Pelvic Pain

Time & Date:

ID:          Name, age

CC:         pelvic pain

HPI:      

  • Onset – acute vs. chronic, recurrent or not recurrent with menses (sudden onset – torsion)
  • Location – unilateral vs. bilateral (PID – bilateral; ectopic, torsion, rupture – unilateral)
  • Duration – acute vs. chronic
  • Provoking/ Alleviating factors
  • Quality – (dysmenorrhea – cramping; fibroid – ache; rupture – sharp pain)
  • Radiation – (uterus/Cx/vagina – low back & buttocks; ovaries/tubes – medial aspect of thigh; endometriosis – rectum/perineum)
  • Severity – (torsion – SEVERE pain)
  • Associated Symptoms:
    • arthralgia (PID)
    • fever (PID, rupture)
    • N/V (torsion, PID), diarrhea, constipation
    • dysuria (fibroid)
    • dyspareunia (fibroid)
    • d/c – (PID)
    • vaginal bleeding (fibroid, PID)
  • Timing – association with menses

MEDs:  



 

ALLERGIES:    

Menstrual history:

  • LMP (missed menses 1-2 wks – ectopic)
  • recurrent spotting
  • menorrhagia

GyneHx:              

  • PID

POBHx:               

  • previous ectopics
  • infertility

Sexual Hx:          

  • contraception, IUD (past use increases risk of ectopics)
  • STDs
  • dyspareunia

PMHx:

PSurgHx:            

  • surgeries on tubes
  • laparoscopy/ laparotomy
  • pelvic surgery

PE:  Say you “would do a full physical, focusing on the abdomen & pelvis”

Differential Dx of acute pelvic pain:  ectopic, torsion, rupture, PID, extrapelvic (e.g. appendicitis)

Differential Dx of chronic pelvic pain recurrent with menses:  dysmenorrhea, desmenorrhea (endometriosis, adenomyosis, chronic PID, assoc’d IUD)

Differential Dx of chronic pelvic pain recurrent but not assoc’d with menses:  mittelschmerz, IBD, IBS

Differential Dx of non-recurrent chronic pelvic pain:   neoplasm, non-gyne, enigmatic or psychogenic

PID         – usually chlamydia or gonorrhea

– to dx, need:          lower abdo pain, tenderness on exam, cervical motion tenderness, adnexal tenderness AND one or more of: fever, d/c, lab evidence of STD, elev’d WBC, elev’d ESR

ECTOPIC

Triad:     abdominal pain, bleeding, + B-HCG

– may have shoulder tip pain, light vaginal bleeding, cervical motion tenderness, adnexal  tenderness +/- mass, enlarged uterus

Risk factors:         PID, tubal surgery, ectopic hx, abortions, endometriosis, IUD, Rx with infertility drugs

TORSION

  • RARE
  • sudden onset severe pelvic pain, N/V
  • unilateral adnexal tenderness
  • usually due to tumor (dermoid) or enlarged ovary

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