Acute Pelvic Pain

Epidemiology

Acute pain caused by pelvic pathology is common, and the presenting complaint may be diffuse or lower abdominal pain, pelvic pain, or low back pain. A patient with chronic pelvic pain may also have an acute process related to the chronic condition or arising de novo.

More than one-third of reproductive age women will experience nonmenstrual pelvic pain. Among diagnoses for women with pain caused by gynecologic disorders in the emergency department (ED), pelvic inflammatory disease (PID) and lower genital tract infections (e.g., cervicitis, candidiasis, Bartholin abscess) account for almost 50%. Other common diagnoses are menstrual disorders, noninflammatory ovarian and tubal pathology (including cysts and torsion), and ectopic pregnancy. Ectopic pregnancy accounts for up to 20% of diagnoses among women presenting with vaginal bleeding or abdominal pain in the first trimester of pregnancy.

Younger patients and those with multiple sexual partners are more likely to have PID, and a previous episode increases the likelihood of a subsequent episode. The risk of ectopic pregnancy is higher in women who have had PID, pelvic surgery, prior ectopic pregnancy, or are using an intrauterine device (IUD). Heterotopic pregnancy is of special concern in women using assisted reproductive technology (ART). Although the rate of heterotopic pregnancy in spontaneous pregnancy is 1 in 30,000, this rate increases to as high as 1:1000 in patients undergoing ART. Common nongynecologic diseases such as appendicitis, diverticulitis, urinary tract infection, and urolithiasis remain important considerations in the woman with acute pelvic pain. Box 29.1 lists conditions accounting for most cases of pelvic pain in women.