Ver el código de «Pelvic pain»

{{AdultPage|Prepubertal pelvic pain}}
==Background==
*This page outlines the general approach to pelvic pain in the emergency department
*Pelvic pain is a common ED complaint, particularly in women of reproductive age
*Must always consider pregnancy-related emergencies ([[ectopic pregnancy]], [[miscarriage]]) as potential life-threatening etiologies
*Other emergent causes include [[ovarian torsion]], [[testicular torsion]], and [[ruptured ovarian cyst]] with hemorrhage
{{Abdominal pain location}}
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]]

==Clinical Features==
===Red Flags===
*Hemodynamic instability (consider ruptured [[ectopic pregnancy]], hemorrhagic cyst, ruptured AAA)
*Peritoneal signs (rebound, guarding, rigidity)
*Fever with pelvic pain (consider [[tubo-ovarian abscess]], [[pelvic inflammatory disease|PID]], or other pelvic abscess)
*Positive pregnancy test with pain (ectopic until proven otherwise)
*Acute onset severe unilateral pain (consider [[ovarian torsion]] or [[testicular torsion]])

===History===
*Onset, duration, character, location, radiation, severity
*Menstrual history: LMP, regularity, abnormal bleeding
*Sexual history: activity, contraception, STI risk factors
*Obstetric history: prior pregnancies, ectopics
*Associated symptoms: vaginal bleeding/discharge, urinary symptoms, GI symptoms, fever
*Surgical history: prior pelvic/abdominal surgeries

===Physical Exam===
*Abdominal exam: tenderness, distension, peritoneal signs
*Pelvic exam: cervical motion tenderness, adnexal tenderness/masses, vaginal discharge/bleeding
*Consider rectal exam if indicated
*Testicular exam in males with lower pelvic/groin complaints

==Differential Diagnosis==
{{Pelvic pain DDX}}
{{Postmenopausal Pelvic Pain DDX}}

==Evaluation==
===Immediate===
*Urine pregnancy test (mandatory in all women of reproductive age)
*Point-of-care ultrasound ([[POCUS]]) if hemodynamically unstable or concern for ectopic, free fluid, or torsion

===Laboratory===
*[[CBC]], [[BMP]]
*[[Urinalysis]], urine culture
*Quantitative beta-hCG if pregnancy test positive
*Gonorrhea/chlamydia testing (NAAT) if concern for [[PID]] or STI
*[[ESR]]/[[CRP]] if concern for inflammatory process
*Type and screen if significant bleeding or concern for ectopic

===Imaging===
*Transvaginal ultrasound is the primary imaging modality for pelvic pain
**Evaluate for intrauterine pregnancy, ectopic pregnancy, ovarian cyst/torsion, free fluid
*[[CT abdomen pelvis]] if broad differential or concern for appendicitis, diverticulitis, or abscess
*Consider [[MRI]] for suspected ovarian torsion with nondiagnostic ultrasound (especially in pregnancy)

==Management==
===General===
*IV access, fluid resuscitation if hemodynamically unstable
*Analgesia: [[ketorolac]] (if not pregnant), [[acetaminophen]], opioids for severe pain
*Antiemetics as needed

===Condition-Specific===
*[[Ectopic pregnancy]]: emergent OB/GYN consultation, may require surgical intervention or methotrexate
*[[Ovarian torsion]]: emergent GYN consultation for surgical detorsion
*[[Ruptured ovarian cyst]]: pain control, hemodynamic monitoring; GYN consult if hemorrhagic
*[[Pelvic inflammatory disease]]: antibiotics per CDC guidelines (see [[PID]] page)
*[[Tubo-ovarian abscess]]: IV antibiotics, GYN consultation, possible drainage
*[[Endometriosis]]: NSAIDs, hormonal management, GYN follow-up
*[[Kidney stones|Nephrolithiasis]]: pain control, hydration (see [[Flank pain]])

==Disposition==
===Admit===
*Hemodynamic instability
*Ectopic pregnancy requiring intervention
*Ovarian torsion (to OR)
*Tubo-ovarian abscess
*Intractable pain or vomiting
*Sepsis from pelvic source

===Discharge===
*Stable patients with benign diagnosis (functional cyst, PID without TOA, mittelschmerz)
*Clear return precautions: worsening pain, fever, heavy bleeding, syncope
*Ensure appropriate follow-up (OB/GYN within 48-72 hours for PID)
*Ectopic precautions in early pregnancy with pregnancy of unknown location

==See Also==
*[[Prepubertal pelvic pain]]
*[[Abdominal Pain]]
*[[Ectopic pregnancy]]
*[[Ovarian torsion]]
*[[Pelvic inflammatory disease]]
*[[Vaginal bleeding]]

==External Links==
*[http://ddxof.com/acute-pelvic-pain-2/ DDxOf: Differential Diagnosis of Acute Pelvic Pain]

==References==
<references/>

[[Category:OBGYN]]
[[Category:Symptoms]]