Acute Pelvic Pain in Women

Michele Tartaglia, D.O.

Basic Information

Definition

Acute pelvic pain in women is defined as pain in either the pelvis or the bilateral lower quadrants of the abdomen that has been present less than 3 months and is usually sudden in onset.

Synonyms

Acute lower abdominal pain
Acute suprapubic pain

ICD 10-CM CODES
R10.2	Pelvic and perineal pain

Epidemiology & Demographics

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Acute pelvic pain occurs in women from adolescence through the postmenopausal period.

Peak Incidence

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Women of reproductive age report the greatest amount of acute pelvic pain.

Prevalence

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Acute pelvic pain is a very broad term with multiple etiologies, thus not lending itself to a single calculable prevalence. However, the prevalence of the most documented common causes in the U.S. include PID (2,500,000 cases per year), ovarian cysts (65,000 per year), and appendicitis (130,000 women per year).

Predominant Sex and Age

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Women of reproductive age report the greatest amount of acute pelvic pain.

Physical Findings & Clinical Presentation

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The history and physical examination are key to narrowing the diagnosis when a patient presents with acute pelvic pain.
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Standard thorough history-taking techniques should be employed, and the patient should be asked about location, onset, severity, radiation, exacerbating and alleviating factors, as well as the quality of the pain.
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Associated symptoms such as nausea, vomiting, anorexia, vaginal discharge, dyspareunia, dysuria, hematuria, urinary frequency, fever, recent upper respiratory infection (URI) symptoms, cyclic midcycle pelvic pain, or any missed or irregular menses should also be inquired about.
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A thorough sexual history should also be taken, including form of birth control used. Patients should also be asked about any history of ovarian cysts, uterine fibroids, recent pregnancies, or other pelvic infections.
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Physical exam is focused on the abdominal and pelvic exam.
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The pelvic exam includes vaginal speculum exam as well as bimanual and rectovaginal pelvic exam. During the speculum exam the patient is evaluated for any active vaginal bleeding, any vaginal or cervical discharge, and for any vulvar or vaginal lesions and masses.
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Testing for gonorrhea and chlamydia via nucleic acid probe should be collected.
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The bimanual and rectovaginal exams help elucidate the size and contour of the uterus, the presence of any adnexal masses or tenderness, and whether the patient has cervical motion tenderness.

Etiology

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Etiologies of acute pelvic pain are varied and depend on the age and pregnancy status of the patient. Please see differential diagnosis for further information.

Diagnosis

Differential Diagnosis

Gynecologic Causes

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Pelvic inflammatory disease
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Ruptured ovarian cyst
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Intact ovarian cyst (most pain from cysts >4-5 cm in size and hemorrhagic in nature)
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Ovarian torsion
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Degenerating or torsed uterine fibroid
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Mittelschmerz
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Tubo-ovarian abscess
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Endometriosis
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Dysmenorrhea

Pregnancy-Related Causes

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Miscarriage
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Ectopic pregnancy
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Postpartum endometritis

Nonobstetric or Gynecologic Causes

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Appendicitis
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Urinary tract infection
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Nephrolithiasis
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Diverticulitis
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Bowel obstruction
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Mesenteric lymphadenitis
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Inflammatory bowel disease
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Constipation
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Hernia
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Gastroenteritis
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Musculoskeletal dysfunction
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Trauma

Adolescent girls—most of above as well as:

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Imperforate hymen
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Transverse vaginal septum

Workup

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The workup of acute pelvic pain begins with a thorough history and physical exam, then targeted imaging and laboratory studies are ordered to further the diagnosis.

Laboratory Tests

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Pregnancy testing via urine or serum
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Rh typing if pregnancy test is positive
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Urinalysis
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Testing for vaginal infections including gonorrhea and chlamydia via direct nucleic acid probe
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Complete blood count (CBC)
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Erythrocyte sedimentation rate (ESR)
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First and foremost, one must determine the pregnancy status of the patient. The most common pregnancy-related causes of acute pelvic pain are ectopic pregnancy (approximately 1 in 7000 spontaneously conceived pregnancies and 1 in 100 pregnancies conceived via artificial reproduction) and spontaneous or threatened miscarriage. In both of these cases, the Rh status of the patient must be determined and RhoGAM administered if she is Rh negative.
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Urinalysis will assist with the diagnosis of both acute cystitis and nephrolithiasis and urine culture should be ordered as well when appropriate. Nucleic acid probes for gonorrhea and chlamydia are very sensitive and specific tests and should be collected on any patient with pelvic pain. CBC and ESR can be utilized in the patient with suspected gastrointestinal disease, appendicitis, and pelvic infection of any kind to help determine the severity of disease.

Imaging Studies

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Pelvic ultrasound is the primary imaging modality for acute pelvic pain in women that is suspected to be of gynecologic origin. Ultrasound can be used to diagnose intrauterine and ectopic pregnancy, uterine fibroids, adnexal masses, nephrolithiasis, and even appendicitis, thus assisting with the diagnosis of the vast majority of the differential diagnosis of acute pelvic pain in women. However, there are limitations to the test, such as the level of expertise of the individual sonographer and patient body habitus interfering with the quality of the images.
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In the case of the patient with nonfocal symptoms or an inconclusive ultrasound, computed tomography (CT) of the abdomen and pelvis can be performed. CT is highly useful in the patient with early pelvic inflammatory disease (PID) or tubo-ovarian abscess, as well as in the nonpregnant patient with appendicitis or other gastrointestinal pathology not seen on ultrasound.
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Magnetic resonance imaging (MRI) also plays a role when CT is unable to discern whether a mass in the pelvis is of uterine or adnexal origin such as with a degenerating fibroid or when one must further characterize an ovarian mass. MRI is also extremely helpful in the pregnant patient who presents with many signs and symptoms of appendicitis but has an inconclusive ultrasound result.

Treatment

Nonpharmacologic Therapy

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The underlying cause of acute pelvic pain cannot always be diagnosed with history, exam, laboratory, and imaging studies alone. In many cases, diagnostic laparoscopy is necessary to complete the diagnosis. In fact, even when the diagnosis seems sure, laparoscopy can reveal an entirely different finding as was illustrated in one study where just over half of women clinically diagnosed with appendicitis actually had the disease.
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The practitioner should not hesitate to take the patient with unstable vital signs and suspected intraabdominal bleeding or findings suggestive of ruptured appendix to the operating room. When one’s clinical suspicion is quite high for such diagnoses, laboratory data and imaging studies should be forgone to expedite getting the patient the surgical interventions she needs.

Acute General Rx

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The initial treatment of the woman with acute pelvic pain must be tailored to the underlying cause. However, as the workup is in progress, her pain must be managed. Although narcotic pain medications are sometimes initially necessary to control pain, nonsteroidal antiinflammatory drugs (NSAIDs) are the traditional first line pharmacotherapy for the patient with pelvic pain of an inflammatory nature. Such medications are highly useful in cases of endometriosis, dysmenorrhea, nonsurgical cases of ovarian masses and ruptured ovarian cysts, spontaneous miscarriage, nephrolithiasis, musculoskeletal dysfunction, and PID/tubo-ovarian abscess. Heat and ice can also be employed as needed for additional symptomatic relief in the appropriate patient.

Chronic Rx

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Once a diagnosis is made, treatment is based on the underlying cause of the pain. Most patients are managed on a combination of NSAID and narcotic pain medications for a short course until the pathology has resolved or after any surgical interventions. Antibiotic therapy is routinely included in the case of an infectious cause.

Referral

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Patients with pain lasting greater than 3 to 6 months should be seen by a specialist in the appropriate field—gynecology, gastroenterology, general surgery, or musculoskeletal medicine—for further workup and management of their now chronic pelvic pain. Referral should also be considered when the underlying cause of pain cannot be found.

Pearls & Considerations

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A solid knowledge of the differential diagnosis of acute pelvic pain in women and a thorough history and physical examination will lead the practitioner to the underlying cause in the vast majority of cases. But all women who present with acute pelvic pain MUST have a pregnancy test as a part of their initial workup. If imaging is needed, pelvic ultrasound is an excellent tool and should be utilized first before CT and MRI in most cases.

Ferri – Acute Pelvic Pain in Women