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Acute Pelvic Pain in the Emergency Department

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General Approach and Resuscitation

  • The approach to the woman with pelvic pain is to start with the initial resuscitation and β-HCG
  • Then the focus should be on emergent gynecologic disease, such as ovarian torsion and PID / TOA (Tuboovarian Abscess)
  • Then expand the differential to think about non-gynecologic causes from Genitourinary or Gastrointestinal origin, most commonly Appendicitis
  • If that work-up is negative, consider treating empirically for PID, and think about other causes of pelvic pain

Acute Pelvic Pain Algorithm
Acute Pelvic Pain Algorithm

Emergent Gynaecological Causes

1. Ovarian Torsion

General

  • Definitive diagnosis of ovarian torsion is based on surgical findings
  • Difficult diagnosis → correct pre-operative diagnosis made in only 38% of cases (J Reprod Med 2000;45:831)

Clinical Presentation

  • Risk Factors: Reproductive age, pregnant, infertility therapy, vigorous activity
  • Acute severe unilateral pelvic pain
  • Radiation to back, flank, groin
  • Nausea / Vomiting

Ultrasound

  • Caution
    • Ovaries have dual blood supply, therefore, the presence of normal flow does not exclude torsion
    • If high clinical suspicion (persistent pain) → may need laparoscopy despite negative ultrasound

Treatment:

  • Pain control
  • Gyn consult for surgical evaluation

2. Tuboovarian Abscess (TOA)

General: Tuboovarian Abscess

  • Definition: Inflammatory mass in fallopian tube/ovary/pelvic organs, found most commonly in reproductive age women and typically results from upper genital tract infection
  • Etiology:
    • PID (most common)
    • pelvic surgery
    • intra-abdominal process
  • Microbiology: same as PID, polymicrobial, anaerobes

Clinical Presentation

  • Abdominal/Pelvic pain
  • PID symptoms, Vaginal discharge
  • CMT / adnexal pain
  • Palpable mass
  • Fever, High WBC

Diagnosis

  • Consider in any woman suspected of PID
  • Ultrasound:
    • Homogeneous, cystic mass with air/fluid levels and septations
    • Utility (Journal Emerg Med 2011;40:170)
      • Newer studies show sensitivities that range from 56% to 93%, with a specificity of 86% to 98%
      • Low sensitivity of Ultrasound → cannot rule out Tuboovarian Abscess, especially in the high risk patient
      • If Ultrasound negative → may need CT to continue evaluation for Tuboovarian Abscess
  • Helps differentiate TOA (Tuboovarian Abscess) vs TOC (tubo-ovarian complex) → perfused inflammatory living tissue without abscess wall, amenable to medical therapy

Treatment

  • Medical: Trial of medical therapy (antibiotics) vs
  • IR guided drainage vs
  • Surgery: operative drainage

3. Pelvic Inflammatory Disease (PID)

General

  • Represents a spectrum of disease from endometritis to fatal intra-abdominal sepsis

Clinical Presentation

  • Abdominal / Pelvic pain
  • Vaginal discharge
  • Fever
  • STD risk factors
  • CMT/adnexal tenderness
  • High WBC / ESR

Diagnosis

  • US
    • Rule-out TOA
    • May be diagnostic of PID
  • CDC has issued a minimum set of criteria for treatment of PID for women with abdominal pain and at least one of the criteria (See Table) (MMWR Recomm Rep 2010;59:1-110)

Criteria for Treatment of PID

□ CMT or uterine/adnexal tenderness
□ Oral Temp > 101F
□ Leukocytosis/left shift
□ Abnormal cervical/vaginal discharge
□ Vaginal secretions with WBC on saline microscopy
□ Elevated ESR
□ Elevated CRP

Treatment

  • Outpatient treatment
    • If stable, well appearing, tolerating po, pain controlled → can be discharged on po antibiotics
    • Antibiotics (see most recent CDC guidelines)
  • Inpatient treatment
    • If patient meets criteria for hospitalization → start IV antibiotics, admit

Criteria for Hospitalization

□ Surgical emergencies (e.g., appendicitis) cannot be excluded
□ Pregnant
□ Does not respond clinically to oral antimicrobial therapy
□ Unable to follow or tolerate an outpatient oral regimen;
□ Severe illness, nausea and vomiting, or high fever; and
□ Tubo-ovarian abscess

Rule Out Non Gynaecological Causes

  • See Abdominal Pain algorithms for more detailed explanation of GI and GU causes of abdominal pain
  • Consider Appendicitis vs Diverticulitis (possible CT AP)
  • Consider UTI (Check Urinalysis)
  • Consider renal colic (UA, US, CT Stone?)

Other Gynaecological Causes

OVARIAN CYST RUPTURE

  • Sudden onset, unilateral abdominal pain, +/- vaginal bleeding, +/- peritoneal signs (blood irritating peritoneum)
  • Uncomplicated (follicular or corpus luteum cyst) → follow expectantly for enlarging hemoperitoneum
  • Complicated: may need surgical management, blood transfusion

MITTELSCHMERZ

  • Mid-cycle pain from rupturing of follicle during ovulation

References

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