Pelvic pain is a major source of concern and morbidity in women. Diagnosis and management of pelvic pain is one of the most frequently encountered clinic problems in the practice of primary care medicine, yet it can be one of the most difficult diagnostic challenges. Pelvic pain in women usually originates from the reproductive organs, but gastrointestinal or genitourinary disease must also be considered. The primary care physician should be able to distinguish pain of a functional nature from that due to infection or an anatomic lesion, and know when referral to the gynecologist or urgent hospital admission is indicated.

Important historical issues include the following:

Pain characteristics Onset (sudden, gradual) Location and radiation Duration Severity Character (constant, intermittent, crampy) Progression Any associated factors such as: Fever Chills Muscle aches Nausea Vomiting Change in appetite Change in bowel movements Urinary symptoms of frequency or pain Dizziness Shoulder pain and/or breast tenderness Factors which aggravate or improve the pain, such as Coughing Moving Eating Lying still Antacids

Prior history of: Similar pain Pelvic / abdominal surgery Cystitis Pyelonephritis Ovarian cyst Endometriosis PID Painful intercourse Menstrual cramps Pregnancy Recent exposure to: Possible STD Current menstrual history Cycle regularity Date of LMP Abnormal bleeding or spotting

 

Physical Examination
There are four aspects of the physical exam that are pertinent in the patient with pelvic pain.

Patient's general appearance
Determine if the patient is in obvious pain or looks septic, "shocky", diaphoretic, or pale.

An accurate measurement of vital signs
Hypotension and tachycardia suggest blood loss and hypovolemia. A positive tilt test (supine and upright blood pressure measurements) which consists of a systolic blood pressure drop of 10 millimeters of mercury or greater and a pulse rate increase of 30 beats or greater is a tool to access volume status. Also check temperature, pulse ox, and capillary refill.

Abdominal exam
The primary value of the abdominal exam is to determine if there is evidence of peritonitis (tenderness, guarding, rebound, rigidity) or masses. Also check bowel sounds and assess whether flank tenderness exists.

Pelvic exam
When performing the pelvic exam, visualize the vagina and cervix. Note the presence of discharge, blood, or products of conception in the vaginal vault or cervical os. Next, perform a bimanual exam checking the bladder, urethra, adnexa, uterus, and finally the cervix. Pay particular attention to the appearance of the vaginal and cervical mucosa, the presence of any exudate, the patency of the internal cervical os, the size and shape of the uterus, the presence of adnexal masses and of course, the elicitation of uterine, adnexal, or cervical motion tenderness.

There are four basic laboratory tests that are helpful for the primary care physician to assess the patient with pelvic pain: CBC, beta HCG, urinalysis, and bacteriological studies. An elevated white blood cell count greater than 12,000 suggests infection in a patient suspected of having a pelvic infection or appendicitis. A hematocrit of less than 30 suggests bleeding or an iron deficiency anemia, although the hematocrit may be normal in acute blood loss. The purpose of urinalysis is primarily to rule out a urinary tract infection. A pregnancy test should be ordered in any patient of reproductive age with pelvic pain. Finally, standard bacteriological studies (gram stain, bacteria, and chlamydia cultures) are generally indicated if the patient is suspected of harboring a pelvic infection.

The differential diagnosis of pelvic pain can be divided into four categories: pelvic infections, complications of pregnancy, adnexal accidents, and other causes of pelvic pain. Pelvic infections include pelvic inflammatory disease (salpingitis), tubo-ovarian abscess, endometritis, and the Fitz-Hugh-Curtis syndrome (a complication of PID consisting of right upper quadrant abdominal pain secondary to perihepatic adhesions usually due to dissemination of a pelvic infection). Complications of pregnancy include ectopic pregnancy, spontaneous abortion (threatened, inevitable, incomplete, and complete), placental abruption, and appendicitis in pregnancy. Adnexal accidents include torsions of the tube and ovary, ovarian cyst rupture, and persistent corpus luteum cyst with hemorrhage. Finally, other causes of pelvic pain include Mittelschmerz (rupture of the graafian follicle and extrusion of the ovary), dysmenorrhea, endometriosis, and acute appendicitis.

Conditions that cause pain can be divided into those which can be treated in the primary care setting and those that should be referred to a gynecologist. In general, all patients who present with pelvic pain, hemodynamically unstable vital signs (tachycardia, hypotension, altered mental status), and positive peritoneal signs should undergo rapid a assessment of the ABC’s (airway, breathing, and circulation), stabilization with two large bore IV's and immediate referral for emergency gynecologic consultation.

PID
Ambulatory treatment of PID is Rocephin 250 mg IM plus Doxycycline 100 mg PO BID for 10 to 14 days, or Azithromycin 1 gram as a single oral dose. Patients with PID who appear toxic (nausea, vomiting, dehydration) or have peritoneal signs (rebound tenderness, rigidity, decrease bowel sounds) are not good candidates for ambulatory treatment and should be expeditiously referred to a gynecologist for further treatment and work-up to rule out tubo-ovarian abscess.

Post-partum or post-abortal endometritis
These conditions are often associated with retained placental tissue or products of conception and should be referred to the gynecologist for definitive therapy.

Ectopic pregnancy
Any patient with pelvic pain, bleeding, and a positive pregnancy test should be carefully evaluated for possible ectopic pregnancy. Emergent medevac is paramount when conditions are favorable for transfer. Although many of these patients may be experiencing a threatened abortion, without ultrasound, differentiating between these two conditions is difficult.

• All pregnant patients suspected of having placental abruption (usually third trimester) should be referred emergently to a gynecologist or surgeon, respectively.

• Patients suspected of having a tubal or ovarian torsion require surgical evaluation and should be expeditiously referred to a gynecologist.

• Patients who are hemodynamically unstable suspected of having an ovarian or corpus luteum cyst with intra-abdominal bleeding should be stabilized and immediately referred to a gynecologist or the nearest emergency department. If these patients are hemodynamically stable, they can be referred for routine consultation.

• Mittelschmerz and dysmenorrhea can be treated with reassurance, patient education, oral contraceptives and Ibuprofen 600 to 800mg PO TID. However, because these are diagnoses of exclusion, other conditions must be excluded first.

• Definitive treatment of endometriosis clearly lies within the realm of the gynecologist and should be referred routinely.

• Finally, if one is unsure of the etiology of pelvic pain, do not hesitate to call a gynecologist and appropriately refer the patient.

References

1. Emergency Medicine: A Comprehensive Study Guide. Tintinalli, Krome, and Ruiz. McGraw Hill: New York, 1996.

2. Emergency Medicine: Concepts and Clinical Practice. Rosen and Barkin, et al., Mosby: St. Louis, 1992.

3. The Clinical Practice of Emergency Medicine. Harwood-Nuss, et al., J.B. Lippincott: St. Louis, 1991.