29 - Acute Pelvic Pain

Abstract

Acute pelvic pain in women is often from a gynecologic source, but urinary and intra-abdominal sources are also common. Less frequently, the pain may arise from vascular, musculoskeletal, neurologic, or psychiatric sources. Potentially lethal diagnoses associated with acute pelvic pain include ectopic pregnancy, ovarian cyst with significant hemorrhage, and domestic violence; highly morbid conditions presenting with acute pelvic pain include pelvic inflammatory disease and ovarian torsion. Nearly all women of childbearing age with pelvic pain should have a pregnancy test performed, and most should have a pelvic ultrasound examination. Ectopic pregnancy should be excluded in the pregnant patient with pelvic pain. Bedside ultrasound is an excellent test for confirming an intrauterine pregnancy (IUP); it excludes ectopic pregnancy with a high degree of certainty in patients who are not using assisted reproductive technology. Pregnant patients with acute pelvic pain may also have non–pregnancy-related disorders; appendicitis, nephrolithiasis, and ovarian torsion, among others, remain in the differential diagnosis. Many patients with acute pelvic pain require imaging as part of their assessment. If a gynecologic source is suspected, begin with an ultrasound and then progress to computed tomography (CT) or magnetic resonance imaging (MRI), if needed. Ultrasound after normal CT is unlikely to be informative. Ovarian torsion may be radiographically occult.