Acute Pelvic Pain
last authored: July 2011, Caitlin Thompson
last reviewed: Oct 2011, Catherine Andrus
Introduction
Abdominal and pelvic pain is a common complaint in Emergency Rooms. In women, the diagnosis can be particularly difficult because of the variety of sources of pain. Causes range from benign to life-threatening so it is important that the proper history, physical examination and investigations be done to identify the more serious causes.
The Case of A Jones
A. Jones is a 30 year old female who presents to the Emergency Room with a two day history of lower abdominal pain. She describes the pain as a crampy feeling that has got worse over the last 24 hours to the point of being unbearable. The pain is equal in her right and left sides and does not radiate. She does state she had an episode of painful intercourse about 4 days ago. She states that she has never felt this pain before. A. Jones admits to having multiple sexual partners and has had one episode of gonorrhea 5 years ago for which she was treated appropriately with antibiotics. She states that she tries to use condoms for birth control but that this does not always happen. Her last menstrual period was approximately 26 days ago and that her cycles are regular and last 29 days. She has never been pregnant. Her medical and surgerical history are insignificant.
- What other information do you want to know about her pain?
- What are some possible causes for her pain?
- What sort of features are you looking for in the history and physical?
Differential Diagnosis
Pregnant
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Non-Pregnant Uterine:
Adenexal
Infectious:
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Non-gynecologic
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History and Physical Exam
- history
- physical exam
History
History of Presenting Illness
Is this a new pain?
Description of the Pain: OPQRST
- onset of pain
- events Precipitating, what makes the pain better or worse
- quality of pain (dull, sharp, ache, crampy, colicky)
- radiation (to back? groin?) and location (unilateral, bilateral)
- severity (rate out of 10, 10 being the worst pain imaginable)
- timing of pain
Associated symptoms: do a Review of Systems, particularly looking for:
- change in bowel habits: constipation, diarrhea, bleeding, pain
- bladder changes: dysuria, urgency, frequency, bleeding
- vaginal bleeding, vaginal discharge, dysmenorrhea, amenorrhea, dyspareunia
- nausea, vomiting, anorexia
Gynecologic and Obstetrical History
- last menstrual period
- description of menstrual cycles (regular, irregular, duration, volume of flow)
- contraception
- sexual history, history of sexually transmitted infections
- last pap smear and previous abnormalities
- previous pregnancies and their outcomes
Past Medical History/Past Surgical History
Medications
Allergies
Family History
Social History
Physical Exam
General appearance: do they look well? are they in a lot of pain? position?
Vital signs (fever, hypotension, tachycardia)
Abdominal exam
- inspect for scars, distension
- auscultate for high pitched bowel sounds (indicates obstruction)
- palpate for masses, rebound tenderness, rigidity or guarding
Pelvic exam
- should be performed in women of reproductive age
- on speculum exam, look for vaginal discharge, cervicitis, vaginal bleeding
- on bimanual exam, assess cervical motion tenderness, uterine size/position/masses, adenexal mass/tenderness
- CVA tenderness
Rectal exam: to further assess pelvic masses or look for rectal masses as a source of pain, look for blood
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
serum or urine Beta HCG
CBC, electrolytes, hematocrit if suspecting blood loss
urinalysis, urine culture
endocervical swab for gonorrhea/chlamydia
vaginal swab for infectious causes (bacterial vaginosis, trichomoniasis, etc)
stool culture as needed for diarrhea
Diagnostic Imaging
Ultrasound: transabdominal or transvaginal (to assess cysts, abscesses, leiomyomas, appendicitis, endometriosis, PID, incarcerated hernia, pregnancy)
Renal Ultrasound if suspecting renal calculi
Abdominal X-Ray if concerns regarding bowels
If concerned about torsion, colour doppler ultrasound to assess blood flow to the ovaries
CT not examination of choice for gynecologic organs - used if appendix not seen on ultrasound and concerned. MRI if concerns with mullerian abnormalities in young women and concerns on ultrasound.
Management
Pain: narcotics may be needed for severe pain
Nausea: Ondansetron, Metoclopramide, Promethazine
Specific treatments:
Infections: Antibiotics
- Aminoglycosides and fluorquinolones provide Gram Negative coverage
- Metronidazole or Clindamycin cover anaerobes
- Cephalosporins provide Gram postive coverage
Combining two or all of them provides braod spectrum coverage for intra-abdominal coverage depending on the suspected source
Remember to always treat the partner with STIs
Laparoscopy/Laparotomy: appendicitis, ovarian torsion and ruptured tubal ectopic pregnancy/ruptured ovarian cyst with hemorrhage. Laparoscopy can also aid diagnosis if other diagnostic measures are unsucessful.
Ectopic pregnancies do not always require surgery and can be treated medically with methotrexate in appropriately selected patients
Pathophysiology
Visceral pain represents pain coming from serosal surfaces such as mesentery or the walls of hollow visercea (vagina, bladder, ureters, ovaries, fallopian tubes, uterus and associated blood vessels and lymphatics). This pain can be caused by distension of an organ capsule such as with a distended hemorrhagic ovarian cyst or obstructed ureter. Visceral pain is also caused by inflammation, ischemia, hemorrhage or neoplasm. Visceral pain is hard to localize to a particular source due to a low concentration of nociceptive nerve endings in the viscera. Referred pain is also a component of visercal pain and further complicates the picture. Referred pain is described as pain felt in a somatic area that is distant from the disease organ. It results from overlapping pathways within spinal segments for pelvic and abdominal viscera. True visceral pain is most commonly felt in the periumbilical area and is described as deep, dull, and poorly defined. Associated symptoms ofen include malaise, discomfort, nausea and vomitting, diarrhea and fever. An increased blood pressure and pallor are also observed.
Somatic pain comes from muscles, fascia, parietal peritoneum, subcutaneous tissue, bones and ligaments. Causes of somatic pain include muscle strain, inflammation, hernias and trauma. When the parietal peritoneum is inflammed, pain is felt via the somatic nerves from the inflammed area. This pain is described as steady and aching and increases with pressure on the affected area or movement. When provoked, this pain is sharp. Somatic pain is well localized to the affected area. Signs of somatic pain on physical exam include tenderness to palpation, involuntary guarding and rebound tenderness.
Resources and References
Canadian Guidelines on Sexually Transmitted Infections, 2006 Edition.
"Differential Diagnoses of Common Presentations: Pelvic Pain" The Toronto Notes 2010 26th Edition. Ed. Simon D. Baxter and Gordon G. McSheffrey. Toronto: 2010
Hall J. (2008) Chapter 50. Menstrual Disorders and Pelivic Pain. In Harrison's Principles of Internal Medicine., 17th Edition (Online). The McGraw-Hill Companies, Inc.
Howard, Fred. (2010) Evaluation of Actue Pelvic Pain in Women. Up To Date Onlin 19.2.
Lukens Thomas W, "Chapter 100. Abdominal and Pelvic Pain in the Nonpregnant Female" (Chapter). Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD:
Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e.
Topic Development
authors: Caitlin Thompson
reviewers: Catherine Andrus
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