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Case 8

Pelvic Pain
A 38-year-old woman (G4,P3013) presents to the emergency room with right lower quadrant
abdominal pain that began 4 days ago and has been increasing in intensity since then. The pain
has been accompanied by nausea but no vomiting. The patient states that her last menstrual
period was 6 to 7 weeks ago and that she had some spotting on the previous day. Her menstrual
cycles are irregular, ranging from 30 to 50 days, and she has an intrauterine device (IUD) in place
for contraception.

What are some of the possible causes of this patients pain?
Are there nongynecologic causes of right lower quadrant pain, and should they be
This patients history suggests a wide range of possible causes for pelvic pain. First is pregnancy. Any
woman of reproductive age can become pregnant, and this is the first thing that should be evaluated in
this woman, even though she is using contraception. The fact that her cycles are long and unpredictable
means that (1) she may not have ovulated, (2) she did ovulate and hasnt had her menses yet, (3) she did
ovulate and has an early pregnancy, or (4) she did ovulate and is several weeks into a pregnancy. If she is
pregnant, then the pregnancy can be normal, even with an IUD in place; in the uterus but not developing
normally (will eventually miscarry); or an ectopic pregnancy. An undiagnosed ectopic pregnancy can
rupture, leading to severe morbidity and possible death. With an IUD there is an increased risk of an
ectopic pregnancy.
Other gynecologic causes of this acute pain that should be considered include the following:

1. Ovarian masses. A corpus luteum is seen in the luteal phase and may rupture, leading to pain. Ovulation
can cause sudden onset of pain that lasts for several hours and can linger for several days. A ruptured cyst
causes sudden onset of pain that usually dissipates over several hours to days. Ovarian endometrioma can
cause pain typically around the time of menses. An ovarian cyst or tumor (i.e., dermoid) can cause pain.
2. Torsion of an ovarian or a paratubal mass causes unilateral pain as well. Pain with torsion is severe and
associated with peritoneal signs, nausea, and vomiting.
3. Infection. Pelvic inflammatory disease can cause pain, though it is usually bilateral lower quadrant pain.
It is often associated with a fever, but not always. Tubo-ovarian abscess is also associated with pain,
usually more severe than with just pelvic inflammatory disease (PID), and is usually accompanied by
nausea, fever, and peritoneal signs. A unilateral tubo-ovarian abscess is associated with IUD use and
presents as focal pain, as in this patient.
4. Fibroids. Degeneration of a fibroid can cause pain, and depending on the location of the fibroid, the
patient can perceive this pain as localized.
5. Cancer of the ovary or fallopian tube can cause pain. The pain could be caused by a large adnexal mass
or peritoneal implants of metastatic cancer. This would be unlikely in this young woman.
All nongynecologic causes of right lower quadrant pain should be considered in any woman who
presents with this complaint. The differential diagnosis for this patient can be organized by organ system:
1. Gastrointestinal. Appendicitis is first on the list, and should be considered because of the location in the
right lower quadrant and associated nausea. If the appendix ruptures, it can cause severe infection and
lead to significant abdominal and pelvic adhesions, which are a significant cause of infertility in women.
Inflammatory bowel disease is less likely.
2. Urinary. Passage of a kidney stone can cause colicky focal pain. Interstitial cystitis, a frequent cause of
chronic pelvic pain, is less likely in this patient.

3. Musculoskeletal. Trigger-point pain can cause focal unilateral pain. It is not precipitated by a traumatic
event, and is usually made worse by movement. It would be unusual for this type of pain to be
accompanied by nausea.

Physical examination in the emergency room reveals a temperature of 99.8F, blood pressure of
140/80, and a normal examination with the exception of the abdomen and pelvis. The abdomen is
soft, with active bowel sounds, and there is guarding without rebound in the right lower quadrant.
Pelvic examination shows a parous cervix with clear, watery mucus and no visible IUD strings. The
uterus is anterior, slightly enlarged, and nontender. A tender, 3- to 4-cm mass is anterolateral to the
uterus on the right, seemingly very close to the uterus.

What additional information has been gained from the physical examination of this
What laboratory studies should be ordered at this time?
The physical examination certainly adds important information to the history, making some diagnoses less
likely than others. The temperature of 99.8F is slightly higher than normal but not in the range expected
in the setting of an acute appendicitis; it also makes generalized pelvic infection unlikely. The cervical
mucus is clear, not purulent, which further suggests that infection is not a problem. Additionally, the
uterus itself is not tender and there is no tenderness of the left side. Of note, care must be taken during
the exam to not rupture an adnexal mass.
The history of IUD placement combined with the absence of IUD strings on pelvic examination
could be significant. Despite the absence of significant temperature elevation, a chronic right-sided tubo-

ovarian abscess could exist (again, recall that unilateral tubo-ovarian abscess can be associated with IUD
use). Or the IUD could have perforated the uterus (no strings were seen), moved into the peritoneal
cavity, and established an abscess involving the fallopian tube, ovary, or bowel. The slight temperature
elevation, presence of the IUD, possible late menses, tender mass, and slight bleeding could represent a
right tubal pregnancy or, possibly, an intrauterine pregnancy with a bleeding or ruptured corpus luteum.
The tender right adnexal mass could represent a degenerating myoma or an ovarian cyst or tumor
undergoing torsion. A temperature of 99.8F would be consistent with any of these conditions.

After 2 hours in the emergency room, the patients condition has not changed. By this time, some
laboratory values are available. The hemoglobin is 12.1 g/dL, and the white cell count is elevated
at 11,000 with a slight shift to the left. Urinalysis shows no bacteria, white cells, or red cells. The
serum hCG test is negative.

How have these laboratory results helped to narrow the differential diagnosis?
What diagnostic studies should be obtained at this point?
The early laboratory results for this patient help to narrow the differential diagnosis. The negative serum
hCG rules out pregnancy (intrauterine or ectopic). In retrospect, the clear, watery mucus now makes
sense: if the patient had ovulated, or if she was pregnant, progesterone would be in the system, changing
the cervical mucus to a viscous, cloudy fluid. The absence of significant findings on urinalysis effectively
rules out urinary tract infection as well as a kidney stone passing through the ureter.
Several diagnostic possibilities still exist, however. The slightly elevated white cell count with the
slight shift to the left could be compatible with a chronic right tubo-ovarian abscess in association with

the IUD, a twisted right ovarian mass, or a degenerating myoma. In thinking about the ovarian
possibilities, either a functional cyst or a benign cyst or tumor under torsion could simulate the clinical
situation as presented. A cystic teratoma (dermoid cyst) of the ovary would be high on the list because of
the anterolateral position.
At this point it is important for the clinician to get some idea of the nature of the mass because of
differences in management plans. A tubo-ovarian abscess would initially be treated with hospitalization
and intravenous antibiotics. A degenerating myoma would be treated with analgesics. An ovarian mass
undergoing torsion is a clinical emergency that would be treated surgically.

Ultrasound examination of the pelvis is performed while the patient is still in the emergency room.
The examination shows a 3- to 4-cm complex mass with solid and cystic elements. The right ovary
cannot be identified. The IUD is seen within the cavity of the uterus.

How has the ultrasound examination helped to narrow the differential?
What would be the next step in evaluating this patient?
Unfortunately, the ultrasound findings are not very helpful in narrowing the diagnostic possibilities in this
case, as they could represent any of the remaining diagnoses. The complex solid and cystic mass could be
a tubo-ovarian abscess, a degenerating myoma with cystic areas, a cystic teratoma, an endometrioma, or
a benign or malignant ovarian tumor. At this point, an ovarian mass that is twisted or in torsion should be
placed at the top of the list, with the degenerating myoma next. A unilateral tubo-ovarian abscess still is a
possibility, but the nontender uterus, the minimally elevated temperature and white cell count, and the
clear cervical mucus all make this diagnosis less likely than the other two conditions.

Because of the need to make a diagnosis, it is important to directly observe this patients pelvis.
Approximately 6 hours after she appeared in the emergency room, she is taken to the operating
room and laparoscopy is performed. Examination shows no sign of infection in the pelvis, no
pathology associated with either ovary, and no evidence of either a tubo-ovarian abscess or cyst of
the right tube and ovary. However, the uterus is distorted by a 3- to 4-cm sessile myoma in the
right corneal aspect. The myoma is closely attached to the uterus but is not a part of the uterine
wall, and it appears to be slightly darker than the rest of the uterine fundus.

What kind of follow-up is advisable for this patient?
Having considered the various clinical possibilities and having used the available diagnostic tools (i.e.,
laboratory, ultrasound, and laparoscopic evaluation), a final diagnosis is made. In this patient, the pelvic
pain was caused by a degenerating myoma and should be self-limited with bedrest and analgesia. If the
problem is recurrent, it would be appropriate to consider a myomectomy in the future. A degenerating
myoma is an unusual cause for pelvic pain and is not an emergency. If a right ovary had been seen on the
ultrasound, then the diagnosis could have been made without performing a laparoscopy because the
concern about an ovarian torsion prompted the laparoscopy. Fibroids are common, and many women are
unaware that they have them; therefore, not having a history of fibroids does not eliminate this diagnosis
from the differential. Conversely, the most important conditions to rule out in any woman with one-sided
pelvic pain and a palpable mass are ectopic pregnancy and torsion of an adnexal massconditions that
are emergencies and demand immediate attention.