gynecology and obstetrics
Female Pelvic Pain
Evaluation of Pelvic Pain
Evaluation of acute pelvic pain must be expeditious because some causes (eg, Ectopic Pregnancy , Pregnancy should be excluded in all patients of reproductive age regardless of menstrual or sexual history. should include onset, duration, location, severity, and character of pain. Relationship of pain to the menstrual cycle is noted. Important associated symptoms include Vaginal Bleeding or Review of systemsshould include the following: Amenorrhea, morning sickness, or breast swelling or tenderness: Pregnancy Fever, chills, or vaginal discharge: Infection Abdominal pain, change in stool habits, or rectal bleeding: Gastrointestinal disorders Urinary frequency, urgency, dysuria, or hematuria: Urinary disorders Past medical historyshould note obstetric and gynecologic history (gravidity, parity, menstrual history, sexual history, history of sexually transmitted infections, infertility, ectopic pregnancy, pelvic inflammatory disease) and history of urinary calculi, diverticulitis, and other gastrointestinal or genitourinary conditions or cancers. Any previous abdominal or pelvic surgery should be noted. The physical examination begins with review of vital signs for fever or signs of hemodynamic instability (eg, hypotension, rapid pulse) and focuses on abdominal and pelvic examinations. The abdomen is palpated for tenderness, masses, and peritoneal signs. Rectal examination is done to check for tenderness, masses, and occult blood. Location of pain and any associated findings may provide clues to the cause (see table Some Clues to Diagnosis of Pelvic Pain ). Pelvic examination includes inspection of external genitals, speculum examination, and bimanual examination. The cervix is inspected for discharge or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness. If ectopic pregnancy is suspected, pressure should not be applied to an adnexal mass because pressure may cause rupture. The following findings are of particular concern: Syncope or hemorrhagic shock (eg, tachycardia, hypotension) Peritoneal signs (rebound, rigidity, guarding) Postmenopausal vaginal bleeding Fever or chills Sudden severe pain with nausea, vomiting, or diaphoresis Acuity and severity of pelvic pain and its relationship to menstrual cycles can suggest the most likely causes (see table Some Gynecologic Causes of Pelvic Pain ). Quality and location of pain and associated findings also provide clues (see table All patients with pelvic pain should have Pregnancy test Urinalysis If a patient is pregnant and has pain or bleeding, ectopic pregnancy is assumed until excluded by ultrasonography or, if ultrasonography is unclear, by Testing . If a suspected pregnancy may be Other testing depends on which disorders are clinically suspected. If a patient cannot be adequately examined (eg, because of pain) or if a mass is suspected, pelvic ultrasonography is done. If the cause of severe or persistent pain remains unidentified and a serious cause (eg, ruptured ectopic pregnancy, peritonitis) is suspected, laparoscopy or laparotomy may be done. Transvaginal pelvic ultrasonography can be a useful adjunct to pelvic examination; it can better define a mass or help diagnose a pregnancy after 5 weeks gestation (ie, 1 week after a missed menstrual period). For example, a positive pregnancy test plus no evidence of an intrauterine pregnancy support a diagnosis of ectopic pregnancy. 