Acute Pelvic Pain

Evaluation of Acute Pelvic Pain

Acute Pelvic Pain

Key Historical Findings

Location
Lateralized: suggests process related to tube or ovary, consider unilateral urinary tract process. On right, add appendicitis to differential; on left, add diverticulitis (particularly if age >40.
Central: suggests process involving uterus, bladder or bilateral adnexa
Diffuse: suggests PID
Radiation
Radiation to rectum suggests pooling of fluid or blood in cul-de-sac
Onset
Abrupt: suggests acute intrapelvic hemorrhage (from ruptured ectopic or ovarian cyst), ovarian torsion, urolithiasis
Gradual: inflammatory process such as PID
Chronic/recurrent: suggests endometriosis, recurrent ovarian cyst, ovarian mass
Associated Symptoms
Fevers/chills: suggests infectious process
Nausea/vomiting: suggests process involving gastrointestinal tract, though may accompany pregnancy or severe pain associated with ovarian torsion, urolithiasis.
Dysuria: suggests process involving urinary tract, though may be associated with local vulvar/vaginal process
Urinary urgency: more specific for bladder or urethral irritation
Obstetric History
History of recurrent spontaneous abortions or prior ectopic pregnancy increases likelihood of recurrence.
Ongoing fertility treatments increase likelihood for ectopic/heterotopic (occurs in 1:100 with assisted reproduction compared to 1:8000 in general population)
Vaginal Bleeding
In non-pregnant: suggests PID, DUB, cervical or uterine cancer
In early pregnancy: may be associated with ectopic pregnancy, non-viable IUP, or subchorionic hemorrhage
In late pregnancy: may be associated with placental pathology (previa, abruption)

Key Physical Findings

  • Pelvic examination: assists with localization of lateralized process. Should be preceded by ultrasound if >20 weeks.
  • Abnormal vaginal discharge: suggests vaginitis, cervicitis, PID, or retained foreign body.
  • Cervical motion tenderness: suggests reproductive tract inflammation or irritation of adjacent structures (appendicitis, cystitis)
  • Unilateral adnexal mass/tenderness: associated with ovarian cyst/mass, TOA, ectopic, or ovarian torsion.

References:

  1. Hart, D., & Lipsky, A. (2013). Acute Pelvic Pain in Women. In Rosen's Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 266-272). Elsevier Health Sciences.
  2. WikEM: Pelvic pain

Ectopic Pregnancy

HPI:

32F G8P7A2 at 5 weeks by LMP presenting with abdominal pain. The patient reports acute onset of sharp left lower abdominal pain 1.5 hours prior to presentation. The pain has been constant since onset, 10/10 in severity, radiating to lower back and exacerbated with movement. She denies vaginal bleeding or discharge, passage of clots or other products. She also denies trauma, lightheadedness/dizziness/syncope, shortness of breath, nausea/vomiting or changes in bowel or urinary habits.
Her pregnancy was detected 3 weeks ago with a home pregnancy test and was confirmed at her PCP one week later. She has not had an ultrasound during this pregnancy but has a history of uterine fibroids. She has no history of sexually transmitted infections, prior ectopic pregnancy, or use of assisted fertilization.

PMH:

  • HTN
  • Uterine fibroids

PSH:

None

FH:

Non-contributory

SHx:

  • Denies tobacco, alcohol or drug use.
  • Sexually active with husband only, no history of STI.

Meds:

None

Allergies:

NKDA

Physical Exam:

VS: T 37.4 HR 108 RR 36 BP 148/104 O2 99% RA
Gen: Alert and oriented female, appears uncomfortable due to pain.
HEENT: PERRL, EOMI, MMM.
CV: Tachycardia, regular rhythm, no murmurs.
Lungs: CTAB, no crackles.
Abd: Normoactive bowel sounds, tenderness to palpation in LLQ and suprapubic area, with guarding but no rebound tenderness. No CVAT.
GU: No external lesions. Closed cervical os, no blood or discharge, +CMT.
Ext: Warm, well-perfused with strong peripheral pulses.

Labs/Studies:

  • POC Hemoglobin: 11.8
  • POC ICON: positive

Imaging:

Bedside Ultrasound

  1. Transabdominal: Free fluid in hepatorenal and splenorenal recesses
  2. Transvaginal: Free fluid and debris in posterior cul-de-sac, likely pseudogestational sac in endometrial cavity, no IUP identified. Formal ultrasound revealed fetus with cardiac activity in left adnexa.
Hepatorenal free fluid

Hepatorenal free fluid

Free fluid in the hepatorenal recess (Morison's Pouch)

Splenorenal Free Fluid

Splenorenal Free Fluid

Free fluid in the splenorenal recess.

Pelvic Free Fluid

Pelvic Free Fluid

Free fluid and debris in the posterior cul-de-sac.

Pseudogestational Sac

Pseudogestational Sac

No obvious yolk sac or fetal pole.

Assessment/Plan:

32 year-old ICON positive female with acute-onset pelvic pain. The patient remained hemodynamically stable and absence of definitive IUP on bedside ultrasound was confirmed with presence of fetal cardiac activity in left adnexa indicative of ectopic pregnancy. OB-Gyn was consulted and the patient was taken emergently to the OR.

Differential Diagnosis of First Trimester Abdominal Pain: 1

Differential Diagnosis of 1st Trimester Abdominal Pain

Initial Evaluation of First Trimester Abdominal Pain: 1

  • 2 large-bore IV’s, begin fluid resuscitation
  • POC testing: hemoglobin, urine pregnancy
  • CBC, type and cross (Rh), serum B-hCG
  • Emergent bedside ultrasound

Features Associated with Ectopic Pregnancy: 1

  • History
    • PID
    • Tubal ligation
    • Prior ectopic
    • IUD
    • Assisted fertilization
  • Physical
    • CMT
    • Peritoneal irritation
  • Ultrasound
    • Empty uterus
    • Adnexal mass
    • Free fluid
  • Ultrasonographic Findings in the Evaluation of Ectopic Pregnancy: 2

    • Discriminatory hCG (1500-3000 mIU/mL): absence of IUP suggests ectopic or abnormal gestation
    • Normal IUP
      • 4-5wks: gestational sac (0.2-0.5cm)
      • 5wks: two echogenic rings
      • 5.5wks: yolk sac
      • 6wk: embryonic pole
      • 6.5wk: fetal cardiac activity
    • Abnormal IUP
      • >2cm gestational sac without fetal pole
      • CRL >0.5cm without cardiac activity
    • Ectopic
      • Extrauterine gestational sac with or without cardiac activity
      • Extrauterine ring sign
      • Non-homogenous adnexal mass

    Contraindications to Medical Management: 2,3

    • Absolute
      • Breast-feeding
      • Immunodeficiency
      • PUD
      • Pulmonary, hepatic or renal dysfunction
    • Relative
      • Ectopic mass > 3.5cm
      • Fetal cardiac activity

    References:

    1. Dart, R. (2003). First Trimester Emergencies A Practical Approach To Abdominal Pain And Vaginal Bleeding In Early Pregnancy. EB Medicine, 5(11), 1–20.
    2. Barnhart, K. T. (2009). Clinical practice. Ectopic pregnancy. The New England journal of medicine, 361(4), 379–387. doi:10.1056/NEJMcp0810384
    3. Jurkovic, D., & Wilkinson, H. (2011). Diagnosis and management of ectopic pregnancy. BMJ (Clinical research ed.), 342(jun10 1), d3397–d3397. doi:10.1136/bmj.d3397

    Acute Pelvic Pain

    Pelvic US - free fluidID:

    19yo G0, hCG negative, presenting with lower abdominal pain for 3 weeks.

    HPI:

    The patient states that she has had progressively worsening lower abdominal pain for the past three weeks. She describes the pain as constant, cramping, currently 8/10 in severity with radiation to the right flank. The pain is improved somewhat with ibuprofen and worsened with movement. She reports subjective F/C, some vaginal bleeding, but no other discharge and no dysuria. She is sexually active with one partner, using condoms occasionally. She has no significant PMH, no history of STI and a PSH of appendectomy. She denies any current or prior T/E/D use.

    PE:

    • VS: 110/60mmHg, 60bpm, 99.5°, 16/min
    • HEENT: NC/AT, PERRL, EOMI, MMM w/o lesions
    • CV: RRR, no M/G/R
    • Lungs: CTAB
    • Abd: +BS, soft, non-distended, TTP RLQ > LLQ, no rebound/guarding
    • Back: no CVAT
    • Pelvic: external genitalia normal, scant blood in vault, os closed, no discharge, + CMT, + uterine tenderness, + adnexal tenderness

    Labs/Imaging:

    • TVUS: normal appearing uterus/adnexa, possible free fluid (hemorrhagic vs. inflammatory) in pelvis
    • Wet mount: negative
    • Urine dip: -LE/nitrites, -protein, +blood

    Assessment:

    19yo G0, hCG negative, with pelvic pain and vaginal bleeding. Findings of lower abdominal tenderness, cervical motion/uterine/adnexal tenderness on examination, and low-grade fever are suggestive of PID. Other considerations include UTI, however, absence of dysuria, CVAT, and negative urine dip do not support this diagnosis. Will evaluate further with GC/CT, and treat empirically with ceftriaxone 250mg IM x1 and doxycycline 100mg PO BID x14d with follow-up in 48h.

    Differential Diagnosis of Acute Pelvic Pain:

    Common causes:

    • Gynecologic
      • PID, TOA
      • Neoplasm (torsion, rupture)
      • Leiomyoma (torsion, degeneration)
      • Endometriosis
      • Endometritis
      • Ectopic pregnancy
      • SAB
    • Obstetric
      • Labor
      • Uterine rupture
      • Abruptio placentae
      • Diastasis symphesis pubis
    • Non-gynecologic
      • Appendicitis
      • Cystitis (UTI)
      • Diverticulitis
      • Urinary tract calculi
      • Abdominal wall trauma

     Location of pain:

    LocationOfPain

    ROS:

    • discharge + dyspareunia: PID
    • missed menses + cramping/bleeding: SAB, ectopic
    • anorexia, N/V: appendicitis, torsion

    A System for the Evaluation and Management of PID:

    • Pathogens: GC, CT, gardnerella, haemophilus
    • Evaluation:
      • Pelvic exam: CMT, uterine tenderness, adnexal tenderness, abnormal discharge, wet mount WBC’s
      • Labs: + GC/CT, ↑ ESR/CRP
      • VS: T > 101°
      • Imaging: thickened tubes, free pelvic fluid, TOA
    • Indications for admission:
      • Acute abdomen, toxic appearance, unstable VS
      • Pregnancy
      • Failed outpatient, can’t tolerate PO
      • TOA
    • Outpatient management:
      • Ceftriaxone 250mg IM x1
      • Doxycycline 100mg PO BID x14d
      • ± Metronidazole 500mg PO BID x14d

    References:

    1. Hacker and Moore’s essentials of obstetrics and gynecology. Philadelphia, PA: Saunders/Elsevier, 2010.
    2. CDC – Pelvic Inflammatory Disease – 2010 STD Treatment Guidelines: http://www.cdc.gov/std/treatment/2010/pid.htm

    3rd Trimester Bleeding

    ID:

    A 34yo G4P2011 at 32w3d by LMP = 2nd trimester ultrasound with a history of GDMA1 is BIB ambulance for vaginal bleeding.

    HPI:

    She states that she awoke at 0230 that morning noting significant vaginal bleeding. She denied any associated abdominal pain, uterine contractions, leakage of fluid or other vaginal discharge and has continued to note fetal movement. Her current pregnancy has been uncomplicated though she reports mention of a “low placenta”.

    PE:

    • VS: 115/80mmHg, 90bpm, 98.1°, 18/min, 99%
    • Gen: Appears distressed
    • HEENT: PERRL, EOMI, MMM, no conjunctival pallor
    • CV: RRR, no M/R/G, Lungs: CTAB
    • Abdomen: gravid (FH 30cm), +BS, NT, no rebound/guarding
    • SSE: os closed, no motion tenderness, several large clots removed from vault

    Imaging/Studies:

    • NST: baseline 140bpm, moderate variability, accelerations, no decelerations
    • U/S: AFI 10.6, placenta entirely covering internal os

    Assessment & Plan:

    34yo G4P2011 at 32w3d by L=2 with complete placenta previa confirmed by TVUS presenting with first episode of vaginal bleeding.

    Differential Diagnosis of 3rd Trimester Bleeding:

    References:

    1. Sakornbut, E., Leeman, L., & Fontaine, P. (2007). Late pregnancy bleeding. American family physician, 75(8), 1199–1206.