13 Week 9: Pelvic Pain (Week of 10/17/2022)
Week 9: Pelvic Pain
DISCUSSION SESSIONS Week of 10/17/22
Assignments Due: 10/16/2022 @11:59PM
PRIOR TO CLASS
- Re-familiarize yourself with the approach to abdominal pain by reading the syllabus section below and that from Week One
- Complete the required quiz (Quiz H) on Canvas.
- Complete pre- class case, Ms. Nelson.
- Prepare answers to discussion questions on pre-class cases (emailed when case opens on Canvas).
Learning Objectives
- Build a prioritized differential diagnosis for pelvic pain that includes common and life/function threatening diagnoses.
- Identify the components of the history and physical, as well as the laboratory and radiological findings, crucial for correctly diagnosing a patient presenting with pelvic pain.
APPROACH TO Pelvic PAIN
Remember from the previous discussions of abdominal pain that the best approach is a balanced one that combines a directed history and physical with a thoughtful approach to diagnostic testing. Eliciting the location of pain and acuity of onset, along with performing a thorough exam, are all critical in distinguishing causes of abdominal pain. Below are the tables that you reviewed in the first section of this syllabus (abdominal pain) which categorize causes of abdominal pain using an anatomic approach. It is extremely important to consider pelvic pathology in the workup of abdominal pain in females in addition to all the other causes of abdominal pain that you learned previously.
| Table 1. Abdominal pain diagnostic grid. | |
| Right upper quadrant | Left upper quadrant |
| Chest (AMI, PE, basilar pneumonia)
Peptic ulcer disease Pancreatitis Hepatitis Gallstone Cholecystitis Incarcerated ventral hernia Small/Large bowel obstruction Right kidney (stone,infarct,infection) Mesenteric ischemia Leaking AAA (less likely) Cecal volvulus |
Chest (MI, PE, basilar pneumonia)
Peptic ulcer disease Pancreatitis Spleen (rupture,abscess,infarct) Incarcerated ventral hernia Small/Large bowel obstruction Diverticulitis Left kidney (stone,infarct,infection) Mesenteric ischemia Leaking AAA Sigmoid Volvulus |
| Right lower quadrant | Left lower quadrant |
| Right gonad (cyst, torsion, infection)
Ectopic pregnancy Right inguinal hernia Small/Large bowel obstruction Diverticulitis Mesenteri cischemia Leaking AAA (less likely) Appendicitis Cecal volvulus |
Left gonad (cyst, torsion, infection)
Ectopic pregnancy Left inguinal hernia Small/Large bowel obstruction Diverticulitis Mesenteric ischemia Leaking AAA Appendicitis (less likely) Sigmoid volvulus |
In a reproductive age woman the causes of pelvic pain can be distinguished between those that are pregnancy related and ones that are not making a pregnancy test extremely important to perform early in the workup (regardless of their reported sexual activity or use of contraception). Pregnancy testing can be performed through quantitative serum beta-HCG which is the most sensitive or by qualitative urine beta-HCG (which can typically detect pregnancy after ∼4 weeks’ gestation).
The table below lists common and uncommon conditions resulting in pelvic pain.
| Table 1. Conditions Causing Acute Pelvic Pain in Different Populations | |||
| Patient Category | Common Diagnoses | Less Common Diagnoses | Rare Diagnoses |
| Reproductive Age (not pregnant) | Endometriosis (ruptured endometrioma)
Idiopathic (no cause identified) Ovarian cyst, ruptured Ovarian torsion PID, tubo-ovarian abscess |
Adenomyosis
Dysmenorrhea Endometritis (postprocedure) Imperforate hymen Intrauterine device perforation Leiomyoma (degenerating) Mittelschmerz |
Endosalpingiosis
Round ligament mass (lipoma, teratoma) Transverse vaginal septum |
| Reproductive Age (pregnancy related) | Corpus luteum cyst
Ectopic pregnancy Endometritis (postpartum) Normal labor Ovarian torsion PID (first trimester) Placental abruption Preterm labor Spontaneous abortion |
Leiomyoma (degenerating)
Pubic symphysis Subchorionic hemorrhage |
Incarcerated gravid uterus
Ovarian vein thrombosis PID (rare after first trimester) Uterine rupture
|
| Reproductive Age (undergoing fertility treatment) | Ectopic pregnancy
Ovarian follicular cyst Ovarian hyperstimulation syndrome Ovarian torsion |
– | Heterotopic pregnancy |
| Postmenopausal | Malignancy | Ischemic colitis | Endometriosis
PID, tubo-ovarian absess Retained intrauterine device |
| All Groups | Appendicitis
Diverticulitis Inflammatory bowl disease Irritable bowel syndrome Musculoskeletal (abdominal wall) pain Urinary tract infection Urolithiasis |
Bowel obstruction
Inguinal hernia Interstitial cystitis Pelvic adhesive disease (postoperative scarring) Perirectal abscess Urethral diverticulum Urinary retention |
Mesenteric adenitis |
| PID = pelvic inflammatory disease
Information from references 6 through 9 Source: American Family Physician (January 2016). |
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RESOURCES FOR FURTHER READING
- UpToDate:
“Evaluation of acute pelvic pain in nonpregnant adult women”
“Evaluation of acute pelvic pain in the adolescent female”