Symptom Finder - Pelvic Pain
Visualizing the anatomy of the pelvic area is the key to forming a list of the causes of pelvic pain. Starting at the skin and working inward, we have the muscles and fascia, bladder, peritoneum, uterus, ovaries, fallopian tubes, intestines, rectum, and spine. The skin helps to recall herpes zoster, the muscle and fascia suggest contusion and hernia, and the peritoneum would remind one of peritonitis and endometriosis. The uterus, ovary, and tubes would prompt consideration of PID, dysmenorrhea, pelvic congestion, and ectopic pregnancy.
Ovarian tumors can also cause pelvic pain by twisting on their pedicle. A pedunculated uterine fibroid can also twist on its pedicle causing severe pain. If the pelvic pain is related to the menstrual cycle, one should recall mittelschmerz. Considering the intestines, one should recall appendicitis and diverticulitis. Considering the rectum should prompt recall of hemorrhoids, fissures, and rectal abscess.
Finally, thinking of the spine should suggest rheumatoid spondylitis, osteomyelitis, herniated disk, and other conditions.
Approach to the Diagnosis
A good pelvic and rectal examination is essential. These will often disclose a mass or other pathology to explain the pain. If there is a vaginal discharge, a smear and culture for gonococcus and Chlamydia need to be done. A pregnancy test will help rule out an ectopic pregnancy, but ultrasonography is most useful.
A gynecology consult should be obtained when there is any doubt. In acute cases, the gynecologist may proceed with an exploratory laparotomy immediately.
Other Useful Tests
1. CBC (PID, ruptured ectopic pregnancy)
2. Chemistry panel
3. Urinalysis (cystitis, pyelonephritis)
4. Urine culture (cystitis, urinary tract infection [UTI])
5. Pregnancy test (ectopic pregnancy)
6. CT scan of abdomen and pelvis (only if pregnancy has been ruled
7. Culdocentesis (PID, neoplasm, ectopic pregnancy)
8. Laparoscopy (PID, neoplasm, ectopic pregnancy)
9. Peritoneal tap (peritonitis, ruptured ectopic pregnancy)