Acute Pelvic Pain
This is nearly always seen in women rather than men. In its mildest form it is experienced universally at some time or other associated with periods, ovulation or sexual intercourse. In its severest form it is the commonest reason for urgent laparoscopic examination in the UK.
- Acute Pelvic Inflammatory Disease (PID)
- Urinary Tract Infection (UTI)
- Ectopic Pregnancy
- Ovarian Cysts: Torsion, Rupture
- Pelvic Abscess (Appendix, PID)
- Pelvic Congestion (Exacerbation of Pelvic Pain Syndrome)
- Prostatitis (Men)
- Functional (Psychosexual origin)
- Misplaced IUCD (Perforated Uterus)
- Referred (e.g. Spinal Tumour, Bowel Spasm)
- Invasive Carcinoma of Ovaries or Cervix
- Fibroid Degeneration
- Strangulated Femoral or Inguinal Hernia
Key distinguishing features of the most common diagnoses
|Abnormal Vaginal Bleeding||Possible||No||Yes||Possible||No|
|Purulent Discharge PV||Yes||No||No||No||No|
|Tender Uterus PV||Yes||No||Possible||No||No|
Likely: HVS, cervical swab, urinalysis, MSU.
Possible: FBC, ESR/CRP, pregnancy test, ultrasound, laparoscopy (all usually arranged by hospital admitting team).
Small Print: None.
- Urinalysis: Look for nitrites and pus cells to make diagnosis of UTI
- MSU will confirm UTI and guide antibiotic treatment.
- HVS for bacteria including gonococcus and endocervical swab for Chlamydia if purulent discharge present
- ESR/CRP: Elevated in PID.
- Pregnancy test: Positive in ectopic and miscarriage
- FBC: Raised WCC helps confirm PID and UTI if not being admitted. Also elevated in pelvic abscess
- Urgent ultrasound helpful if miscarriage or ectopic pregnancy suspected.
- Cases referred to hospital are likely to undergo laparoscopy.
- In miscarriage, pain follows bleeding. In ectopic pregnancy, the sequence is usually reversed.
- Remember that there may be no bleeding with an ectopic pregnancy – or that the vaginal loss may be a light, blackish discharge.
- PV bleeding will cause haematuria on urinalysis. Only diagnose UTI if the symptoms are suggestive and urinalysis also shows nitrites and pus cells.
- Severe unilateral pain in very early pregnancy suggests ectopic pregnancy, even with no bleeding. Admit urgently.
- If PID does not settle within 48 hours of appropriate antibiotic treatment, consider abscess formation.
- Don’t forget to check femoral and inguinal canals for a possible strangulated hernia.