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KEY QUESTIONS
What is the differential diagnosis for a patient with acute pelvic pain?
What causes of pelvic pain require inpatient admission?
What causes of pelvic pain require surgical management?
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CASE 55-1
A 27-y.o. gravida 1 para 1 presents to the emergency room with 4 hours of crampy pain in the right lower quadrant. She has intermittent nausea, and her last menstrual period was 3 weeks ago. Her urine pregnancy test is negative, and her pelvic exam is notable only for mild right adnexal tenderness.
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Acute pelvic pain is an exceedingly common complaint. In the most recent, nationally representative data from Emergency Department (ED) use in the United States, the most common reason for an emergency room visit by females aged 15 to 64 years old (5.5 million visits) was for abdominal pain, cramps, or spasms. This was also the most common complaint in female patients aged 65 years and older.1 This chapter will review the general approach to the ED patient with pelvic pain, followed by details on individual gynecologic conditions that may present with pelvic pain. The diagnosis and management of ectopic pregnancy is discussed in Chapter 54.
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The list of conditions that may present with pelvic pain is intimidatingly long and includes diagnoses associated with significant morbidity and mortality risks (Table 55-1). The close proximity of the female pelvic organs and their visceral innervations mean that vague, poorly localized and/or referred pain is often present. The first step in the assessment is to determine the stability of the patient, and if she proves unstable, to help ED staff determine the interventions necessary to stabilize her condition. This may include the recognition of a surgical emergency, such as a ruptured ectopic pregnancy, followed by immediate surgical intervention. More commonly, however, the patient is stable, and it is best to start with a full, broad differential diagnosis.
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The history of present illness, risk factors, review of systems, and abdominal and pelvic examination make each item on the differential more or less likely, narrowing and focusing the differential to a manageable level and guiding laboratory and imaging workup. It is particularly useful to figure out early in the encounter whether the pain is truly acute, as opposed to an exacerbation of chronic pelvic pain, because the latter can lead to an entirely different ...