Acute pelvic pain: clinical approach

Acute pelvic pain is identified as pain originating from the pelvic organs and structures that has persisted for less than three months. It represents a frequent gynecological issue that might necessitate immediate evaluation and intervention, such as in instances of a ruptured ectopic pregnancy or adnexal torsion. Other gynecologic causes of acute pelvic pain, generally less urgent, include early pregnancy loss, primary dysmenorrhea, endometriosis, adnexal masses, and pelvic inflammatory disease.

Furthermore, acute pelvic pain may result from intimate partner violence or assault. It can also stem from non-gynecologic sources, such as the gastrointestinal tract, urinary tract, or musculoskeletal system.

In the evaluation of a patient experiencing acute pelvic pain, the initial step is to determine their CABCDE to ascertain their stability. If the patient is unstable, the priorities are to control bleeding; stabilize the airway, breathing, and circulation; secure IV access; and monitor vital signs. Following this, conduct a focused history and physical examination, administer an hCG test to check for pregnancy, and perform a pelvic ultrasound. Employing a rapid bedside ultrasound may be crucial to prevent treatment delays.

If the hCG test results are positive, an ectopic pregnancy should be considered. The patient's history might include syncope and vaginal bleeding, and the physical examination could show signs of hypotension and tachycardia, along with abdominal tenderness, rebound pain, or guarding. If the ultrasound reveals no intrauterine pregnancy and possible free fluid or an adnexal mass, a ruptured ectopic pregnancy should be considered. An operative laparoscopy should be performed to confirm the diagnosis and stabilize the patient.

Conversely, if the hCG test is negative, consider other gynecologic emergencies like adnexal torsion, which can occur even during pregnancy. This condition is typically associated with an ovarian cyst and involves the twisting of an enlarged adnexa—which includes the ovary, fallopian tube, and supporting ligaments—cutting off blood flow to these structures. Symptoms might include a sudden onset of pelvic or abdominal pain, fever, nausea, and vomiting. The physical exam may reveal abdominal tenderness with rebound pain or guarding, and possibly a pelvic mass.

An ultrasound may display an enlarged adnexa, generally over 5 centimeters, and could show absent Doppler flow in the ovarian vessels and the whirlpool sign, indicating twisted arterial and venous flow. These signs suggest adnexal torsion. Proceed with an operative laparoscopy for both diagnosis and swift intervention to preserve ovarian function and fertility.

Now, turning to the assessment of stable patients:

Begin with a thorough history and physical examination, and perform an hCG test to determine pregnancy status. If the hCG is positive, explore potential pregnancy-related causes of acute pain.

Starting with ectopic pregnancy, the history may often involve unilateral pelvic pain and possibly vaginal bleeding. The patient might also have a history suggesting potential fallopian tube injury, such as previous pelvic inflammatory disease, tubal surgery, or an earlier ectopic pregnancy. The physical examination might show abdominal or pelvic tenderness, or tenderness of an adnexal mass.

Under these circumstances, consider an ectopic pregnancy. Proceed by obtaining a quantitative hCG and a pelvic ultrasound. If the hCG level exceeds 3,500 and the ultrasound does not show an intrauterine pregnancy, with or without an adnexal mass, then an ectopic pregnancy is likely.

Here's a key point to remember: if the hCG level reaches 3,500 or higher, an ultrasound should typically show signs of an intrauterine pregnancy. The absence of such findings at this hCG level strongly suggests an ectopic pregnancy.

If the hCG level is below 3,500, the situation could either represent a miscarriage or a normal early pregnancy. In these cases, it's crucial to closely monitor the patient with repeated hCG tests and ultrasounds.

Next, let's consider early pregnancy loss. Patients often describe midline pelvic pain, which may accompany cramping and vaginal bleeding. The physical examination might detect an open cervical os with bleeding and tissue passage. In cases of suspected early pregnancy loss, a pelvic ultrasound is essential. If it reveals signs of a nonviable intrauterine pregnancy, the diagnosis of early pregnancy loss is confirmed.

Here's an important clinical insight: a nonviable pregnancy on ultrasound may be indicated by a crown-rump length of 7 mm or more without cardiac activity, or a mean gestational sac diameter of 25 mm without an embryo.

Now, let’s discuss cases where the hCG test is negative, starting with primary dysmenorrhea. Patients often report cyclic pelvic pain that began between 6 to 12 months after menarche, accompanied by symptoms like nausea, vomiting, diarrhea, headaches, and muscle cramps. Physical examination might show mild abdominal or pelvic tenderness, but with a normal uterus and no adnexal masses. The diagnosis of primary dysmenorrhea hinges on the cyclic nature of the symptoms and the absence of other pelvic pathologies.

Another useful clinical pearl: a pelvic examination isn't always necessary for diagnosing primary dysmenorrhea, especially in adolescents. Initial management can include a trial period of medical therapy lasting 3 to 6 months; if symptoms persist, a pelvic examination and possibly an ultrasound should be considered to rule out other causes of the symptoms.

Moving on to endometriosis, patients may present with what's often described as the 4 "Ds": dysmenorrhea, dyspareunia, dyschezia, and dysuria. These symptoms might be cyclic or worsen during menstruation. A physical exam can show abdominal or pelvic tenderness and may reveal an abdominal or pelvic mass, restricted uterine mobility, tenderness in the posterior vaginal fornix, or rectovaginal nodularity.

In cases suggestive of endometriosis, consider conducting a pelvic ultrasound and potentially a diagnostic laparoscopy to confirm the diagnosis. Ultrasound findings may include an endometrioma, while laparoscopy might reveal endometriotic implants and scarring. Some clinicians might opt for a presumptive diagnosis based on history and physical examination alone to avoid the risks and costs associated with surgery.

Finally, for patients presenting with adnexal masses, history may include intermittent unilateral pain, abdominal distention, and pelvic pressure. The physical exam may reveal abdominal or adnexal tenderness, or adnexal fullness.

In such scenarios, a pelvic ultrasound should be performed. If it identifies a cystic or solid adnexal mass, this supports the diagnosis of either a benign or malignant adnexal mass.

Here’s an essential clinical insight: The approach to diagnosing and managing adnexal masses is intricate and relies on various factors such as the patient's history, potential risk factors for malignancy, and ultrasound results. The differential diagnosis for adnexal masses is broad, including options like a simple ovarian cyst, endometrioma, cystadenoma, teratoma, hydrosalpinx, tubo-ovarian abscess, adnexal leiomyoma, or malignancy. Surgical evaluation becomes necessary in cases involving significant pain or when the mass appears complex and raises suspicion for malignancy.

Another prevalent cause of acute pelvic pain is a ruptured ovarian cyst. Typically, this occurs when a functional ovarian cyst forms after ovulation and subsequently ruptures, releasing its contents into the abdominal cavity, which irritates the peritoneum. Patients often describe experiencing a sudden onset of pain at the time of the rupture, though the pain usually subsides gradually over several days.

Next, let’s discuss pelvic inflammatory disease (PID). The history might include recent sexual activity and intermenstrual bleeding, along with symptoms like pelvic or abdominal pain, vaginal discharge, or fever.

During the physical examination, the presence of mucopurulent cervical discharge might be noted. A clinical diagnosis of PID can be made if the exam reveals pelvic tenderness, abdominal tenderness, or cervical motion tenderness. Although ancillary findings like an elevated white blood cell count or a positive test for cervical infection can increase diagnostic specificity, the clinical findings alone are sufficient for diagnosis.

Here’s a vital fact to remember: PID is frequently caused by sexually transmitted organisms such as gonorrhea, chlamydia, and mycoplasma. However, it can also be instigated by organisms commonly found in the vaginal flora.

Let’s also consider the possibility of intimate partner violence or assault. Patients may report experiences of physical or sexual violence, psychological or verbal abuse, or symptoms like depression or anxiety. Physical examination could reveal unexplained injuries, including bruises in concealed or unusual locations like the breasts, abdomen, or perineum. Patients may not readily disclose histories of assault or violence, making it crucial to ensure confidentiality and sensitivity during these discussions, and to ask partners or caregivers to step out to provide privacy.

After evaluating gynecologic causes of acute pelvic pain, it's important to also consider and assess for non-gynecologic causes. These might include conditions like appendicitis, diverticulitis, small bowel obstruction, urinary tract infection, interstitial cystitis, nephrolithiasis, and various musculoskeletal conditions.

To summarize:

Emergent causes of acute pelvic pain include:

- **Ruptured ectopic pregnancy:** This requires immediate attention as it can be life-threatening.

- **Adnexal torsion:** Also an emergency due to the risk of ovarian damage.

Other gynecologic causes include:

- **Early pregnancy loss:** Characterized by symptoms like pelvic pain, cramping, and vaginal bleeding.

- **Primary dysmenorrhea:** Commonly presents as painful menstrual cramps that may be accompanied by nausea, vomiting, and diarrhea.

- **Endometriosis:** Can cause cyclic pelvic pain, often exacerbated during menstruation.

- **Adnexal masses:** These could be benign or malignant, and might present with pelvic pain or pressure.

- **Pelvic inflammatory disease (PID):** Typically presents with pelvic or abdominal pain, possibly accompanied by fever, vaginal discharge, and other symptoms.

Non-gynecologic cause:

- **Intimate partner violence or assault:** This can lead to acute pelvic pain and other physical injuries, often requiring sensitive and confidential handling during assessment.

It's essential to evaluate these conditions promptly and accurately for appropriate management and treatment.

- - - - - - - END - - - - - - -

作者：Joy，

澳洲最佳高校非首席脑科学科学家/博导，

德国精英大学非精英医学博士，

欢迎合作让我们一起成为首席和精英：

MRYIXUEYANJIU666

请加上述微信进博士职位申请交流群，

欢迎前往公众号菜单栏查阅更多内容，

如常用科研技能集锦，

零基础入门R语言，

医学生申请出国读博教程，

GraphPad Prism使用教程，

Image J使用教程，

好书推荐（请加上述微信进购书/购物优惠群）。

http://mp.weixin.qq.com/s?__biz=MzUxMzQyMjM0NQ==&mid=2247487518&idx=1&sn=f9541608a3377c38fc41ea4f74986d31

医学研究笔记

医学博士分享医学与科研相关知识与经验，助力您的医学与科研。

最新文章

Diabetes in pregnancy: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Hypertensive disorders in pregnancy: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Gestational hypertension/preeclampsia/eclampsia/HELLP: clinical

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Congenital infections: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Lower urinary tract infection: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Pyelonephritis: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Nephrolithiasis: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Ovarian cyst

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

Pelvic inflammatory disease: clinical approach

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

零基础玩转GraphPad Prism教程，快速学会SCI统计作图

零基础入门R语言教程，快速玩转数据分析利器！

零基础入门R语言统计与作图教程，打造专业数据分析师！

医学生申请出国读博，一站式指南助你圆梦国际学术之旅！

如何使用GraphPad Prism进行单因素方差分析one-way ANOVA

分类

时事

民生

政务

教育

文化

科技

财富

体娱

健康

情感

旅行

百科

职场

楼市

企业

乐活

学术

汽车

时尚

创业

美食

幽默

美体

文摘

原创标签

时事社会财经军事教育体育科技汽车科学房产搞笑综艺明星音乐动漫游戏时尚健康旅游美食生活摄影宠物职场育儿情感小说曲艺文化历史三农文学娱乐电影视频图片新闻宗教电视剧纪录片广告创意壁纸头像心灵鸡汤星座命理教育培训艺术文化金融财经健康医疗美妆时尚餐饮美食母婴育儿社会新闻工业农业时事政治星座占卜幽默笑话独立短篇连载作品文化历史科技互联网

发布位置

广东北京山东江苏河南浙江山西福建河北上海四川陕西湖南安徽湖北内蒙古江西云南广西甘肃辽宁黑龙江贵州新疆重庆吉林天津海南青海宁夏西藏香港澳门台湾美国加拿大澳大利亚日本新加坡英国西班牙新西兰韩国泰国法国德国意大利缅甸菲律宾马来西亚越南荷兰柬埔寨俄罗斯巴西智利卢森堡芬兰瑞典比利时瑞士土耳其斐济挪威朝鲜尼日利亚阿根廷匈牙利爱尔兰印度老挝葡萄牙乌克兰印度尼西亚哈萨克斯坦塔吉克斯坦希腊南非蒙古奥地利肯尼亚加纳丹麦津巴布韦埃及坦桑尼亚捷克阿联酋安哥拉