Acute Pelvic Pain-2019

A c u t e Pe l v i c P a i n
a, b
Kayla Dewey, MD *, Cory Wittrock, MD
KEYWORDS
Pelvic pain Ovarian torsion Pelvic inflammatory disease Ovarian cyst
Nongynecologic pain
KEY POINTS
Acute pelvic pain can have gynecologic and nongynecologic causes.
Determining pregnancy status is the critical first step in the management of patients with
pelvic pain who are of reproductive age.
Pelvic ultrasound is the most useful imaging test for pelvic pathologic conditions.
Ovarian torsion can occur with normal vascular flow on Doppler ultrasound.
Pelvic inflammatory disease can occur without risk factors for sexually transmitted
infections.
Rare but serious complications of intrauterine devices include uterine perforation.
INTRODUCTION
Pelvic pain is a frequent complaint of female patients presenting to the emergency

department (ED). Abdominal pain is the most common reason behind 5% to 10% of
ED visits annually; exact prevalence of visits due to pelvic pain specifically is unknown,
because pelvic pain is rarely separated from abdominal pain in the various studies and
available survey data.1–3 Pelvic pain can be a challenging complaint because of the
wide array of possible pathologic conditions. Determining pregnancy status is the crit-
ical first step in the management of patients with pelvic pain who are of reproductive
age. In nonpregnant patients, both gynecologic and nongynecologic causes of pelvic
pain must be considered. Emergency physicians should understand the initial man-
agement of nonpregnant patients who present with acute pelvic pain as well as the
critical diagnoses and how to safely disposition these patients from the ED.
EMERGENCY DEPARTMENT EVALUATION
The initial ED evaluation of the patient with pelvic pain includes general overall impres-
sion, identification of vital sign abnormalities, obtaining a history, and performing a
Disclosure Statement: No disclosures.

a
Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood
Avenue, Rochester, NY 14642, USA; b Medstar Georgetown University Hospital, 3800 Reservoir
Road Northwest, Washington, DC 20007, USA
* Corresponding author.
E-mail address: Kayla_Dewey@urmc.rochester.edu
Emerg Med Clin N Am 37 (2019) 207–218

https://doi.org/10.1016/j.emc.2019.01.012 emed.theclinics.com
0733-8627/19/ª 2019 Elsevier Inc. All rights reserved.
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uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2019. Elsevier Inc. Todos los derechos reservados.
208 Dewey & Wittrock
physical examination. Characteristics of the pain, including timing and severity, asso-
ciated symptoms, such as vomiting, fever, vaginal bleeding or discharge, history of
similar symptoms from known diagnoses, and risk factors play a part in establishing
an initial differential.4 Because of the multiple organ systems that contribute to or
are contained within the pelvis, a broad differential must be initially considered in these
patients (Table 1).
Pregnancy status is the single most important determination for a patient of child-
bearing age presenting with pelvic pain. Urine pregnancy tests are widely available
and most commonly used in the ED. Establishing pregnancy status is also possible
via blood tests in the form of qualitative or quantitative b-human chorionic gonado-
tropin (b-hCG) levels. In the unstable patient, it may be necessary to use serum tests
or point-of-care ultrasound to determine if there is an obvious pregnancy or free fluid in
the abdomen. In stable patients, urine or blood b-hCG testing can be performed
depending on the availability of specimens and clinician preference.
Traditionally, a full pelvic examination consisting of a bimanual and speculum exam-
ination is performed as part of the ED evaluation of nonpregnant patients with pelvic
pain. A bimanual examination can be helpful in identifying cervical motion tenderness,
or uterine or adnexal tenderness, and is necessary to make the diagnosis of pelvic in-
flammatory disease (PID). Speculum examination is frequently performed, although it
often does not add useful clinical information. In one study of women presenting to the
ED with either acute abdominal pain or vaginal bleeding, the pelvic examination find-
ings were unexpected and changed clinical management in only 6% of patients.5
Sexually transmitted infections (STI), such as Chlamydia trachomatis and Neisseria
gonorrhoeae, can be detected from urine antigens, making obtaining cervical samples
unnecessary. If urine antigen tests are unavailable, patients may self-administer
vaginal swabs to obtain samples for STI testing. The decision to perform a pelvic ex-
amination ultimately rests with the patient and the clinician. In diagnosing gynecologic
emergencies, history and a focused ultrasound examination were found to be the
most successful combination, whereas physical examination did not add substantial
diagnostic value.6 Laboratory tests, such as complete blood counts, chemistry
panels, and urinalysis, may be helpful especially if the cause of the patient’s pain is
suspected to be nongynecologic.
Many patients presenting to the ED with pelvic pain will require imaging studies.
Indeed, up to 65% of patients presenting with nontraumatic abdominal or pelvic
pain will receive an imaging study in the ED.7 Because the differential diagnosis for
pelvic and/or lower abdominal pain in women is so broad, choosing an initial imaging
modality can be difficult. Ultrasound is the initial imaging modality of choice for women
Table 1
Gynecologic versus nongynecologic causes of pelvic pain
Gynecologic Causes Nongynecologic Causes

Ovarian torsion Appendicitis
Ovarian cyst Nephrolithiasis
Pelvic inflammatory disease Hernia
Tubo-ovarian abscess Diverticulitis
Fibroid disease Small bowel obstruction
Dysmenorrhea/menorrhagia Cystitis/urinary tract infection
Malpositioned IUD Adhesions/functional abdominal pain
Endometriosis Musculoskeletal pain
Acute Pelvic Pain 209
with acute pelvic pain and concern for gynecologic cause because there is high sono-
graphic resolution of pelvic organs, and ultrasound does not confer ionizing radiation,
is less expensive compared with computed tomography (CT) or MRI, and is readily
available in most EDs.8 If the suspicion for nongynecologic causes of pelvic pain is
significantly higher than the gynecologic causes, CT scans offer superior diagnostic
efficacy and can be performed first.9 If the CT shows concerning pelvic findings, a
follow-up ultrasound should be performed to further evaluate the pelvic structures.
In one study, 22% of CT examinations performed on women of reproductive age
were found to have isolated pelvic conditions.10 If a CT is entirely negative, there is lit-
tle to no utility in obtaining an immediate follow-up ultrasound.11 Reimaging the pelvis
with ultrasound is also not useful if the CT detected abnormalities in which there is a
characteristic diagnostic appearance, if the finding has a clearly established origin
within the myometrium, or if there is an abnormality that has a limited differential diag-
nosis and requires temporal observation to distinguish further.12
GYNECOLOGIC CAUSES OF PELVIC PAIN
When considering the gynecologic causes of pelvic pain, it is helpful to divide the
causes into adnexal causes, including ovarian cysts, ovarian torsion, PID, and tubo-
ovarian abscess (TOA), and uterine causes, including dysmenorrhea, fibroids, and
complications of intrauterine devices (IUDs).
ADNEXAL CAUSES
Ovarian Cysts
Ovarian cysts are a common cause for pelvic pain in women, with ruptured cysts more
likely in women of reproductive age.13 Most ovarian cysts begin as physiologic follic-
ular or corpus luteal cysts; they can cause pain when they grow rapidly, hemorrhage,
or rupture. Follicular cysts occur when the nondominant follicle does not reabsorb and
instead grows in size. These cysts are thin-walled, avascular, and usually unilocular.
Corpus luteal cysts, if they persist beyond menstruation, are thicker, with irregular
and hypervascular walls.8 Follicular cysts are more common than corpus luteal cysts;
corpus luteal cysts are more likely to be symptomatic and more likely to rupture or
hemorrhage.14 Pathologic cysts, such as endometriomas, dermoid cysts, or cystic
components of benign or malignant neoplasms, can also cause pain from growth,
rupture, or hemorrhage.15 Risk of cyst rupture increases with ovulation; there is an
increased risk with ovulation induction treatments and a decreased risk with use of
oral contraceptive pills.16 Patients will usually report sudden-onset, unilateral, dull,
or colicky pain, and sometimes symptom onset after sexual intercourse. A bimanual
examination can be performed to evaluate for adnexal tenderness and the presence
of an adnexal mass. Transvaginal ultrasound is the imaging modality of choice and
will be able to characterize the cyst as well as free fluid. If a cyst has ruptured, the
ovary may appear normal because the rupture has decompressed the cyst; however,
a moderate to large amount of free fluid is usually present.17 Assessment of hemoglo-
bin and hematocrit is necessary in the presence of hemorrhage, and serial testing can
be helpful in the disposition decision.
Management depends largely on the degree of pain and hemorrhage, and some-
times on the type of cyst or mass. Patients with cysts without concern for torsion
and without large hemorrhage can be managed conservatively as outpatients with
symptom control and follow-up with a gynecologist for a repeat ultrasound in 4 to
6 weeks.17 Patients who are hemodynamically unstable with a large degree of hemor-
rhage require emergent gynecology consultation because they may require
laparoscopy or admission for monitoring with serial examinations.18,19 Rarely, a der-

moid cyst (mature teratoma) can rupture and sebaceous material can spill into the
abdominal cavity, leading to chemical peritonitis and hemorrhagic shock. These pa-
tients will almost always require emergency surgery.20 Similarly, if an endometrioma
ruptures, the patient can experience significant hemorrhage and will likely need surgi-
cal intervention.21
Ovarian Torsion
Ovarian torsion is a “can’t-miss” diagnosis that must be made in the ED, because early
diagnosis is critical in preserving ovarian function and future fertility. Although
frequently discussed, it is an uncommon cause of pelvic pain, accounting for only
3% of gynecologic emergencies.22 Torsion occurs when the adnexa, ovary, or more
rarely the fallopian tube alone, completes at least one full turn around the long axis
of the infundibulopelvic ligament and the tubo-ovarian ligament.23 This leads to stro-
mal edema because the venous system is impaired first, followed by hemorrhagic
infarction and necrosis of the adnexal structures distal to the point of torsion. The de-
gree of vascular compromise depends on the number and severity of rotations. The
ovaries have dual blood supply from the ovarian and uterine arteries, and thus, torsion
can occur without complete loss of vascularity.24
Patients will present with pelvic or lower abdominal pain, usually unilateral, and
frequently with nausea and vomiting. Premenopausal women often describe the
pain as acute, sharp, intermittent, colicky, and severe. Postmenopausal women
more commonly describe continuous dull abdominal pain.25 Risk factors for adnexal
torsion include previous torsion, adnexal masses or cysts, use of assisted reproduc-
tive technologies leading to ovarian hyperstimulation, polycystic ovarian syndrome,
pregnancy, and previous tubal ligation.26 Endometriosis, PID, and malignant lesions
make torsion less likely because they have a role in affixing the ovary to the pelvic
wall.27 Torsion occurs more frequently on the right side compared with the left,
because mass effect of the sigmoid colon is thought to prevent left adnexal twisting.
Physical examination findings include localized lower abdominal/pelvic tenderness,
adnexal tenderness, or mass on bimanual examination, and severe cases can result
in frank peritonitis. Laboratory tests rarely add to the diagnosis beyond the initial preg-
nancy test, although a leukocytosis has been shown to have a modest positive predic-
tive value for adnexal torsion.28
Pelvic ultrasonography is the initial study of choice for ovarian torsion. Transvaginal
ultrasound and color Doppler should be used whenever possible for increased accu-
racy. Previous studies have cited rates of diagnostic accuracy from 74.6% to
87%.29,30 There is a spectrum of sonographic findings, ranging from ovarian enlarge-
ment and edema to complete loss of vascular flow (Table 2). The presence of the
“whirlpool sign,” a clockwise or counterclockwise wrapping of hypoechoic vessels
around a central axis, correlates closely with surgically proven torsion.31,32 In addition,
women with pathologic vascular flow were statistically significantly more likely to have
surgically demonstrated torsion.33 However, it is essential to know that the persis-
tence of arterial flow on Doppler does not rule out adnexal torsion, because several
factors can contribute to the preservation of arterial flow despite active torsion,
including dual arterial supply to the ovary, intermittent and partial torsion, or isolated
venous occlusion.24 Although CT is not the ideal study for evaluation of the pelvic or-
gans, patients with torsion may have received a CT before ultrasound because of
concern for other causes of pain. Common CT findings that should raise concern
for ovarian torsion include displacement of the adnexa to the contralateral side, devi-
ation of the uterus to the side of the torsed ovary, adnexal enlargement, ovarian cysts
Table 2
Ultrasonographic findings in ovarian torsion
Early/Indeterminate Findings Late/Diagnostic Findings

Ovary size >4 cm “Follicular ring sign”
Hyperechoic stromal edema “Whirlpool sign”
Peripherally displaced follicles Venous flow impedance
Pelvic ascites Arterial flow impedance
or masses, twist of the ovarian pedicle, infiltration of pelvic fat, and pelvic ascites.34,35
In one study of surgery-proven cases of torsion, CT and ultrasound showed equal
diagnostic performance.36 Although a CT with concerning features for torsion should
prompt increased suspicion and may incite the evaluating clinician to consult gynecol-
ogy, an ultrasound may provide further evidence for the consulting team. MRI is
another imaging modality option, although often limited in availability from the ED.
MRI allows for the distinction between the edema of the ovary and the adjacent fallo-
pian tube, but similar to the limitations of ultrasound, persistence of adnexal enhance-
ment does not exclude torsion.24,37
Ovarian torsion is a surgical emergency, yet several studies have consistently
demonstrated that the diagnosis is often missed initially. For most patients with torsion
who have a delayed diagnosis, clinicians failed to consider the diagnosis at initial pre-
sentation.22 Timely detection is key because there is a higher chance of successful
detorsion, and therefore, preservation of ovarian function, the earlier the diagnosis
is made. Gynecologic consultation should be obtained early in the ED course of any
patient with suspected ovarian torsion. If no gynecologist is immediately available,
transfer to a tertiary center for higher level of care is warranted. If the adnexa can
be successfully detorsed in the operating room, there is an approximately 80%
chance of normal follicular development on follow-up ultrasound.38 Salpingo-
oophorectomy may be required if the adnexa remains necrotic after detorsion. If a
cyst or other adnexal mass is found and is considered to be the cause of torsion, cys-
tectomy or cyst drainage is usually performed; this along with adnexal fixation has
been shown to significantly reduce the chance of retorsion.39 In postmenopausal pa-
tients with an adnexal mass concerning for malignancy, ultimate surgical care may be
delayed because more extensive resections with biopsies may be required.40
Pelvic Inflammatory Disease and Tubo-Ovarian Abscess

PID is an infection of the upper genital tract in women and may include the uterus, fal-
lopian tubes, and ovaries. Cervicitis is infection limited to the cervix; endometritis,
salpingitis, and oophoritis all fall under the umbrella of PID. TOA is a complication in
which infection becomes localized and contained into abscess formation. Other com-
plications include peritonitis, pyosalpinx, and perihepatitis (Fitz-Hugh-Curtis syn-
drome). Long-term sequelae of PID include increased risk for ectopic pregnancy,
infertility, recurrent infection, and chronic pelvic pain.41 Most acute infections
(<30 days’ duration) are attributed to untreated STIs, including N gonorrhoeae and
C trachomatis or bacterial vaginosis-associated microbes. The remainder of cases
are attributed to respiratory or enteric organisms that have colonized the lower genital
tract.42 Although most patients have mild to moderate disease and many can be safely
treated with outpatient management, serious complications can occur, such as Fitz-
Hugh-Curtis syndrome (4%–6% of patients with PID) and TOA (3%–16% of patients
hospitalized for PID).41
EMERGENCY DEPARTMENT EVALUATION
PID is largely a clinical diagnosis. PID should be suspected in any sexually active
woman presenting with pelvic or lower abdominal pain. Women who are younger
(<25), report a higher number of sexual partners, lack of condom use, recent STI treat-
ment, or HIV-positive status are at increased risk.41 Patients often present with com-
mon and nonspecific symptoms, such as pelvic pain, vaginal discharge, dysuria, and
postcoital bleeding. Systemic symptoms, such as nausea, vomiting, and fevers, are
less common in uncomplicated PID.43
Patients suspected of having PID should have a bimanual examination to evaluate for
cervical motion tenderness, uterine tenderness, or adnexal tenderness. Patients with
pyosalpinx or a TOA may have a palpable adnexal mass.44 A speculum examination
can be done to examine for cervical discharge and friability.41 Laboratory tests beyond
the initial pregnancy test include nucleic acid amplification tests for N gonorrhoeae/C tra-
chomatis from either cervical or vaginal swabs or from first-void urine.45 Cervical wet
mount can be useful in detecting bacterial vaginosis and trichomoniasis. Patients who
have recently completed an antibiotic course for gonorrhea or chlamydia should have a
cervical culture sent in order to identify potentially antibiotic-resistant organisms.41
Pelvic ultrasonography is often obtained in patients with suspicion for PID in order to
evaluate for other potential causes of pain as well as to evaluate for complications of
PID. Patients with mild PID will usually have normal ultrasounds. However, ultrasound
can have some findings indicative of PID, including thick tubal walls and the cogwheel
sign.46 Other nonspecific findings, including incomplete septations, polycystic
ovaries, adnexal masses, free fluid, and hydrosalpinx, are not helpful in differentiating
between patients with PID versus those without.41 CT and MRI can also be used but
have low sensitivity in mild to moderate PID. MRI has superior resolution when
compared with CT in identifying tubal thickening.47
Current guidelines from the Centers for Disease Control and Prevention recommend
that presumptive therapy for PID be initiated in sexually active women with unex-
plained pelvic pain and one or more of the following: cervical motion tenderness, uter-
ine tenderness, or adnexal tenderness. Although this may seem overly expansive,
these criteria have a sensitivity of greater than 95%.48 Additional criteria can support
the diagnosis of PID but are not required to initiate treatment (Table 3). Given that the
consequences of untreated PID include future infertility, this broad definition helps to
minimize the rates of misdiagnosis.
Once PID has been clinically diagnosed, treatment and disposition depend on degree
of severity. Patients with mild to moderately severe PID can receive intramuscular and
oral antibiotics (Table 4) and be safely discharged, with the instructions to abstain from
Table 3
Diagnosis of pelvic inflammatory disease
Unexplained pelvic or lower abdominal pain plus one or more minimum criteria on
examination
Minimum criteria: Additional criteria, not required:
Cervical motion tenderness Oral temperature >101 F (38.3 C)
Uterine tenderness Abnormal cervical discharge or cervical friability
Adnexal tenderness Presence of white blood cells on microscopy of
vaginal fluid
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Cervical infection with N gonorrhoeae or C trachomatis
Table 4
Antibiotic regimens for pelvic inflammatory disease
Mild to Moderate PID Severe PID TOA

Ceftriaxone 250 mg Cefotetan 2 g IV q12h Same as for severe PID
intramuscularly 1 or Cefoxitin 2 g IV q6h
AND AND AND
Doxycycline 100 mg Doxycycline 100 mg Clindamycin, metronidazole,
po bid 14 d orally or IV q12h or ampicillin/sulbactam
sexual intercourse until treatment is complete and until their partner or partners have
been treated. It is important to note that although cervicitis may be treated with a single
dose of intramuscular ceftriaxone and a single dose of oral azithromycin, this treatment
regimen is not sufficient for PID. Patients with severe disease should be admitted for
intravenous (IV) antibiotics and further monitoring; this includes patients who have he-
modynamic instability, peritonitis, severe systemic symptoms, concern for treatment
failure of oral antibiotics, and inability to tolerate oral antibiotics.42 Patients with a
TOA should be observed for at least 24 hours to ensure clinical stability and improve-
ment.48 If there is evidence of TOA rupture, urgent gynecologic consult is needed for
operative management. Antibiotic regimens should be broadened to include coverage
of anaerobic organisms in patients with TOA because of their higher prevalence (see
Table 4). Special consideration should be made in patients with an IUD and PID; in
most cases, the IUD is left in place with no difference in patient outcomes.49
UTERINE CAUSES
Acute pelvic pain can also be due to pathologic conditions localized to the uterus.
Dysmenorrhea, or painful cramps that coincide with menstruation, is one of the
most common causes of pelvic pain in women of reproductive age.50 Primary
dysmenorrhea is pain in the absence of recognizable pelvic pathologic condition,
whereas secondary dysmenorrhea is from an identified cause. Primary dysmenorrhea
usually occurs in adolescents and younger women, whereas endometriosis is the
most common cause of secondary dysmenorrhea. Symptoms may include menor-
rhagia, dyspareunia, postcoital bleeding, and infertility.51 Most patients with dysmen-
orrhea can be safely discharged from the ED with symptom control and outpatient
gynecology follow-up. Nonsteroidal anti-inflammatory drugs, such as ibuprofen and
naproxen, are first-line treatments for pain control. Hormonal contraceptives are
commonly recommended, although there are no large studies to suggest efficacy.52
These contraceptives may be initiated from the ED if the clinician desires and if the pa-
tient has adequate follow-up care.
Fibroids are another common cause of pelvic pain and are found in up to 70% to
80% of women by age 50.53 Patients with uterine fibroids may be asymptomatic
with incidentally found fibroids, or they may be chronically or acutely symptomatic.
Twenty percent to 50% of women with symptomatic fibroids report a significant
impact on their quality of life.54 Uterine fibroids are the most common gynecologic tu-
mor; they are benign and arise from the uterine smooth muscle tissue or myometrium.
Fibroids, or myomas, can be solitary or multiple and vary in size, location, and vascu-
larity. Subserosal fibroids project outside the uterus; intramural are contained within
the myometrium, and submucosal project into the cavity of the uterus.54 Fibroids
are a common source of menorrhagia, but they rarely cause acute pelvic pain unless
they have degenerated, have torsed, or are associated with adenomyosis or endome-
triosis. Larger fibroids may impact neighboring anatomic structures and cause pelvic
pressure, and bowel and urinary symptoms. Acute torsion of a subserosal fibroid
around its vascular pedicle can cause ischemia and peritonitis; although this is very
rare, it is a surgical emergency requiring gynecologic consultation.55,56 In the absence
of a surgical emergency or vaginal bleeding requiring observation or transfusion, pa-
tients with symptomatic fibroids can safely be discharged from the ED with close gy-
necology follow-up.
Another rare but important cause of pelvic pain is complications of IUDs. As the use
of IUDs has increased in recent years, so too has the need for the emergency clinician
to understand possible complications and side effects. Patients can present with
postinsertion bleeding and uterine cramping, which can be safely managed conserva-
tively if there is no evidence of severe bleeding or uterine perforation. Perforation is
rare, occurring in 1 to 2/1000 patients, usually immediately postinsertion with one-
third occurring 12 months after insertion.57,58 Lactation and recent delivery are inde-
pendent cofactors for increased risk of perforation following IUD insertion.59 Rarely,
IUDs can be spontaneously expelled from the uterus. To evaluate for perforation or
IUD expulsion, a speculum examination can be performed to visualize IUD strings in
the cervical os. If the strings are not visualized or appear unusually short, an ultrasound
can be performed to identify IUD position. If ultrasound confirms correct IUD position,
no further action is necessary. If the IUD is not visualized in the uterus on ultrasound, a
kidney, ureter, bladder (KUB) radiograph can be obtained. If the KUB does not show
the IUD, it can be assumed that the IUD was expelled. If the KUB shows an intraper-
itoneal IUD, gynecology should be consulted for surgical removal. Rarely, patients
present with hemodynamic instability and peritonitis. These patients should be emer-
gently evaluated for laparoscopy. Expert consultation is recommended for all patients
with confirmed or suspected uterine perforation.
NONGYNECOLOGIC CAUSES
Appendicitis is the most common cause of abdominal pain that requires surgery, and
the presentation can often mimic that of right adnexal torsion.24 In young women in
which the two diagnoses are equally suspected, initial imaging with ultrasonography
is recommended to help identify adnexal pathologic conditions early, preserve fertility
if torsion is confirmed, and avoid radiation from CT. As outlined in earlier discussion,
many patients with suspicion for nongynecologic causes receive CT imaging first,
which can identify some pelvic pathologic conditions that may be the source of the
patient’s pain. Other causes in addition to appendicitis that should be considered
include nephrolithiasis, diverticulitis, cystitis/pyelonephritis, hernias, small bowel
obstruction, musculoskeletal pain, functional abdominal pain, and pain from adhe-
sions of prior surgeries (see Table 1). It is important to remember that abdominal
and pelvic pathologic conditions often have poorly localizing symptoms, and it may
be necessary to pursue further imaging or testing if the initial workup is unrevealing.
SUMMARY
Acute pelvic pain in women is often related to the pelvic organs, but it can be difficult
to distinguish between gynecologic and nongynecologic causes on initial history and
examination only. Advanced imaging with pelvic ultrasound and CT imaging can help
delineate the cause. Determining pregnancy status is the critical first step in the man-
agement of patients with pelvic pain who are of reproductive age. Ovarian torsion is a
serious cause of acute pelvic pain and can occur with normal vascular flow on Doppler
ultrasound. PID can be difficult to diagnose, and clinicians should have a low threshold
for initiating presumptive treatment to avoid serious long-term sequela, such as
infertility. Many pelvic conditions, such as ovarian cysts, fibroids, and dysmenorrhea,
can safely be managed conservatively as outpatients. Rare but serious complications
of IUDs include uterine perforation and device expulsion. Emergency clinicians must
be well versed in the approach to pelvic pain and prepared to manage the various
complications that can arise.
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Acute Pelvic Pain-2019

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Acute Pelvic Pain-2019

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A c u t e Pe l v i c P a i n

Pelvic pain is a frequent complaint of female patients presenting to the emergency

EMERGENCY DEPARTMENT EVALUATION

Disclosure Statement: No disclosures.

Emerg Med Clin N Am 37 (2019) 207–218

Gynecologic Causes Nongynecologic Causes

GYNECOLOGIC CAUSES OF PELVIC PAIN

laparoscopy or admission for monitoring with serial examinations.18,19 Rarely, a der-

Early/Indeterminate Findings Late/Diagnostic Findings

Pelvic Inflammatory Disease and Tubo-Ovarian Abscess

EMERGENCY DEPARTMENT EVALUATION

Mild to Moderate PID Severe PID TOA

1. Mura P, Serra E, Marinangeli F, et al. Prospective study on prevalence, intensity,

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