Acute Pelvic Pain




© Springer International Publishing Switzerland 2017
Bobby Desai and Alpa Desai (eds.)Primary Care for Emergency Physicians10.1007/978-3-319-44360-7_20


20. Acute Pelvic Pain



Joshua Gordon , Bobby Desai  and Alpa Desai 


(1)
Emergency Medicine, UF Health Shands Hospital, Gainesville, FL 32610, USA

(2)
Community Health and Family Medicine, University of Florida, Newberry, FL, USA

 



 

Joshua Gordon (Corresponding author)



 

Bobby Desai



 

Alpa Desai



Keywords
VaginaOvariesPainPelvic painVulva



20.1 Introduction


Acute pelvic pain is commonly defined as pain in the pelvis or lower abdomen lasting less than 3 months [1]. Pelvic pain is a common complaint, and it is estimated that approximately one in seven women of reproductive age will be evaluated for pelvic pain [2]. The workup and diagnosis of acute pelvic pain can be challenging, because signs and symptoms are often nonspecific and insensitive. Also, the clinical presentation of each cause of pelvic pain may vary from patient to patient. Therefore, an effort must be made to keep a broad differential diagnosis when assessing patients with acute pelvic pain in order to consider both common causes, such as urinary tract infections and cervicitis, and also uncommon causes, such as heterotopic pregnancy and mesenteric adenitis. It is critical to quickly identify emergent conditions of acute pelvic pain such as ectopic pregnancy, ovarian torsion, and appendiceal perforation. The consequences of missing these diagnoses are high and may result in infertility or death.


20.2 Differential Diagnosis


The differential diagnosis of acute pelvic pain is vast and includes pathology from a wide variety of organ systems. The differential diagnosis of pelvic pain also varies with respect to the patient’s age. Therefore, when constructing a differential diagnosis for acute pelvic pain, it can be helpful to categorize conditions based on pregnancy status, organ systems, and the patient’s age.


20.2.1 Obstetric






  • Ectopic pregnancy


  • Abortion



    • Threatened


    • Inevitable


    • Incomplete


    • Complete


    • Missed


    • Septic


  • Normal labor


  • Preterm labor


  • Placental abruption


  • Uterine abruption


  • Incarcerated gravid uterus


  • Postpartum endometritis


  • Ovarian vein thrombosis


  • Pubic symphysis separation


  • Fertility treatment related



    • Heterotopic pregnancy


    • Ovarian hyperstimulation syndrome


20.2.2 Gynecologic (Reproductive Age)






  • Vulva and vagina



    • Bartholin gland cyst/abscess


    • Vulvovaginitis



      • Bacterial vaginosis


      • Candida vaginitis


      • Trichomonas


      • Contact vaginitis


    • Imperforate hymen


    • Transverse vaginal septum


    • Vaginismus


  • Cervix and uterus



    • Cervicitis


    • Endometriosis


    • Adenomyosis


    • Post-procedure endometritis


    • Intrauterine device (IUD) perforation


    • Leiomyoma


  • Fallopian tube and ovary



    • Pelvic inflammatory disease


    • Salpingitis


    • Tubo-ovarian abscess


    • Ruptured ovarian cyst


    • Corpus luteum cyst


    • Ovarian torsion


    • Round ligament mass



      • Lipoma


      • Teratoma


  • Endocrine



    • Primary dysmenorrhea


    • Mittelschmerz


20.2.3 Gynecologic (postmenopausal)






  • Malignancy



    • Uterine


    • Ovarian


    • Endometrial


  • Atrophic vaginitis


  • Uterine prolapse


  • Uterine fibroids


20.2.4 Gastrointestinal






  • Appendicitis


  • Diverticulitis


  • Inflammatory bowel disease


  • Mesenteric ischemia


  • Irritable bowel syndrome


  • Bowel obstruction


  • Inguinal hernia


  • Perirectal abscess


  • Mesenteric adenitis


20.2.4.1 Genitourinary






  • Cystitis


  • Pyelonephritis


  • Urolithiasis


  • Interstitial cystitis


  • Urethral diverticulum


  • Urinary retention


20.2.5 Others






  • Abdominal aortic aneurysm


  • Aortic dissection


  • Lead poisoning


  • Abdominal wall pain


  • Porphyria


  • Sickle cell crisis


  • Malingering


  • Somatization disorder


  • Idiopathic


20.3 History


A thorough history and physical examination is essential to the diagnosis of acute pelvic pain in the emergency department. Eliciting specific information about the patient’s clinical situation and correlating that information with the patient’s physical examination allow a physician to choose the appropriate laboratory testing and imaging modalities in order to identify the cause of that patient’s pain.

Important historical features to elicit include:



  • Location of pain



    • Where is the pain located?



      • Right-sided pelvic pain can be suggestive of conditions such as appendicitis.


      • Left-sided pelvic pain can be suggestive of conditions such as diverticulitis.



        • Beware that some conditions can present as either right- or left-sided pelvic pain, such as ovarian torsion, tubo-ovarian abscess, or ectopic pregnancy.


      • Suprapubic pain can be suggestive of conditions such as cystitis.


  • Radiation of pain



    • Where does the pain radiate?



      • Pain that radiates to the groin can be suggestive of urolithiasis or ovarian torsion.


      • Pain that radiates to the back can be suggestive of aortic dissection.


      • Many conditions have pain that does not radiate.


  • Quality of pain



    • What does the pain feel like? (pressure, sharp, crampy, burning, colicky, etc.)



      • Burning pain can be suggestive of cystitis.


      • Colicky pain can be suggestive of urolithiasis.


  • Onset of pain



    • How long has the patient had the pain?


    • What was the patient doing when the pain first began?


    • Was the pain gradual or sudden in onset?


    • Since the pain began, has it gotten better, worse, or stayed the same?


  • Timing/frequency of pain

Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Acute Pelvic Pain

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