Assess, diagnose, manage, and refer where applicable a woman presenting with acute pelvic pain

Clinical overview

This chapter is the operational complement to Acute pelvic pain pathophysiology. There you learn why pelvic pain hurts. Here you learn what to do when she walks through the door at 02:00 on a Saturday with severe lower abdominal pain. Acute pelvic pain in a woman of reproductive age is a high-stakes presentation: an unrecognised ruptured ectopic, a missed torsion, or a delayed tubo-ovarian abscess all carry serious morbidity, and three of those are routinely missed because the clinician anchored on a benign diagnosis early.

A safe approach is a parallel resuscitation–assessment–diagnosis pathway. You do not move sequentially from history to examination to investigation to disposition; you do all four simultaneously, with re-evaluation at fixed intervals. The single most important triage question is "is this patient haemodynamically stable?" — because the answer drives whether she goes to a CT scanner or straight to theatre.

The chapter is organised the way the consultation actually flows: initial triage (ABCDE), focused history, focused examination, prioritised investigations, working differential, definitive disposition, follow-up. We then drill into the three high-risk diagnoses you cannot miss: ectopic pregnancy, ovarian torsion, and tubo-ovarian abscess.

Core knowledge

Triage and primary survey

Resuscitate first. ABCDE.

• Airway and breathing: usually unremarkable unless septic.
• Circulation: tachycardia, narrow pulse pressure, cool peripheries, delayed capillary refill, low or postural blood pressure. Two large-bore cannulae. Blood for FBC, U&E, CRP, group-and-save (cross-match 2 units if any haemodynamic concern), lactate, blood culture if febrile.
• Disability: GCS, glucose.
• Exposure: temperature, full abdominal exposure, look for surgical scars and signs of self-harm or trauma.

A pregnant or pregnancy-possible woman in shock without obvious external bleeding is a ruptured ectopic until proven otherwise. Do not wait for ultrasound; alert theatre and resuscitate with crystalloid and group-specific blood while you confirm.

Assessment

Focused history

Ten minutes, structured. The non-negotiable items:

1. Onset, character, radiation, severity, time course — already discussed in Acute pelvic pain pathophysiology. Has the pain changed in character (dull → sharp) suggesting peritoneal involvement?
2. Last menstrual period; cycle regularity; possibility of pregnancy. Always assume pregnancy is possible until β-hCG returns. Sexual activity, partners, condom use, contraception (and exact contraception type — a Mirena dramatically shifts your differential).
3. Associated symptoms: bleeding (amount, clots, products), discharge (colour, odour), nausea/vomiting, fever, dysuria, bowel symptoms, shoulder-tip pain.
4. Past gynaecological history: prior STIs, prior PID, prior ectopic, fertility treatment, fibroids known, endometriosis known, ovarian cysts known, recent gynaecological procedures (TOP, hysteroscopy, IUD insertion).
5. Obstetric history: parity, prior caesarean (consider scar ectopic), recent delivery (consider postpartum endometritis or ovarian vein thrombosis).
6. Past medical and surgical: appendicectomy done?, IBD, prior pelvic surgery, anticoagulants, immunosuppression.
7. Allergies, drug history, social (smoking, alcohol, recreational drugs, partner abuse — see Gender based violence).
8. HIV status and current ART regimen if positive — see HIV counselling. PID in immunocompromised patients runs a more aggressive course.

Focused examination

• General: pallor, sweating, restlessness, distress level (cannot lie still suggests colic; lying very still suggests peritonism).
• Vitals: full set, including temperature; capillary refill; postural BP if stable enough.
• Abdomen: inspect (scars, distension, masses), palpate (start away from the pain, work towards it; document guarding, rebound, percussion tenderness), auscultate (absent bowel sounds → ileus; tinkling → obstruction).
• Pelvis:
  • Inspection: vulval lesions, bleeding, products at the os.
  • Speculum: cervical bleeding, discharge, products, cervix open or closed, identify the os.
  • Bimanual: cervical motion tenderness, uterine size and tenderness, adnexal masses and tenderness, fullness in the pouch of Douglas.
  • Rectovaginal exam when posterior masses or uterosacral nodularity suspected.