Pelvic pain (females)

Pelvic pain in females is a common presentation to the ED.

Causes are legion, but can be thought of as:

• Pregnancy related
• Gynaecological
• Non-gynaecological.

The most important consideration in women of child bearing age will be to rule out pregnancy and specifically ectopic pregnancy.

Imaging involves ultrasound and CT scan with contrast if ultrasound is inconclusive

Ultimately laparoscopy may be required.  

Definitive diagnosis is frequently not possible in the ED and assessment necessarily involves ruling out immediately serious / life-threatening conditions, managing pain and formulating an appropriate disposition plan.

See also separate documents on:

●          Ovarian Torsion (in O&G folder)

●          Ectopic Pregnancy (in O&G folder)

●          PID (in O&G folder)

●          Dysmenorrhea (in O&G folder)

Pathophysiology

Causes:

Pelvic pain in women can be thought of in 3 categories:

1.         Pregnancy related

2.         Gynaecological related.

3.         Non-gynaecological related.

Pain may additionally be:

1.         Acute

2.         Chronic:

●          Usually defined as pain pelvic pain persisting for 6 months.

3.         Acute on chronic

4.         Cyclic

Pregnancy related:

Early < 20 weeks:

1.         Ectopic

2.         Abortion

Late > 20 weeks:

           

1.         Abruption (or accidental) haemorrhage

2.         Premature Labour

3.         Round ligament pain

Gynaecological related:

1.         PID:

            ●          And related secondary complications.

2.         Mittelschmerz

            ●          i.e. mid-cycle or ovulation pain

3.         Endometriosis / adenomyosis:

●          Endometriosis is a common, chronic gynaecological condition defined as the presence of functional endometrial glands and stroma-like lesions      outside the uterus.

It manifests in 3 ways:

♥          Superficial (peritoneal) disease

♥          Ovarian disease (endometriomas)

♥          Deep infiltrating endometriosis.

Adenomyosis is ectopic endometrial tissue within the myometrium, and is considered a subset of endometriosis.

4.         Fibroids, (leiomyoma):

●          Fibroids are responsive to hormones (e.g. stimulated by oestrogens).

They are rare in prepubertal females

They commonly accelerate in growth during pregnancy

They tend to involute with menopause.

They can degenerate, resulting in pain.

♥          Most commonly this will be due to hyaline degeneration. This        happens when fibroids outgrow their blood supply.

Hyaline degeneration involves the presence of homogeneous eosinophilic bands or plaques in the extracellular space, which represent the accumulation of proteinaceous tissue.

                        Pedunculated serosal fibroids can also cause pain if they undergo torsion.   

5.         Pelvic vascular:

●          Pelvic venous thrombosis.

●          Pelvic congestion syndrome:

♥          This is a condition that results from retrograde flow through incompetent valves in ovarian veins.

It is a commonly missed and potentially-treatable cause of chronic abdominopelvic pain.

It can be a cause of chronic pelvic pain, predominantly in multiparous, premenopausal women.

6.         Ovarian cyst pathology:

            The causes include: “THINRIM”:

●          Torsion                       (May be intermittent, unilateral, lead to necrosis)

●          Haemorrhage            (Usually unilateral signs)

●          Infection                     (Tubo-ovarian abscess)

●          Necrosis                      (Usually unilateral signs)

●          Rupture                       (Often bilateral signs)

●          Incarceration

●          Malignancy

            ♥          Complications thereof.

Non-gynaecological related:

1.         Adhesions from previous surgery.

2.         GIT

●          Appendicitis.

●          Irritable bowel syndrome.

●          Diverticulitis

●          Inflammatory bowel disorders.

            ♥          RIF pain is suggestive of the terminal ileitis of Crohn’s disease. 

●          Inguinal / femoral hernias

3.         Urinary Tract

●          UTI

●          Renal colic with stones at or near the VUJ.

●          Urinary retention.

4.         Musculoskeletal

5.         Psychogenic:

●          Psychosomatic:

♥          There is an association between chronic pelvic pain and somatization disorders.

Additionally, many women with chronic pelvic pain have suffered physical, sexual and emotional abuse or have other concomitant psychiatric illnesses. 

●          Munchausen’s syndrome

Clinical Assessment

Important points of history:

1.         Is the patient pregnant?

●          The most important consideration in women of child bearing age will be         to rule out pregnancy and specifically ectopic pregnancy.

2.         Nature of the pain:

            Acuteness of onset:

            Gynecologically acute onset may suggest:

            ●          Ovarian cyst rupture

            ●          Ovarian cyst bleed

            ●          Torsion of an ovary

            ●          Rupture of an ectopic pregnancy

            For non-gynaecological causes consider:

            ●          Ruptured appendix.

            Severe /unrelenting pain:

The pain is severe, unrelenting and / or difficult to control even with adequate analgesia.

From the gynecological perspective this can often be a sign of:

●          Ruptured ectopic pregnancy.

●          Ovarian torsion

●          Tubo-ovarian abscess

●          A bleed into an ovarian cyst.

            Is the pain subacute, chronic?

            Chronic pain is generally defined as that lasting ≥ 6 months. 

            Consider in particular:

●          Endometriosis / adenomyosis.

●          Adhesions:

♥          These are associated with previous abdominal/pelvic surgery/ PID/             IBD/ perforated appendix endometriosis.   

●          PID (chronic).

            ●          Pelvic congestion syndrome.

            ●          Psychogenic:

                        ♥          There is an association between chronic pelvic pain and somatisation                                 disorders.

Additionally, many women with chronic pelvic pain have suffered physical, sexual, and emotional abuse and/ or psychiatric illness.

In many instances however, no cause can be found.

            Is the pain cyclical?

Causes of cyclic pain include:

            ●          Dysmenorrhoea

●          Mittelschmerz

●          Endometriosis (in women of reproductive age).

            ●          Adenomyosis

            ●          IUDs

            ●          Fibroids.

3.         Does the patient have risk factors for PID?

●          Sexual history.

●          Recent pelvic instrumentation

4.         Dyspareunia:

            This  may indicate:

●          PID

●          Endometriosis

5.         Past history:

●          As a routine, but in particular any previous gynaecological surgery including         tubal ligation.

6.         Are there any psycho-social stresses?

Important points on examination:

Indicators for a potentially serious / urgent problem on examination include:

1.         Abnormal vital signs:

●          Tachycardia, hypotension, fever, tachypnea or looks unwell in general.

2.         Signs of abdominal or pelvic “peritonism”.

Pelvic peritonitis is indicated by:

●          Guarding

●          Rigidity

3.         PV examination:

●          “Cervical excitation” on PV bimanual rocking of cervix, indicates  inflammation.

            ●          A bulky uterus may indicate fibroids.

4.         Exclude inguinal/ femoral hernias

5.         Rectal examination:

●          If considered necessary, this should only be performed once, and preferably by the doctor with ongoing clinical care. ¹

Investigations

These will be guided by the degree of clinical suspicion for any given condition

The following should be considered:

Blood tests:

1.         FBE

2.         CRP:

●          If an inflammatory / infective process is being considered.

3.         Beta HCG:

●          Should be done in any female of child bearing age with pelvic pain.

            ●          It should be done regardless of when the last period is said to have occurred.

●          It should be done regardless of whether contraceptive precautions have been taken.

●          It should be considered regardless of whether or not a patient claims they “could not be pregnant”

Urine:

1.         FWT:

●          Especially for nitrites and white cells if UTI is suspected.

2.         MSU:

●          For M&C if UTI is suspected.

Vaginal and Cervical Swabs:

Swabs for N. gonorrhoeae or C. trachomatis will need to be done if PID is suspected.

PCR testing technique can also be performed on swabs and urine for:

●          N. gonorrhoeae

●          C. trachomatis

Viral swabs re taken for suspected herpes infections.

Ultrasound:

Ultrasound is virtually a non-invasive extension of the physical examination, in the female patient with pelvic pain. ¹

The timing and urgency of the examination however will be dictated by how unwell the patient is, availability, as well as the index of suspicion for any given pathology.

Techniques include, transabdominal ultrasound, transvaginal ultrasound, and Doppler ultrasound.

Ultrasound is first line investigation for:

●          Pregnancy related causes, (in particular ectopic pregnancy).

●          Gynaecological related causes, in particular:

            ♥          Ovarian torsion

            ♥          Tubo-ovarian abscess

            ♥          Bleed into an ovarian cyst

 

♥          Rupture of an ovarian cyst.

Ultrasound may also be useful in cases of suspected appendicitis.

CT scan pelvis and abdomen:

This may be required to help rule out other non-gynecological related problems or complicated or complex gynaecological related problems.

CT with contrast is a more sensitive imaging modality than ultrasound for ovarian torsion, however, the risk of radiation to a young female however must always be weighed against the possible benefits of the examination.

MRI:

MRI has the advantage over CT of avoiding radiation and contrast exposure.

Pelvic MRI is the modality of choice to diagnose and characterise endometriosis and adenomyosis.

Laparoscopy:

Ultimately laparoscopy may be necessary to determine the cause of pelvic pain in both the acute and chronic settings.

Management

Management will of course depend on the cause of the pelvic pain.

It will also be guided by the degree of clinical suspicion for any given condition, when the diagnosis is uncertain.

The important issues will include:

●          Initial resuscitation

●          Analgesia

●          Ruling out pregnancy

●          The extent of investigation required in the ED

●          An adequate period of observation in the ED, when the diagnosis is unclear

●          A decision on whether admission is necessary.

●          A decision on disposition, when discharge from the ED is appropriate

Disposition:

Indications for admission:

These include:

●          Patients requiring resuscitation.

●          Confirmed or suspicion of serious pathology, (such as ruptured ectopic pregnancy).

●          Intractable pain

●          Uncertain diagnosis, where ongoing observation is warranted, especially in the presence of abnormal vital signs, or abnormal but non-diagnostic investigation results.

●          Threshold should be low for patients in late pregnancy

Discharge: Patients who are well, and have had other serious pathology ruled out may be discharged with analgesics and have an US as an outpatient with GP or Gynecology outpatients review as appropriate. 

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References

FOAMed

Publications