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Acute Pelvic Pain in Women

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Acute Pelvic Pain in Women, Acute Pelvic Pain, Pelvic Pain

  • See Also
  1. Acute Pelvic Pain Causes
  2. Chronic Pelvic Pain
  3. Chronic Pelvic Pain in Men
  4. Acute Abdominal Pain
  5. Acute Abdominal Pain Causes
  6. Suprapubic Abdominal Pain
  • Causes
  1. See Acute Pelvic Pain Causes
  2. No cause found in 8-37% of cases
  3. Most common and important causes
    1. Acute Appendicitis
    2. Pelvic Inflammatory Disease
    3. Ovarian Cyst
    4. Ectopic Pregnancy
    5. Endometriosis
    6. Ovarian Torsion
  1. Menses
    1. Last Menstrual Period, typical cycle length, number of days of bleeding, Menarche
    2. Amenorrhea
      1. Pregnancy
      2. Imperforate Hymen
      3. Transverse vaginal septum
    3. Dysmenorrhea
      1. Endometriosis
      2. Ovarian Cyst
    4. Midcycle Pain
      1. Mittelschmerz
  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
  4. Pregnancy History
    1. Contraception
    2. Prior pregnancies
    3. Fertility treatment
      1. Ovarian Hyperstimulation Syndrome
      2. Heterotopic Pregnancy (rare)
  • History
  • Pain
  1. Location
    1. Bilateral Pelvis
      1. Pelvic Inflammatory Disease
    2. Unilateral Pelvis
      1. Nephrolithiasis
      2. Ruptured Ovarian Cyst
      3. Ovarian Torsion
      4. Ectopic Pregnancy
      5. Diverticulitis (left Pelvis)
      6. Appendicitis (right Pelvis)
  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 or Urolithiasis
      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. EctopicVaginal Pregnancy
      2. Miscarriage
      3. Uterine Fibroid
    4. Vaginal Discharge
      1. Pelvic Inflammatory Disease
  • Exam
  • Focal findings
  1. Fever
    1. Acute 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. Acute Appendicitis (25% of Appendicitis cases)
    3. Ectopic Pregnancy (50% of ectopic cases)
  4. Adnexal Mass or pelvic mass
    1. Ectopic Pregnancy
    2. Pelvic Inflammatory Disease (Tubo-Ovarian Abscess)
    3. Ovarian Cyst
    4. Ovarian Torsion
    5. Uterine Fibroids
    6. Ovarian Cancer
  5. Mucopurulent Cervical Discharge
    1. Pelvic Inflammatory Disease (PID)
  6. Carnett Sign (Muscle wall tenderness)
    1. Abdominal Muscle Wall Pain
  • Labs
  1. Urine Pregnancy Test or serum Qualitative hCG
  2. Urinalysis and Urine Culture
  3. Complete Blood Count with differential
  4. Cervical swab for Gonorrhea and Chlamydia PCR
  5. Vaginal Discharge Testing or Wet Prep (Trichomonal Vaginitis, Bacterial Vaginosis, Yeast Vaginitis)
  6. C-Reactive Protein
    1. Not recommended due to non-specific, False Positive which does not change management
  • 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. Acute 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)
  • Imaging
  • Pregnancy
  1. Transabdominal and Transvaginal Pelvic Ultrasound (first-line)
    1. See above for 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
  • 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. Acute 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
  • 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)
  • References
  1. Bhavsar (2016) Am Fam Physician 93(1): 41-8 [PubMed]
  2. Cartwright (2008) Am Fam Physician 77(7): 971-8 [PubMed]
  3. Frasca (2023) Am Fam Physician 108(2): 175-80 [PubMed]
  4. Kruszka (2010) Am Fam Physician 82(2): 141-7 [PubMed]
  5. Vandermeer (2009) Clin Obstet Gynecol 52(1): 2-20 [PubMed]