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
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.
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:
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.