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Acute pelvic pain

Common presentation Usually considered as pain in the lower abdomen or pelvis of < 3 months Challenging as wide types of pathologies can be responsible Many symptoms and signs are insensitive and non-specific Ectopic pregnancy , pelvic inflammatory disease and ruptured ovarian cyst represent the most common gynaecological causes of acute pelvic pain

 

History- Use the SOCRATES to get a good history History may not help in reaching a diagnosis but helps in narrowing differentials and to guide further evaluation Think reproductive tr / urinary tr / intestines / PREGNANCY Pregnancy is the single most crucial determinant factor in women of childbearing age Most acute serious pathologies have < 48 hrs of pain Vaginal bleeding / discharge Menstrual history / LMP /Sexual history H/O ectopic H/O uterine fibroids / ovarian cysts Past medical and surgical history Contraceptive history.

 

Examination / tests- Baseline vital signs Abdominal & pelvic examination Bimanual examination – helpful if PID is suspected and can reveal
○ cervical motion tenderness
○ uterine or adnexal tenderness Pregnancy test in all sexually active females of reproductive age History and focused US are often more successful in reaching a diagnosis A pelvic examination carries low sensitivity and specificity Ultrasound is generally the 1st line imaging ( transvaginal )
○ no radiation
○ cheap and widely available CT is the preferred choice if non -gynaecological cause is suspected or US equivocal Bloods and urinalysis

 

Gynaecological – Ectopic pregnancy Spontaneous abortion Hemorrhagic / ruptured cyst Pelvic inflammatory disease Adenomyosis Degenerating uterine fibroid Endometriosis Mittelschmerz ( mid cycle ovulatory pain) Ovarian torsion Tubo-ovarian abscess Corpus luteum haematoma Ovarian vein thrombosis Placental abruption Uterine impaction Ovarian hyperstimulation syndrome Ovarian cancer / tumour

 

Gastrointestinal – Appendicitis Bowel obstruction Diverticulitis Gastritis Inguinal hernia Irritable bowel syndrome Mesenteric venous thrombosis Perirectal abscess Adhesions / functional abdominal pain Constipation.

 

Urinary tract – Cystitis Pyelonephritis Interstitial cystitis Kidney stones.

 

Others – Strained tendons / muscles Joint infection/ inflammation Hernia Aortic aneurysm Aortic dissection Porphyria.

 

Life threatening – Pelvic inflammatory disease Tubo-ovarian abscess Ectopic pregnancy Ruptured haemorrhagic cyst Appendicitis Bowel / uterine perforation

 

Ovarian torsion- twisting of the ligaments that support the adnexa which cuts off the blood supply if the fallopian tube also twists with ovary it is called as adnexal torsion a true surgical emergency but fortunately rare with about 3 % of all emergency gynaecological operations this can affect females of all ages
( more common on women of child-bearing age ) but majority of cases are accompanied by presence of an ovarian mass or cyst this can also happen in paediatric population with normal ovaries

Primary risk in ovarian torsion is an ovarian mass

 

acute/ abrupt onset of pelvic pain pain can be sharp , dull , intermittent or constant pain may radiate to abdomen , back or flank nausea and vomiting fever ( of ovary is necrotic ) non-specific presentation poses a diagnostic challenge seen more commonly on right often misdiagnosed as acute appendicitis pregnancy is an independent risk factor for torsion
( also fertility treatment – enlarged follicles ) Gold standard to treat ovarian torsion is surgery which isalso the only way to confirm torsion

 

haemorrhagic / ruptured cysts – Ovarian cysts are more common in reproductive years Rupture , haemorrhage and torsion of cysts can present as gynaecological emergencies Ruptured functional ( follicular and corpus luteal cysts) ovarian cyst is a frequent cause of APP in women of reproductive age Follicular cysts are more common than corpus luteal ( CL ) cysts but CL cysts are more likely to haemorrhage Haemorrhagic corpus luteum ( HCL ) is an ovarian cyst formed after ovulation and caused by spontaneous bleeding into CL – a rupture of HCL causes hemoperitoneum with main manifestations due to peritoneal irritation and effusion of blood HCL can be due to exercise , coitus , trauma or a pelvic examination and the DD includes ectopic pregnancy , adnexal torsion , neoplasm and pelvic inflammatory disease

 

Can present with sharp , sudden onset pelvic pain May also present with hemorrhagic shock , hypotension Distinguishing between a ruptured ovarian cyst and ovarian torsion based on history and physical examination can be very difficult Ectopic pregnancy can mimic haemorrhagic cyst Patients need to be under observation in hospital environment and surgery may be needed in case of haemodynamic compromise or deterioration of clinical status

 

Pelvic inflammatory disease – PID is defined as inflammation of the upper genital tract due to infection in women ( more frequently in women 15-25 yrs ) Usually due an infection ascending from the endocervix causing endometritis , salpingitis , parametritis , oophoritis , tubo-ovarian abscess and or pelvic peritonitis Common cause of infertility , chronic pain and ectopic pregnancy Most PIDs are related to STIs Can be caused by several microbes as ( often polymicrobial aetiology )
○ Neisseria gonorrhoeae
○ Chlamydial trachomatis○ anaerobic and mycoplasmal bacteria ( Mycoplasma genitalium has been independently associated with PID ) It is estimated of those women who get infected with endocervical
N gonorrhoeae or C trachomatis about 8% to 10 % would go on to develop PID Hence risk factors for developing PID are same as those for developing STIs , they also include any recent instrumentation of the uterus or interruption of cervical barrier ( e.g TOP , IUD insertion , hysterosalpingography , in vitro fertilization and intrauterine instrumentation ) Infection leads to inflammatory damage causing scarring , adhesions and a partial or total obstruction of the fallopian tubes

 

Assessment – lower abdominal pain ( can be b/l or u/l ) particularly right upper quadrant pain pelvic pain , discharge , dyspareunia Bimanual vaginal examination
○ adnexal tenderness
○ a tender mass can be felt some times
○ cervical motion tenderness abnormal vaginal discharge which is often purulent speculum -note friability and mucopurulent cervical discharge microscopic examination of the sample of cervicovaginal discharge fever ( > 38 ° ) deep dyapreunia abnormal vaginal bleeding which includes post coital bleeding , intermenstrual bleeding and menorrhagia secondary dysmenorrhoea

 

diagnosis can be challenging and imprecise as symptoms and signs can vary widely diagnosis is usually established on basis of clinical history and examination ( CLINICAL DIAGNOSIS ) presentation may also vary base on pathogen ( for e.g infection with gonococcal infection is more likely to present with fever , adnexal tenderness , mucopurulent cervicitis and elevated WBC ) laparoscopic visualisation of inflamed , purulent fallopian tubes can aid in establishing a definitive diagnosis tubo-ovarian abscess or pelvic abscess are acute short term complications a negative NAAT test or US/CT does not exclude a diagnosis of PID.

 

Diagnostic criteria have been proposed by US CDC -min , additional and definitive( find it under links ) More than 85 % of infections are due to STIs

 

PID should be suspected in any young female who presents with lower abdominal pain and pelvic discomfort.

 

Consider pregnancy test , HVS for M/C and a pelvic US if tubo-ovarian abscess is suspected.

 

suspected ectopic pregnancy cases where the patient may require IV therapy for e.g
○ pyrexia > 38 °
○ signs of tubo-ovarian abscess or pelvic peritonitis a surgical emergency cannot be excluded 
( e.g acute appendicitis ) patient is pregnant no response to oral therapy a complication of PID as peri-hepatitis is suspected immunocompromised women with clinically severe PID

 

If admission is not required
 do not delay in making a diagnosis offer pregnancy test consider FBC , ESR , CRP and HVS initiate treatment while results from investigations are awaited consider referring to GUM clinic or other local specialist sexual health clinic ( for further screening for infections / investigations and for contact tracing ) follow local protocol in deciding choice of antibiotic- BASHH guidance shown for reference here.

 

IM ceftriaxone 1000 mg single bolus + 
oral doxycycline 100 bd PLUS oral metronidazole 400 mg bd x 2 wks

 

oral ofloxacin 400 mg bd x2 weeks ( consider ↑ quinolone resistance ) oral metronidazole 400 mg bd x 2 weeks

 

Oral moxifloxacin 400 mg od x 2 weeks

 

IM ceftriaxone 1000 mg immediately +
oral azithromycin 1 g/ week for 2 weeks

References

  1. Jennings LK, Krywko DM. Pelvic Inflammatory Disease. [Updated 2021 May 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499959/
  2. Mitchell, Caroline, and Malavika Prabhu. “Pelvic inflammatory disease: current concepts in pathogenesis, diagnosis and treatment.” Infectious disease clinics of North America vol. 27,4 (2013): 793-809. doi:10.1016/j.idc.2013.08.004
  3. Curry A, Williams T, Penny ML. Pelvic Inflammatory Disease: Diagnosis, Management, and Prevention. Am Fam Physician. 2019 Sep 15;100(6):357-364. PMID: 31524362.
  4. BASHH guideline Pelvic Inflammatory Disease BASHH Guidelines
  5. Mobeen S, Apostol R. Ovarian Cyst. [Updated 2020 Jul 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560541/
  6. Medvediev, Mykhailo V et al. “Hemorrhagic corpus luteum: Clinical management update.” Turkish journal of obstetrics and gynecology vol. 17,4 (2020): 300-309. doi:10.4274/tjod.galenos.2020.40359
  7. Guile SL, Mathai JK. Ovarian Torsion. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560675/
  8. Huang, Ci et al. “A review of ovary torsion.” Ci ji yi xue za zhi = Tzu-chi medical journal vol. 29,3 (2017): 143-147. doi:10.4103/tcmj.tcmj_55_17
  9. Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic Pain. Am Fam Physician. 2016 Jan 1;93(1):41-8. PMID: 26760839.

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