Acute Pelvic Pain | Dr. Pixel

Educational and clinical decision support tool. Does not replace a complete medical evaluation.

Clinical assessment

Hemodynamic stability

Signs of shock or acute clinical deterioration.

Does the patient show signs of instability?

Pregnancy / β-hCG

Current pregnancy, suspicion, or unknown status.

Positive β-hCG or suspected pregnancy?

Fever

Fever or suspected infectious process.

Does the patient have fever?

Cervical motion pain

Pain with cervical motion on examination.

Cervical motion tenderness?

Adnexal / pelvic mass

Palpable mass or suggestive finding on exam.

Adnexal or pelvic mass on examination?

Right lower quadrant pain

Peritoneal signs and maneuvers suggestive of appendicitis.

Signs suggestive of appendicitis?

Carnett sign

Differentiates abdominal wall from visceral pain.

Positive Carnett sign?

Suspected endometriosis

Uterosacral nodularity or compatible history.

Uterosacral nodularity or history suggestive of endometriosis?

Summary of physical examination findings in women with acute pelvic pain

Finding	Suggested diagnosis	Considerations for further testing
Adnexal mass and/or unilateral adnexal tenderness	Ovarian cyst or torsion	Transvaginal ultrasonography; gynecology consultation if ovarian torsion is suspected
Carnett sign (increased pain to palpation when the abdominal wall is voluntarily contracted)	Musculoskeletal or abdominal wall pain	No further testing needed
Cervical motion tenderness	Sexually transmitted infection or pelvic inflammatory disease	Testing for sexually transmitted infections; if fever or leukocytosis is present: transvaginal ultrasonography to evaluate for tubo-ovarian abscess; gynecology consultation if tubo-ovarian abscess is suspected
Fever	Appendicitis	Transabdominal ultrasonography (especially if pregnant); computed tomography of the abdomen and pelvis if non-pregnant or ultrasonography is inconclusive
	Pelvic inflammatory disease	Testing for sexually transmitted infection
	Complicated urinary tract infection / pyelonephritis	Urinalysis, urine culture, complete blood count
	Tubo-ovarian abscess	Transvaginal ultrasonography; pelvic magnetic resonance imaging if pelvic ultrasonography is inconclusive; complete blood count
Pelvic mass	Ectopic pregnancy	Beta human chorionic gonadotropin test, pelvic ultrasonography
	Uterine fibroids	Pelvic ultrasonography
	Ovarian cancer	Pelvic ultrasonography; computed tomography of chest, abdomen, and/or pelvis if concern for metastasis
	Ovarian cyst	Pelvic ultrasonography
	Tubo-ovarian abscess	Pelvic ultrasonography
Right lower quadrant pain, McBurney point tenderness, Rovsing sign (palpation of the left lower quadrant causes pain in the right lower quadrant), psoas sign, or obturator sign	Appendicitis	Transabdominal ultrasonography; if it cannot be performed or is inconclusive, computed tomography of abdomen and pelvis with oral and intravenous contrast; complete blood count, infectious disease workup; surgery consultation for appendicitis management
Tachycardia or hypotension	Ruptured ectopic pregnancy or ruptured hemorrhagic cyst	Urgent surgical consultation; complete blood count; beta human chorionic gonadotropin test
Uterosacral ligament tenderness or nodularity	Endometriosis	Ultrasonography; consider laparoscopy if findings are unremarkable