Common Questions About the Evaluation of Acute Pelvic Pain

 


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Acute pelvic pain is defined as lower abdominal or pelvic pain of less than three months' duration. It is a common presentation in primary care. Evaluation can be challenging because of a broad differential diagnosis and because many associated signs and symptoms are nonspecific. The most common diagnoses in reproductive-aged women with acute pelvic pain are idiopathic pelvic pain, pelvic inflammatory disease, acute appendicitis, ovarian cysts, ectopic pregnancy, and endometriosis. Among postmenopausal women, cancer must be considered. Findings from the history and physical examination can point to likely diagnoses, and laboratory testing and imaging can help confirm. Women of reproductive age should take a pregnancy test. In early pregnancy, transvaginal ultrasonography and beta human chorionic gonadotropin levels can help identify ectopic pregnancy and spontaneous abortion. For nonpregnant women, ultrasonography or computed tomography is indicated, depending on the possible diagnosis (e.g., ultrasonography is preferred when ovarian pathology is suspected). If ultrasonography results are nondiagnostic, magnetic resonance imaging can be helpful in pregnant women when acute appendicitis is suspected. If magnetic resonance imaging is unavailable, computed tomography may be indicated.

Acute pelvic pain is often defined as lower abdominal or pelvic pain lasting less than three months.1 Although most patients with acute pelvic pain are diagnosed with one of a few common conditions, the differential diagnosis is broad. Many case studies describe acute pelvic pain caused by conditions that are uncommon but clinically important.

WHAT IS NEW ON THIS TOPIC: ACUTE PELVIC PAIN

C-reactive protein measurement is not recommended in the routine evaluation of acute pelvic pain because of a high false-negative rate for acute conditions.

If computed tomography has already been performed and is unrevealing, follow-up transvaginal ultrasonography is unlikely to provide additional useful information.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

When patients have adnexal tenderness with cervical motion tenderness, pelvic inflammatory disease should be considered as a likely diagnosis.

C

13

A normal transvaginal ultrasonography with Doppler flow study does not necessarily rule out ovarian torsion. Although it has a high positive predictive value for detecting ovarian torsion, it also has a high false-negative rate.

C

26

Transvaginal ultrasonography should be the initial imaging test in pregnant women presenting with acute pelvic pain.

C

31

If transvaginal ultrasonography is nondiagnostic in pregnant patients and additional imaging is required, magnetic resonance imaging should be used instead of computed tomography.

C

3234


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

When patients have adnexal tenderness with cervical motion tenderness, pelvic inflammatory disease should be considered as a likely diagnosis.

C

13

A normal transvaginal ultrasonography with Doppler flow study does not necessarily rule out ovarian torsion. Although it has a high positive predictive value for detecting ovarian torsion, it also has a high false-negative rate.

C

26

Transvaginal ultrasonography should be the initial imaging test in pregnant women presenting with acute pelvic pain.

C

31

If transvaginal ultrasonography is nondiagnostic in pregnant patients and additional imaging is required, magnetic resonance imaging should be used instead of computed tomography.

C

3234


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Acute pelvic pain is a common presentation in primary care. Although well-designed studies on the prevalence of pelvic pain are lacking, one study estimated that up to 39% of reproductive-aged women who presented to their primary care physician had symptoms related to pelvic pain, and one in seven women has acute or chronic pelvic pain at some point.2,3 The consequence of a missed diagnosis can be serious. For example, delay in diagnosis of an ectopic pregnancy can result in rupture and life-threatening hemorrhage. Untreated sexually transmitted infections and pelvic inflammatory disease (PID) can lead to long-term sequelae, such as infertility and chronic pain.

The workup of acute pelvic pain in the office setting can be challenging. This article provides an evidence-based framework to narrow the differential diagnosis while assuring

The Authors

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AMIT K. BHAVSAR, LTC, MC, USA, is a staff family physician at Tripler Army Medical Center Family Medicine Residency Program, Department of Family Medicine, and Department of Obstetrics and Gynecology, Honolulu, Hawaii. Dr. Bhavsar is also an assistant professor of family medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md....

ELIZABETH J. GELNER, CPT, MC, USA, is a third-year resident in the Tripler Army Medical Center Department of Obstetrics and Gynecology.

TONI SHORMA, CPT, MC, USA, is a second-year resident in the Tripler Army Medical Center Department of Obstetrics and Gynecology.

Address correspondence to Amit K. Bhavsar, LTC, MC, USA, Tripler Army Medical Center, 1 Jarret White Rd, Honolulu, HI 96859 (e-mail: amit.k.bhavsar.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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