Pelvic pain: Acute

Published on 10/03/2015 by admin

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Last modified 22/04/2025

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Chapter 26 PELVIC PAIN: ACUTE

Acute pelvic pain is pain felt in the pelvic area for less than 48 hours. It can be difficult to make the diagnosis on the basis of history and physical examination alone, because acute pelvic pain can have gynecologic, obstetric, urologic, musculoskeletal, or gastrointestinal causes. When a patient with acute pelvic pain initially presents for evaluation, it is important to quickly determine whether the patient is pregnant and whether the patient has a surgical emergency.

Pelvic inflammatory disease should be considered as a cause in all patients who are sexually active. Aggressive diagnosis and appropriate treatment in adolescent patients are important in order to avoid the long-term sequelae of pelvic inflammatory disease, including infertility, chronic pelvic pain, and ectopic pregnancy. Ectopic pregnancy also should be considered in all sexually active patients with acute pelvic or abdominal pain.

Key Historical Features

• Fevers and chills, which may indicate infection

• Decreased appetite, which may indicate peritonitis

• Quality, onset, location, and duration of pain

• Increased thirst and weight loss, which may indicate diabetes

• History of recent trauma or assault

✓ Gynecologic

• Prior episodes of similar pain and association with menses

• Most recent normal menstrual period

• Vaginal discharge, which may indicate pelvic inflammatory disease

• Sexual history

• Prior surgery

• Prior sexually transmitted diseases (STDs)

• Previous pregnancies, including ectopic pregnancies

• Recent miscarriages or therapeutic abortions

• Contraceptive method, especially IUD

✓ Gastrointestinal

• Nausea and vomiting, which may indicate obstruction, appendicitis, gastroenteritis, or urinary tract stone

• Prior abdominal surgery, which increases the risk for bowel obstruction

• History of diverticulitis or findings of diverticular disease on prior colonoscopy

• Absence of bowel movements, which may indicate bowel obstruction

• Dysuria, hematuria, or urinary frequency or urgency, which may indicate a urinary tract infection; dysuria may also indicate a sexually transmitted disease

Key Physical Findings

✓ Vital signs, especially for signs of dehydration, sepsis, infection, or severe blood loss

✓ General appearance

✓ Gastrointestinal examination

• Inspection of the abdomen for distension, scars, or hernias

• Palpation of the abdomen for tenderness, guarding, or rebound, which may indicate peritonitis

• Palpation of the abdomen for masses

• Auscultation of the abdomen for bowel sounds, the absence of which may indicate peritonitis or obstruction

• Rectal examination to evaluate for rectal bleeding, masses, or tenderness

✓ Gynecologic examination

• Examination of the external genitalia for lesions or tenderness

• Single-finger vaginal examination for areas of tenderness

• Bimanual examination to examine the uterus and adnexa for tenderness, masses, or evidence of pregnancy

• Speculum examination to inspect the vaginal mucosa and cervix, especially for blood, discharge, or lesions and to determine whether the cervical os is open or closed

✓ Musculoskeletal examination

• Palpation of the back to evaluate for areas of tenderness

• Evaluation of the back for range of motion and any obvious masses or deformities

✓ Skin examination to evaluate for any skin lesions that may indicate shingles

Suggested Work-Up

Urine pregnancy test	To evaluate for pregnancy
Cervical culture/swab for Neisseria gonorrhoeae and Chlamydia trachomatis	To evaluate for gonorrhea and chlamydia infection
Complete blood cell count	To evaluate for infection or anemia
Chemistry panel	To evaluate for dehydration or acidosis
Urinalysis	To evaluate for urinary tract infection, urinary tract stones, or diabetic ketoacidosis

Additional Work-Up

Urine culture	If a urinary tract infection is suspected
Pelvic ultrasonography	If the patient is pregnant or gynecologic disease is suspected
Quantitative β–human chorionic gonadotropin measurement	If the urine pregnancy test yields positive results and an intrauterine pregnancy is not seen on ultrasonography
Blood culture	If sepsis is suspected
Computed tomographic (CT) scan of abdomen and pelvis	If the examination findings suggest appendicitis, diverticulitis, urinary tract stone, or abscess (pregnancy test should be performed before CT scanning is done)
Abdominal radiography	If bowel obstruction or urinary tract stone is suspected (pregnancy test should be performed first)
Blood typing and screening	If the patient is pregnant to evaluate whether patient is Rh negative

FURTHER READING

Baines PA, Allen GM. Pelvic pain and menstrual related illness. Emerg Med Clin North Am. 2001;19:763-780.

Hewitt GD, Brown RT. Acute and chronic pelvic pain in female adolescents. Med Clin North Am. 2000;84:1009-1025.

Samraj GPN, Curry RWJr. Acute pelvic pain: evaluation and management. Compr Ther. 2004;30:173-184.

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