Pelvic pain - Clinical Tree

Essentials

1
History, abdominal and age-appropriate pelvic examination guide diagnosis.
2
History and examination can be supplemented, but not replaced, with appropriate investigations.
3
A normal pelvic examination should not preclude gynaecological referral, even in the absence of other findings.
4
The possibility of pregnancy must be considered in all patients of reproductive age with abdominal or pelvic pain under the following well-iterated tenets:
- All female patients are pregnant until proven otherwise.
- All pregnant patients have an ectopic pregnancy until proven otherwise.
5
Give effective analgesia with the regular administration of non-steroidal anti-inflammatory drugs (NSAIDs).

Introduction

Pelvic and lower abdominal pain in female patients is a complex and challenging complaint. It is the second most common gynaecological symptom after vaginal bleeding, and the large differential diagnosis for female pelvic pain makes a definitive diagnosis in the emergency department (ED) difficult. A systematic approach is essential.

The emergency physician should aim to stabilize the haemodynamically unstable patient, provide adequate analgesia where appropriate, identify conditions that require early surgical intervention and expedite the investigation and further management of females with pelvic pain.

Classification

Pelvic pain is traditionally classified as either acute or chronic. Conditions causing pelvic pain can be life threatening or inconsequential, gynaecological or non-gynaecological and/or non-organic. These presentations are often complex and require ongoing care and management, often by multiple specialties.

Presentation

This chapter outlines the initial presentation and management of the most common gynaecological conditions associated with acute and chronic pelvic pain.

History

A detailed pain history is essential in the assessment of abdominopelvic pain. This should include the site, severity, onset and time course, character, radiation, associated symptoms, radiation or shift and exacerbating or relieving factors.

As such, parietal pelvic pain may be well localized and occur secondary to peritoneal irritation, such as in appendicitis and mittelschmerz. More generalized and diffuse abdominal pain may be associated with intraperitoneal blood or inflammation resulting from an ectopic pregnancy or a tubo-ovarian abscess. Severity of pain is best assessed by the impact of the pain on function, such as activities of daily living or acute incapacitation.

Pain of abrupt onset is associated with sudden events, such as ovarian cyst rupture or adnexal torsion. Gradually worsening pain is suggestive of a long-term process, such as endometriosis or chronic pelvic inflammatory disease (PID). Pain with sexual intercourse (dyspareunia) may be associated with any pelvic process, including adnexal pathology and endometriosis.

Pain radiation may provide a clue to the underlying origin, such as pain referred via the hypogastric nerve plexus to the lower abdomen from the uterine fundus, adnexae and bladder dome. The S2–4 sacral nerve roots transmit pain from the lower uterine segment, cervix, bladder trigone and rectum to the lower back, buttocks, perineum and legs. A history of associated urological, gastrointestinal and musculoskeletal symptoms is essential.

Sexual and reproductive history

The reproductive history should focus on the current menstrual pattern and any relation to pain, the last normal menstrual period (LNMP), menarche, menopause, pregnancies (regardless of outcome) and previous gynaecological surgery. A sexual history, taken appropriately and with due consideration to privacy and confidentiality, should include time of last intercourse, contraception, number of partners, possibility of physical or sexual abuse and sexually transmitted diseases (STDs).

Psychosocial impact

Finally, the clinician should particularly consider psychosocial factors in the evaluation of chronic pain. The symptoms of fatigue, loss of energy and depressed mood are commonly associated with chronic pelvic pain; thus a screen for anxiety, depressive and somatoform disorders is essential.

Enquire about relationship distress, the partner’s understanding and response to the pain and the family’s response to how the patient is managing her pain.

Examination

Examination starts with an assessment of the body habitus and an establishment of baseline observations, including height, weight, temperature, pulse and blood pressure, which may indicate life-threatening haemorrhage, such as an ectopic pregnancy or overwhelming sepsis associated with a tubo-ovarian abscess. The examination then proceeds in a systematic manner from the hands to the feet. As in all intimate examinations, it is important to provide early analgesia and establish rapport with the patient, who may be reticent, frightened or embarrassed.

Abdominal examination

Commence the abdominal examination with inspection for distension associated with obstruction, ascites or abdominal masses. Palpation and percussion can delineate areas of generalized or localized tenderness and may replicate the patient’s pain. Check for hernias, inguinal nodes and other non-gynaecological causes for the patient’s symptoms at the same time ( Table 19.1.1 ).

Table 19.1.1

Causes of acute pelvic pain

	Non-gynaecological
Gynaecological	Intestinal	Urological	Other
Complication of pregnancy: ectopic, miscarriage	Appendicitis	Cystitis	Hernia
Complication of ovarian and adnexal cysts and masses	Diverticulitis	Acute urinary retention	Pelvic vein thrombophlebitis
Pelvic inflammatory disease	Inflammatory bowel disease	Urolithiasis
Adnexal torsion	Gastroenteritis	Pyelonephritis
Leiomyoma complication	Bowel obstruction Constipation

Pelvic examination

In the sexually active patient, a pelvic examination is an important differentiator of the aetiology of pain. However, it is not mandatory when the diagnosis is certain – for example, in early-pregnancy bleeding (see Chapter 19.4 ). Perform this only in the presence of a chaperone, after providing a careful explanation of the procedure and obtaining consent.

It is important to note that bimanual examination has been shown to have limited sensitivity and specificity in the evaluation of pelvic organs, independent of the experience the examiner. The overall accuracy of pelvic examination under anaesthesia compared with operative findings has been estimated at 70% for specialists and 60% for medical students. Not surprisingly, there is lower sensitivity for the detection of adnexal pathology compared with the assessment uterine size or contour. Similarly, even in specialized endometriosis units, the sensitivity and specificity of vaginal examination for retro-cervical and recto-vaginal disease is only around 70%.

However, as a low-cost, low-risk intervention, it is recommended that a vaginal examination be considered as part of the assessment of the infertile couple. The pelvic examination guides the suspicion of pelvic pathology, which will then increase the predictive value of any subsequent targeted investigations, such as ultrasound.

The pelvic examination includes the following:

Visual examination of the vulva and urethral meatus to identify varicosities, infection or abnormal lesions.
Speculum examination to visualize the cervix, cervical os and the vaginal vault. Note any vaginal discharge and take endocervical and vaginal swabs. However, performance of a routine cervical screening test is not encouraged.
Bimanual (vagino-abdominal) examination to examine the cervix, uterus and adnexae.

The uterus is normally mobile, but conditions such as endometriosis or adhesions may cause fixation. An enlarged uterus is associated with pregnancy, fibroids or adenomyosis. The uterine axis is dependent on a number of other local pelvic factors such as the content of the bladder or bowel. A retroverted uterus can be normal, but a fixed retroverted uterus is classically associated with pouch-of-Douglas pathology, such as endometriosis.

Uterine tenderness occurs with any cause of pelvic peritonism but also conditions such as adenomyosis or fibroid degeneration. An open cervical os may be associated with the passage of intrauterine pathology, such as a failed pregnancy or clots. Cervical excitation (pain on moving the cervix) is non-specific and associated with any condition producing pelvic peritonism, such as blood or other irritants in the peritoneal cavity, including PID (see Chapter 19.2 ). Palpable adnexal masses are associated with more gross pathology, such as an ovarian cyst.

A normal pelvic examination does not exclude pelvic pathology but guides the selection of further definitive investigations, such as an ultrasound scan (USS) or laparoscopy.

Rectal examination

A rectal examination, where appropriate, completes the pelvic examination. This should be performed only once, preferably by the doctor providing continued clinical care. Practitioners should take note of stool consistency, faecal occult blood and the presence of a mass lesion. A rectovaginal examination allows palpation of the posterior cul-de-sac for ovarian masses, the posterior wall of the uterus and the uterosacral ligaments for nodularity and tenderness in association with endometriosis.

Laboratory investigations

Laboratory investigations depend on the history and physical examination and are tailored to the individual patient. They include the following.

Urinalysis

Urinary beta subunit of human chorionic gonadotrophin (β-hCG) is rapid, inexpensive and accurate. This should be performed in all female patients of childbearing age. The presence of leucocytes in the urine may indicate infection with a sensitivity of around 70% to 75%, but it may also be associated with inflammation of adjacent pelvic organs. The presence of red cells may indicate urolithiasis.

The urine should be sent for microscopy, culture and sensitivity if urinary tract pathology is suspected. The urine should also be sent for chlamydial and gonorrhoea polymerase chain reaction (PCR) in suspected PID (see Chapter 19.2 ).

Microbiological swabs

Take endocervical swabs for chlamydia, gonorrhoea and Ureaplasma during the speculum examination. Specific viral and bacterial swabs vulval swabs should be taken only in the presence of a vulval lesion, such as suspected herpes simplex infection.

Blood tests

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