Pains, PELVIC PAIN, Pain, Pelvic, Pains, Pelvic, [D] Pelvic pain, pelvic pain (symptom), pelvic pain, Pain pelvic, Pelvic pain NOS, Pelvic Pain [Disease/Finding], pain in pelvis, pelvic pains, pelvis pain, [D]Pelvic pain, Pelvis painful, Pelvic pain, Pain in pelvis, Pain in pelvis (finding), Pelvic pain, NOS, Pelvic Pain
French DOULEUR PELVIENNE, Douleur pelvienne SAI, Douleur pelvienne
Portuguese DOR PELVICA, Dor pélvica NE, Dor pélvica, Dor Pélvica
Dutch pijnlijk bekken, bekkenpijn NAO, bekkenpijn, Bekkenpijn, Pijn, bekken-
German Pelvisschmerz NNB, SCHMERZEN BECKENBODEN, Beckenschmerz, Beckenschmerzen
Italian Dolore pelvico NAS, Dolore pelvico
Spanish Dolor pélvico NEOM, [D]dolor pélvico, Dolor Pelviano, dolor pelviano, dolor pélvico (hallazgo), dolor pélvico, Dolor pélvico, Dolor Pélvico
Japanese 骨盤痛NOS, 骨盤痛, コツバンツウNOS, コツバンツウ
Swedish Bäckensmärta
Czech pánevní bolest, Pánevní bolest, Pánevní bolest NOS, pelipatie
Finnish Lantiokipu
Russian TAZOVYE BOLI, ТАЗОВЫЕ БОЛИ
Croatian Not Translated[Pelvic Pain]
Polish Ból miednicy
Hungarian Pelvikus fájdalom, Kismedencei fájdalom k.m.n., Kismedencei fájdalom
Norwegian Smerter i bekkenregionen, Underlivssmerter, Bekkensmerter, Bekken- og underlivssmerter

Ontology: Acute pelvic pain (C1282322)

Concepts Sign or Symptom (T184)
SnomedCT 314716005
English acute pelvic pain, acute pain pelvic, Acute pelvic pain (finding), Acute pelvic pain
Spanish dolor pélvico agudo (hallazgo), dolor pélvico agudo