Acute pelvic pain
| Cause | Clues | First test |
|---|---|---|
| Ectopic pregnancy | Positive test, unilateral pain, bleeding, shoulder tip | hCG and transvaginal ultrasound |
| Ovarian torsion | Sudden severe unilateral pain, vomiting, a known cyst or a dermoid, adnexal tenderness | Ultrasound with Doppler (flow may be present; the clinical picture decides); laparoscopy |
| Ruptured or haemorrhagic cyst | Sudden pain mid-cycle, free fluid | Ultrasound; observe if stable |
| Pelvic inflammatory disease | Fever, discharge, cervical motion and adnexal tenderness, risk factors | Swabs, treat empirically; ultrasound for a tubo-ovarian abscess |
| Appendicitis | Migrating pain, anorexia, right lower quadrant | Ultrasound or CT |
| Urinary | Dysuria, frequency, flank pain, haematuria | Urinalysis, culture |
| Degenerating fibroid | Known fibroid, pregnancy | Ultrasound |
Torsion
Doppler flow does not exclude torsion: the ovary has a dual blood supply and venous obstruction comes first. A young woman with sudden severe unilateral pain, vomiting and an enlarged tender ovary goes to laparoscopy. Detorsion saves the ovary; the ovary is not removed because it looks dark.
Haemorrhagic ovarian cyst
Transvaginal. A unilocular ovarian cyst with a fine reticular (lace-like) internal pattern of fibrin strands.
Open in the Ultrasound LabMature cystic teratoma (dermoid cyst)
Transvaginal. A complex cystic mass with a very echogenic component.
Open in the Ultrasound LabChronic pelvic pain
- Pain for 6 months or more, cyclical or not, affecting function. Endometriosis, adenomyosis, pelvic inflammatory sequelae and adhesions on the gynaecological side; irritable bowel, interstitial cystitis, myofascial pain and central sensitisation alongside.
- History: relation to the cycle, dyspareunia (deep suggests endometriosis or pelvic pathology), dyschezia and dysuria with menses, prior infection or surgery, mood and trauma history, taken without assumptions.
- Examination with consent and pacing: abdominal wall trigger points, pelvic floor tenderness, uterosacral nodularity, adnexal masses, a fixed retroverted uterus.
- Ultrasound for endometrioma and adenomyosis; MRI for deep disease; laparoscopy when it will change management, not as a reflex.
- Treatment is layered: hormonal suppression, analgesia that avoids long-term opioids, pelvic physiotherapy, psychological support, surgery for defined disease.
On the modelOvariesFallopian tubesRectum and pouch of DouglasBladder