Pelvic pain

This page is for adult patients. For pediatric patients, see: 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

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.

Chart of commonly reported referred pain sites.

RUQ pain	Epigastric pain	LUQ pain
Flank pain	Diffuse abdominal pain	Flank pain
RLQ pain	Pelvic pain	LLQ pain

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, 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

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervical Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Postmenopausal Pelvic Pain

Gynecologic

• Vulvovaginitis
  • Atrophic vaginitis
  • Infectious (STI)
  • Allergic
• Uterine prolapse
  • Cystocele
  • Rectocele
  • Enterocele
  • Uterine/Vaginal Vault Prolapse
• Cervical polyps
• Uterine fibroids
• Endometrial hyperplasia
• Neoplasm
  • Uterine
  • Ovarian

Gastrointestinal

• Rectocele
• Diverticulitis
• Neoplasm
• Appendicitis
• Ischemic Bowel (Mesenteric Ischemia)

Urologic

• Infection
  • Cystitis
  • Urethritis
  • Pyelonephritis
• Cystourethrocele

Prepubescent-Urethral prolapse

Urologic

• Sarcoma botryoides

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
• 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

• DDxOf: Differential Diagnosis of Acute Pelvic Pain