Acute Pelvic Pain

Acute pain due to ischemia or injury to a viscus is accompanied by autonomic reflex responses such as nausea, vomiting, restlessness, and sweating. The following is a discussion of some of the important gynecologic causes of acute abdominal pain.

Culdocentesis is a very useful diagnostic aid for differentiating the cause of acute gynecologic pain. In the absence of a positive pregnancy test result, fresh blood suggests a corpus luteum hemorrhage, old blood suggests a ruptured endometrioma (chocolate cyst), purulent fluid suggests acute pelvic inflammatory disease (PID), and sebaceous fluid indicates a dermoid cyst.

Ectopic pregnancy

An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients.

Abdominal examination findings include tenderness and guarding in the lower quadrants. Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish bowel sounds may develop.

Pelvic examination may reveal cervical motion tenderness that is exaggerated on the side of the tubal ectopia.

Initially, a sensitive serum or urine pregnancy test should be performed. Transvaginal ultrasonography should be performed. If an intrauterine gestational sac with a fetal pole is identified, the chances of a coexisting ectopic pregnancy are remote. Such a heterotopic gestation should be considered in patients taking ovulation-inducing drugs. Serial serum beta-human chorionic gonadotropin (hCG) estimations are often helpful in making the diagnosis. In early intrauterine gestations, the doubling time for hCG is usually 48 hours. Only 15% of cases are exceptions to this rule. In the absence of the availability of ultrasonography or in an emergency setting, culdocentesis can be of value to detect unclotted blood. A hematocrit of less than 16% (in the peritoneal blood) excludes hemoperitoneum.

Laparoscopy should be attempted if the patient is hemodynamically stable, a high index of suspicion remains, or the patient complains of increasing pain despite adequate analgesia.

Treatment options for an unruptured ectopic pregnancy include salpingostomy and salpingectomy. These may be performed laparoscopically or by open procedure. Methotrexate, a folic acid antagonist, is also used for the treatment of unruptured ectopic pregnancy. A ruptured ectopic pregnancy requires a laparotomy with removal of blood clots.

Adnexal masses

Corpus luteum hematoma

This condition develops in the luteal phase of the menstrual cycle. Slow leakage produces minimal pain. Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock. Generalized abdominal pain and syncope are features of such a presentation. Treatment includes laparoscopy or laparotomy, evacuation of clots, and control of ovarian bleeding.