Sheila Marie G.

Pineda-Almazan,
MD,FPOGS,FPSUOG

Explain the systematic assessment of a

patient presenting with acute pelvic
pain

Diagnose the different conditions that

may present with acute pelvic pain

generally defined as pain in the lower

abdomen/ pelvis of less than 3
months
originate in reproductive organs
(cervix, uterus, adnexa) or
Non- reproductive organs

Location of pain
Pelvic

organs share the same

visceral innervations with the lower
ileum, sigmoid and rectum (T10
L1)
Referred pain
Diffuse and generalized pain
peritonitis

Poses a challenging clinical

scenario
Non-specfic

History & P.E.

wide variety of clinical
presentation
requires priority management of
urgent life and fertility threatening
conditions

History of Present Illness

Gynecologic history (OB Score, Menstrual
Hx)
onset, duration, location, & character
of pain.
severity of pain and its relationship to
the menstrual cycle
history of STI
presence of vaginal bleeding or
discharge
symptoms of hemodynamic instability

Review of Systems:

Amenorrhea, morning sickness, breast

tenderness(pregnancy)

fever and chills (infection);

abdominal pain, nausea, vomiting, or
change in stool habits (GI disorders)

frequency,

disorders).

urgency, or dysuria (urinary

Past Medical History

History

of infertility, ectopic pregnancy,

pelvic inflammatory disease,

urolithiasis, diverticulitis, and any GI or

GU cancers.
previous abdominal or pelvic surgery

Physical Examination

Vital

signs for signs of instability

Abdominal

palpation for tenderness,

masses, & peritoneal signs

Rectal examination to check for

tenderness, masses, and occult blood.

Pelvic Examination

Inspection of external genitals, speculum

examination, and bimanual examination.

Cervix : discharge, uterine prolapse, and

cervical stenosis or lesions.

Bimanual examination:
cervical motion tenderness
uterine enlargement or tenderness
adnexal masses or tenderness

logically divided by the age and

pregnancy status of the patient

Urgent conditions are the first

etiologies to be considered : ectopic
pregnancy, ruptured ovarian cyst, ovarian
torsion, appendicitis, and pelvic
inflammatory disease (PID)

Less urgent conditions span many other

organ systems

GI : gastroenteritis, inflammatory bowel

disease, appendicitis, diverticulitis,
tumors, constipation, intestinal
obstruction, perirectal abscess, irritable
bowel syndrome

Urinary :cystitis, interstitial cystitis,

pyelonephritis, calculi

Musculoskeletal : diastasis of the

pubic symphysis , abdominal muscle
strains

Psychogenic: somatization; effects of

previous physical, psychologic, or sexual
abuse

All patients : Urinalysis &

Urine Pregnancy Test
other testing depends on clinical
disorders suspected:
vaginal wet mount, cervical CT
and NG testing
urine C&S, CBC, ESR, and fecal
occult blood test

Imaging/Ancillary procedures:

most

accurate diagnosis using the least

amount of radiation

Ultrasound

for patients inadequately

examined or if a mass is suspected
Computed Tomography (CT) for
negative or inconclusive ultrasonography
Laparoscopy If the cause of severe or
persistent pain remains unidentified

other pelvic mass

Degenerating Myoma
Follicle/Functional Cyst Rupture
Endometriosis
Ovarian HSSS
Torsion of Adnexal Mass

Benign tumors of muscle cell origin

fibrous tissue from smooth
muscles degeneration
1 of 3 experience pelvic pain or
pressure
relatively poor vascular supply

Vascular compromise: acute degeneration

or torsion produce pelvic pain
pelvic heaviness or dull aching sensation
from edematous swelling
severity of the discrepancy between its
growth and blood supply determines the
extent of degeneration

Hyaline, myxomatous, calcific, cystic, fatty or red

degeneration
Hyaline is the mildest, grossly the surface of the
myometrium is homogenous with loss of whorled
pattern, cellular detail is lost replaced by fibrous
connective tissue

Red or carneous infarction is the most

acute form and causes severe pain and
localized peritoneal irritation
Occurs during pregnancy in approximately
5-10% of gravid women

D/Dx: Pregnancy, adenomyosis and ovarian

neoplasm
discrimination between large ovarian tumors
and myomatous uteri is difficult on PE
The pelvic mass mobility and whether it
moves independently or as part of the
uterus helps
Ultrasound: mixed echodense and
echolucent areas
MRI expensive

72H NSAIDs ( < than 32 weeks AOG)

surgery is discouraged for profuse blood
loss
Medical management options for nongravid
Myomectomy : care should be taken to
prevent adhesion
Myomectomy vs Hysterectomy :
patients age, parity, future reproductive
plans

Pain from ovarian cyst:

expansion of the ovarian cortex

growth phase of follicles last less than

72H

Peritoneal bleeding

rupture
bleeding disorder

ovarian

torsion

cyclic rupture of mature follicle can either

be asymptomatic or with mild transient
pain (mittelschmerz)

results from temporary variation of a

normal physiologic process dependendent
on gonadotropins:
dominant follicle failing to rupture
immature follicle failing to undergo
atresia

appears translucent, thin walled and fluid

filled with watery or clear to straw colored

less common but clinically more

important
develop from mature graffian follicle
during stage of vascularization
becomes cystic from gradual
reabsorption of hemorrhage
3-15 cm in size, average: 4cm
associated with prolonged secretion of
progesterone
Menstrual pattern: normal, delayed or
amenorrhea

Halban syndrome:
Persistently functioning corpus luteum
cyst
Delay in normal period followed by
spotting
Unilateral adnexal pain
Small, tender adnexal mass

Right sided predominance because of

ovarian vein architecture

unilateral mid-cycle acute pain:

tenesmus , transient pelvic tenderness
or deep dyspareunia

typically during strenuous physical

activity, exercise or sexual intercourse

abdominal pain & signs of intravascular

volume depletion

very rare circumstance : intraperitoneal

hemorrhage , death

Vital signs usually normal range

orthostatic changes relative to volume of
hemorrhage
from mild unilateral low abdominal
tenderness to an acute abdomen with
severe tenderness, guarding, rebound,
and peritoneal signs
low-grade fever is sometimes observed
an adnexal mass may be palpable
absence of mass on examination has no
diagnostic value as many cysts
decompress after rupture

Ultrasonography for assessing

gynecologic structures, recognizing
adnexal cysts & hemoperitoneum

instances in which the ultrasound are

nonspecific:
after rupture and decompression of a
cyst
apparent fluid in the pelvis

CT for ambiguous results in a patient

with significant pain

Most pressing issues :

to rule out ectopic pregnancy
ensure adequate pain control
rapidly assess for hemodynamic
instability
allow appropriate triage

Most cyst ruptures are self-limiting requiring

expectant management
symptom dependent on the type
(hemorrhagic vs non-hemorrhagic) and
volume of cyst fluid in the pelvis.
OPD treatment with oral analgesics in the
stable patient
if evolving, admission and anticipatory
management with pain control and serial
abdominal examinations, laboratory testing,
and imaging,

Surgery for continuous bleeding or if unstable

Laparoscopy vs Laparotomy, depending on
clinical presentation, amount of
hemoperitoneum, stability, & operator skill
Hemostasis: suturing, cautery, cystectomy,
wedge resection, or, salpingo-oophorectomy
when necessary
For multiple episodes of ruptured physiologic
cysts or following a single severe episode, it is
reasonable to consider suppression of
ovulation with oral hormonal contraception,
as this may help reduce the risk of recurrence

one of the common causes of

ovarian enlargement

Small superficial black implants

to large frequently bilateral 510 cm multiloculated
hemorrhagic cysts

Pelvic pain, dyspareunia and

infertility

PE: tender and fixed ovaries

Ultrasound: thick walled cyst with

homogenous echo pattern

Laparoscopy provides information about

the location, extent & size of the
endometrial implants for the best
treatment options.

Primary symptom is dysmenorrhea , gradually

worsening over time
pelvic pain and cramping before upto several
days into the period
include lower back and abdominal pain
dyspareunia
pain with bowel movements or urination.
other symptoms: fatigue, diarrhea,
constipation, bloating or nausea,
severity of pain isn't a reliable indicator
of the extent of the condition

medications vs surgery
approach will depend on the severity of
signs and symptoms and pregnancy
plans

pain medications
Hormone therapy: Hormonal
contraceptives, Gonadotropin-releasing
hormone (Gn-RH) agonists and
antagonists, progesterone, Danazol
Conservative surgery
Hysterectomy in severe cases

result from taking fertility medications

ovaries swollen and tender

severe form which can cause rapid

weight gain, abdominal pain,
vomiting and shortness of breath

symptoms begin within 10 days after intake

of ovulation medications , when the ovarian
blood vessels have an abnormal reaction to
the hormone and begin to leak fluid into the
cavity

Follicle-stimulating hormone (FSH),

which stimulates the formation of multiple
fluid-filled cysts (follicles) on the ovaries
Luteinizing hormone (LH), which
supports egg maturation and triggers
ovulation
Human menopausal gonadotropin
(hMG), which has both LH and FSH
Human chorionic gonadotropin (HCG),
a stand-in for the LH surge that, in natural
cycles, causes the follicle to release the
egg

Polycystic ovary- highest risk

Large number of follicles
Young age
Low body weight
High or steeply increasing level of
estradiol (estrogen) before an HCG shot
Previous episodes of OHSS
Migraine headache

aimed at keeping patient comfortable, reducing

ovarian activity & prevention of complications.

Moderate OHSS:
anti-nausea or pain relievers
frequent physical & ultrasound exams
weight monitoring(abdominal girth)
daily urine output monitoring
correction of electrolyte imbalance
paracentesis for excess fluid
encourage mobility
support stockings to prevent blood clot
formation

Severe OHSS
hospitalization for careful monitoring &
more aggressive treatment
intravenous (IV) fluids
surgery for a ruptured ovarian cyst
treatment for liver or lung
complications
anticoagulant medications to reduce the
risk of blood clot formation

twisting of the ovary and rarely the fallopian

tube, cutting off its blood
sudden, severe pain and often with vomiting
likely to occur in women of reproductive age
RISKS: Pregnancy, hormonal use to trigger
ovulation, ovarian neoplasms

Transvaginal ultrasonography for diagnosis

Surgery is done immediately to untwist the

ovary and often to remove it.

Laparoscopy or Laparotomy: to
untwist the ovary and/or the fallopian
tube

Aim is to restore normal circulation:

manually untwisting, sutured into a
secure position to prevent recurrence
salpingo-oophorectomy: gangrene or
with tissue necrosis
Cystectomy or oophorectomy If an
ovarian cyst is present

Uterus
Cervicitis (NG/Chlamydia)
Endometritis
Adnexa
PID/ Salpingitis
TOA/Pelvic TB

Inflammation of cervical epithelium & stroma

deep dyspareunia with discharge & post-coital
bleeding
Histopathology: epithelial necrosis with
severe inflammatory reaction in the mucosa &
submucosa infiltrated with PMN & monocytes

Objective criteria:
gross visualization of yellow mucopurulent
material on white cotton swab &
10 or more PMN leukocytes on gram stained
smear

Alternative criteria:
erythema and edema in an area of cervical
ectopy or
bleeding from endocervical ulceration or
friability when smeared

NAAT of urine or cervix

columnar epithelium attachment
most sensitive & specific(DNA particles)

Ceftriaxone 250mg IM once or

Cefixime 400 PO single dose or
single dose injectable Cephalosporin
(Ceftizoxime, Cefoxitin w/ Probenecid or
Cefotaxime)
Plus treatment for Chlamydia
AZITHROMYCIN 1g single dose oral or
oral Doxycycline 100 BID x 7 days.

Obligatory intracellular organism

NAAT is gold standard

Antigen detection is insensitive & no
longer recommended
cytobrush use for epithelial cell
collection

CDC recommends annual screening:

sexually active women </= 25 years ,
older women with risk factors , new
partner or multiple partners
Partner in the last 60 days is treated

Risk factors:
douching D 1-7 of menses
douching in the last 30 days,
IUD

C T, NG, BV, TV, M. genitalium are

associated
Pain is described as uterine tenderness

2010 CDC: treatment is similar with

ambulatory management of Acute PID

Endometrial biopsy: gold standard

1 plasma cell/120 field of endometrial

stroma combined with

5 or more neutrophils in the superficial
endometrium /400 field
Severe cases: presence of diffuse
lymphocytes and plasma cell in stroma or
necrosis

Spectrum of inflammatory d.o. of upper female

genital tract
Including any: salpingitis, endometritis, tuboovarian abscess & pelvic peritonitis

Polymicrobial
N. Gonorrhoea; C. trachomatis
Vaginal flora
CMV, M. hominis, U. urealyticum,
M. genitalium

All acute cases are screened for HIV

wide variety of symptoms contributes to delay

diagnosis , treatment & prevention of
sequelae

Laparoscopy for diagnosis of salpingitis and

bacteriologic diagnosis but NOT endometritis
not justified when symptoms are vague

Diagnosis is based on clinical findings

65-90% PPV for salpingitis

Maintain low threshold for diagnosis

Diagnosis & management of other causes of

pelvic pain unlikely to be impaired by PID
empiric therapy

Empiric treatment initiated in sexually active

young women, risk for STI, no cause other
than PID, or one of the following minimum
criteria present on PE:
cervical motion tenderness or
uterine tenderness or
adnexal tenderness

oral temperature > 38.3 degrees C

Abnormal cervical or vaginal muco-purulent
discharge
Presence of abundant WBC on wet mount
Elevated ESR
Elevated C-Protein
Laboratory documentation of cervical
gonorrhea or chlamydia infection

Endometrial biopsy of endometritis

TVS or MRI showing
thickened fluid filled tubes with or
without free pelvic fluid or
tubo ovarian complex or
Doppler suggesting pelvic infection
(increase vascularity-hyperemia)
Laparoscopic abnormalities
consistent with PID

Peritoneal involvement in PID

Inflammation leading to localized fibrosis &
scarring of the anterior surface of the liver &
adjacent peritoneum (classic violin string sign)
caused by chlamydia more than gonorrhea sp.

All should be effective against N. gonorrhea

& C. Trachomatis
coverage for anaerobic flora

early treatment to prevent sequelae

consider availabilty, cost, patient

acceptance, and microbial susceptibility
OPD & in-patient therapy yields similar
short and long term clinical outcomes

Shifted to IV regimen after 72H w/o

clinical imrovement
Recommended:
Ceftriaxone 250mg /IM single dose or
Cefoxitin 2g IM & Probenecid 1g single
dose or
Ceftizoxime or cefotaxime (IV 3rd gen
cephalosporins)
PLUS Doxycycline 100mg BID x 2 weeks
+/- Metronidazole 500 BID x 2 weeks (BV)

Quinolones no longer recommended

ONLY if cephalosporins not feasible
Low GC risk and community prevalence
NG test prior to therapy

Levofloxacin 500mg OD or
Ofloxacin 400mg BID x 2weeks +/- Metronidazole

add : Azithromycin 2 g single dose for

NG+ culture
QRNG
or undertermined antimicrobial susceptibility

Surgical emergencies (T/C Appendicitis)

Pregnant
Does not clinically respond to oral
therapy
Unable to follow or tolerate OPD
regimen
Severe illness, nausea and vomiting, or
high fever
Tubo-ovarian abscess
Adolescent

same criteria for

older women ( similar response)

Recommended Regimen A:
Cefotetan 2g IV every 12 H OR
Cefoxitin 2g IV very 6H PLES
Doxycycline 100mg oral or IV every 12
H

Recommended Regimen B:
Clindamycin 900 mg IV every 8H PLUS
Gentamicin 2 mg/Kg BW IV or IM loading,
1.5 mg/kg every 8H or 3-5mg/kg single
daily dosing

IV therapy until 24 H after clinical improvement

Oral doxycycline 100mg BID x 2 weeks

Tubo-ovarian abscess : (anerobic coverage):

Regimen A: add clindamycin or
metronidazole
Regimen B: clindamycin 450 mg QID x
2weeks
Instead of doxycycline

Repeat testing 3-6 months after treatment

for documented NG or CT infection( high
reinfection rate within 6 months of
treatment)

Offer HIV testing more likely to require

surgery

Manage sex partners (asymptomatic)

IUD use 3 weeks after insertion

frequent cause of chronic PID & infertility

M. tuberculosis:
hematogeonous spread from the
lungs

M. bovis (unpasteutized milk):

hematogenous and lymphatic from
GI

Fallopian tubes: predominant site

Mild adnexal tenderness with inability to manipulate

adnexa because of scarring & fixation

suspected when not responding to conventional

antibiotic therapy for acute bacterial PID

Tuberculin test positive

CXR :(+/-)
Laparoscopy: tobacco pouch appearance of the
tubes (distal end everted)
Endometrial biopsy in the secretory phase (sample
for culture as well)- classic giant cell
granulomas & caseous necrosis

Treatment is medical
Five drug treatement (MDR) until
culture yields specific sensitivity
Surgery is reserved for:
persistent pelvic mass,
resistant organism,
older than 40,
endometrial cultures remain positive

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