Acute Pelvic Pain

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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