Posted: September 6th, 2023

Acute pelvic pain

Acute pelvic pain is defined as pain of less than three months duration. Discuss a common diagnosis of acute pelvic pain in a woman of child-bearing years or a woman who is postmenopausal. How does a focused history and physical guide your work up? What labs/diagnostics would you consider? What are your differentials, including your must not miss diagnosis? Is a referral necessary based on your final diagnosis?

Acute pelvic pain in women of childbearing age or postmenopausal women can have various etiologies. One of the most common causes of acute pelvic pain in women of childbearing age is pelvic inflammatory disease (PID), while in postmenopausal women, a common cause is ovarian torsion.

A focused history and physical examination can help guide the workup for acute pelvic pain. The history should include questions regarding the onset and duration of the pain, its location, and any associated symptoms such as fever, vaginal discharge, or abnormal vaginal bleeding. A detailed gynecological history, including menstrual cycle regularity, sexual activity, contraceptive use, and past history of sexually transmitted infections (STIs), is also important. The physical exam should include a pelvic exam to assess for cervical motion tenderness, uterine or adnexal tenderness, and the presence of any masses or discharge.

Based on the history and physical examination, the following labs and diagnostics may be considered:

Urinalysis and urine culture to rule out a urinary tract infection
Complete blood count (CBC) to assess for leukocytosis, which may indicate infection
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to assess for inflammation
Pelvic ultrasound to assess for ovarian torsion, tubo-ovarian abscess, or other gynecological abnormalities
Endometrial biopsy to rule out endometrial cancer in postmenopausal women
The differential diagnosis for acute pelvic pain in women includes:

Pelvic inflammatory disease (PID)
Ovarian torsion
Endometriosis
Ectopic pregnancy
Ovarian cyst
Uterine fibroids
Adenomyosis
Urinary tract infection
Appendicitis
Gastrointestinal disorders
The must-not-miss diagnosis in acute pelvic pain is ectopic pregnancy, which can be life-threatening. Therefore, a pregnancy test should be performed in all women of reproductive age with acute pelvic pain.

Referral to a gynecologist may be necessary based on the final diagnosis. For example, patients with suspected ovarian torsion or tubo-ovarian abscess may require surgery, while patients with suspected endometriosis or uterine fibroids may benefit from medical management.

In conclusion, acute pelvic pain is a common complaint in women, and a thorough history and physical examination are important for guiding the workup. Labs and diagnostics should be selected based on the suspected diagnosis, and a must-not-miss diagnosis such as ectopic pregnancy should always be ruled out. Referral to a gynecologist may be necessary based on the final diagnosis.

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