Acute Pelvic Pain

Christopher R. Graber, MDSalina Women’s Clinic

15 April 2011

Definitions and Symptoms Acute OB/Gyn Pain

• Complication of pregnancy• Acute infection• Adnexal disorders

Other• GI, GU, Musculoskeletal, other

Acute pain• Sudden onset, sharp rise, short course

Cyclic pain• Definite association with mestrual cycle• Dysmenorrhea – painful menstruation

Primary or secondary Chronic pelvie pain

• Greater than 6 months duration

Rapid onset• Perforation of hollow viscus or ischemia

Colic or severe cramps• Muscular contraction, obstruction of hollow

viscus such as uterus or intestines Entire abdomen

• Generalized reaction to irritating fluid within the peritoneal cavity

Complications of pregnancy• Ectopic, abortion, leiomyoma degeneration

Acute infections• Endometritis, PID, TOA

Adnexal disorders• Hemorrhagic functional cyst, ovarian

torsion, torsion of paratubal cyst• Ruptured cyst – functional or neoplastic

Ectopic pregnancy – implantation in a site other than the uterus (95% in tube)• Acute pain due to tubal dilation• If rupture localized changes to generalized

peritonitis (due to hemoperitoneum)• hCG less than expected or abnormal rise• Use ultrasound to locate pregnancy

Heterotopic pregnancy rare (both uterine and ectopic)

Treatment• Methotrexate

50 mg/m2 IM x1 Multiple-dose regimen an alternative

• Surgery Linear salpingostomy Partial salpingectomy

• Follow quant hCG if no fetal tissue recovered MTX: quant on days 4 and 7, expect 15% drop

Absolute contraindications• Breastfeeding, immunodeficiency• Chronic liver disease, active pulmonary disease• Leukopenia, thrombocytopenia, anemia• Peptic ulcer disease, renal dysfunction• Known sensitivity to methotrexate

Relative contraindications• Gestational sac >3.5 cm, embryo cardiac

motion• Elevated hCG quant

Abortion (loss of pregnancy <20w)• Threatened – any vaginal bleeding• Inevitable – bleeding plus dilation• Complete – spontaneous expulsion• Incomplete – passage of some tissue• Missed – no expulsion of tissue for 8w• Induced – medical or surgical

Degeneration of leiomyoma• Rapid growth during pregnancy, outgrowing

blood supply• If pedunculated, can cause torsion• Increased progesterone• Degeneration sometimes seen on imaging• Supportive care unless torsion or not

pregnant

Endometritis (postpartum uterine infection)• Fever, abdominal pain, leukocytosis• Vaginal delivery

Overall risk 1%, increased after prolonged labor or rupture of membranes

13 % risk if chorioamnionitis during labor• Cesarean delivery

Decreased by single-dose pre-op abx Increased risk with manual extraction of placenta

• Treatment – Abx: amp, gent, clinda

Pelvic inflammatory disease• Acute salpingo-oophoritis• Pain, fever, purulent vaginal/cervical

discharge• Cervical motion tenderness, adnexal

tenderness• Outpatient vs. inpatient mgmt

Inpatient if: acute abdomen, pregnancy, vomiting, no response to PO abx, TOA

• http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

Tuboovarian abscess (TOA)• Sequela to PID• May be palpated on exam, seen on imaging• Treatment with IV abx• Exploratory surgery may be needed,

especially if rupture occurs

An ovarian cyst that is not torsing, rapidly expanding, infected, or leaking does not cuase acute pain

Ovarian cysts – leaking, hemorrhagic• May be mittleschmertz• Similar symptoms as a ruptured ectopic

Increasing abd pain, dizziness if hemoperitoneum

May be a surgical abdomen• Diagnosis: hCG, CBC, ultrasound• Treatment: supportive or surgical

Adnexal torsion• Ischemia from twisting of the vascular

pedicle of an ovary, tube, or paratubal cyst• May be constant or intermittent pain• Onset may coincide with physical activity• Diagnosis – sono: rapidly increasing mass• Treatment – surgery, with possible removal• Benign cystic teratoma is most common

neoplasm to undergo torsion

GI• Gastroenteritis, appendicitis (can be similar

to PID), bowel obstruction, diverticulitis, IBS GU

• Cystitis, pylonephritis, ureteral lithiasis Musculoskeletal

• Abdominal wall hematoma, hernia Other

• Acute porphyria, pelvic thrombophlebitis, aneurysm, abdominal angina

Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010;59.

Comprehensive Gynecology. Stenchever MA editor. Mosby Inc., St. Louis, MO. 2001.

Novak’s Gynecology – 13th edition. Berek JS editor. Lippincott, Williams, and Wilkins, Philadelphia, PA. 2002.

Williams Obstetrics – 22nd edition. Cunningham FG editor. McGraw-Hill, New York, NY. 2005.

Acute Pelvic Pain

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