Evaluation of 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