Pocket ObGyn – Acute Pelvic Pain
See Abbreviations
Definitions and Epidemiology (Natl Health Stat Report 2010;6:1)
- Lower abdominal or pelvic pain present for <7 Most common presenting complaint & primary dx for women of ages 15–64 who are seen in the ER.
| Causes of pelvic pain | |
| OBGYN causes of acute pelvic pain | Other causes of acute pelvic pain |
| Dysmenorrhea Ectopic Preg Spont miscarriage
Ovarian tumor or cyst Ovarian torsion PID TOA Degenerating leiomyoma Herpes simplex virus, chancroid Bartholin duct cyst or abscess |
Gastro Appendicitis Small bowel obst Sev constip Hernia Diverticulitis Nephrolithiasis Pyelonephritis Cystitis |
| From Flasar MH, Cross R, Goldberg E. Acute abdominal pain. Prim Care. 2006;33(3):659. | |
Pathophysiology and Clinical Manifestations (Prim Care 2006;33:659)
- Visceral pain: Stretch, distention, torsion, or contraction of abdominal organs is detected by autonomic, afferent nociceptors ® “slow,” C-fibers relay the signal to the CNS ® pain is usually midline or bilateral, poorly localized, dull, achy, or
- Parietal pain: Direct irritation of the peritoneal lining is detected by somatic, afferent nociceptors ® “fast,” A-delta fibers relay the signal ® pain is unilateral, localized,
- Referred pain: Visceral nerve afferents carrying stimuli from a diseased organ enter the spinal cord at the same level as somatic afferents from a remote anatomic Eg, free fluid in the abd can irritate the diaphragm causing referred pain in the shoulder.
Physical Exam
- Fever, tachy, HoTN ® expedite w/u, concern for sepsis/infxn, intra-abdominal bleeding (eg, ruptured ectopic Preg, hemorrhagic ovarian cyst), ovarian torsion,
- Abdominal exam: Note prior surgical scars, distention, hyperactive or high- pitched bowel sounds, rebound, guarding, Palpate 4 quadrants.
- Pelvic exam: Note swelling, erythema, lesions, bleeding, discharge, masses, nodularity, cervical motion tenderness, or
Diagnostic Workup and Studies
- Labs: Urine or serum beta hCG (on every reproductive age woman in the ER), CBC, urinalysis & culture, vaginal wet prep, gonorrhea & chlamydia PCR
- Imaging: Transabdominal US or TVUS
- Culdocentesis: Rarely Aspiration of fluid from the post cul de sac. Considered in limited resource settings.
- Diagnostic laparoscopy: Consider for the unstable pt w/ abdominal
- Rx & medications depend on dx (see other sections, below).