This post is part of a series called “Cardinal Presentations”, based on Rosen’s Emergency Medicine (8th edition).
Evaluation of Acute Pelvic Pain
Key Historical Findings
- 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 to rectum suggests pooling of fluid or blood in cul-de-sac
- 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.
- 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.
- WikEM: Pelvic pain