Acute Pelvic Pain

Differential Diagnosis

Common Diagnoses

Rare Diagnoses

  • Misplaced IUCD (Perforated Uterus)
  • Referred (e.g. Spinal Tumour, Bowel Spasm)
  • Proctitis
  • Invasive Carcinoma of Ovaries or Cervix
  • Fibroid Degeneration
  • Strangulated Femoral or Inguinal Hernia

Ready Reckoner

Key distinguishing features of the most common diagnoses

PIDUTIMiscarriage EctopicOvarian Cyst
Abnormal Vaginal Bleeding PossibleNoYes PossibleNo
Purulent Discharge PVYesNoNoNoNo
Palpable MassNoNo PossibleNo Possible
Tender Uterus PVYesNo PossibleNoNo

Possible Investigations

Likely:HVS, cervical swab, urinalysis, MSU, pregnancy test.

Possible:FBC, ESR/CRP, 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 may undergo laparoscopy.

Top Tips

  • 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.

Red Flags

  • 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.
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