Overview
Pelvic pain of sudden onset. Of women of reproductive age it is a ectopic pregnancy until proven otherwise. Refer immediately to gynaecology all patients with a pelvic mass, abnormal cervix, or persistent bleeding.
| Definition Chronic pelvic pain (CPP): refers to pain of at least six months’ duration that occurs below the umbilicus and is severe enough to cause functional disability or require treatment. Acute pelvic pain: generally defined as pain in the lower abdomen or pelvis lasting less than three months. In women, it can pose a challenging clinical scenario in which history and physical examination findings are often nonspecific, and the clinical presentation of each condition can vary widely. |
Differential Diagnosis
Acute pelvic pain – Gyaenacological
- Ectopic pregnancy
- Miscarriage
- Ovarian cyst rupture
- Ovarian torsion
- Ovarian haemorrhage
- Fallopian torsion
- Endometritis
- Pelvic Inflammatory Disease
- Mittelschmerz
Acute Pelvic Pain – Non-Gyaenacological
- Appendicitis
- Urinary stones
- Urinary Tract infection
| Remember In a pregnant woman these differential will be different as the pain might be due to the obstetric complications. |
| Side note In Adolescents don’t forget transverse vaginal septum and imperforate hymen. |
| Think In postmenopausal women who present with acute pelvice pain, ectopic pregngnacy and ovarian torsion is unlikely. |
Chronic Pelvic Pain will be discussed elsewhere
More info on Chronic Pelvic Pain
| DIFFERENTIAL DIAGNOSIS OF ACUTE PELVIC PAIN | ||
| Condition | History | Examination |
| Ectopic Pregnancy | Nausea, vaginal bleeding | Adnexal mass, hypotension |
| Miscarriage | vaginal bleeding | |
| Ovarian torsion | Nausea, vomiting, radiation of pain to groin, right sided or left sided pelvic pain | |
| Ovarian cyst | Dyspareunia, left sided pelvic pain, Hypotension (ruptured left cyst) | Adnexal mass |
| Endometriosis/endometritis | Dysmenorrhoea, Dyspareunia | Adnexal mass |
| Pelvic inflammatory disease | Bilateral pelvic pain, Dysuria, Vaginal Discharge | Adnexal mass, bilateral adominal examination, cervical motion, uterine or adnexal tenderness, Fever, vaginal discharge |
| Appendicits | Nausea, vomiting, pain migration from periumbilical to RLQ of abdomen | Fever, RLQ pain |
| Urinary tract infection | Dysuria, Gross haematuria, Urinary Frequency | Fever |
| Urinary stones | left sided pelvic pain, Gross haematuria, radiation of pain to groin | |
| Think Life threatening causes of pelvic pain are ectopic pregnancy, ruptured ovarian cyst, ovarian torsion, appendicits and PID. |
Evaluation and Approach
- History
- Examination
- Psychological Assessment
- Investigations
- β-hCG
- FBC, group and save – if ectopic suspected
- ESR/ CRP
- Urinary/serum hCG
- MSU
- Triple swabs – STI?
- Pelvic USS
- Abdominal X-ray
- CT
- MRI
- Diagnostic laprosocopy
| Remember β-hCG to rule out pregnancy. |
Discussion