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Probability diagnosis

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Primary dysmenorrhoea

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Mittelschmerz

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Pelvic/abdominal adhesions

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Endometriosis

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Serious disorders not to be missed

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Vascular:

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  • internal iliac claudication

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Neoplasms including cancer

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  • ovary

  • uterus

  • other pelvic structures

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Infection:

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  • PID

  • pelvic abscess

  • appendicitis

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Other:

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  • ectopic pregnancy

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Pitfalls (often missed)

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Endometriosis/adenomyosis

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Torsion of ovary or pedunculated fibroid

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Constipation/faecal impaction

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Pelvic congestion syndrome

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Misplaced IUCD

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Nerve entrapment

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Referred pain (to pelvis):

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  • appendicitis

  • cholecystitis

  • diverticulitis

  • UTI

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Masquerades checklist

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Depression

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Drugs

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Spinal dysfunction (referred pain)

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UTI

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Is the patient trying to tell me something?

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Can be very relevant. Consider various problems and sexual dysfunction.

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Key history

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The pain should be linked with the menstrual history, coitus and the possibility of an early pregnancy. For recurrent and chronic pain, it is advisable to instruct the patient to keep a diary over two menstrual cycles. Risk factors in the past history should be assessed, for example:

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  • IUCD (salpingitis, ectopic pregnancy)

  • infertility (endometriosis, salpingitis)

  • tubal surgery (ectopic).

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Key examination

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Use the traditional abdominal and pelvic examination to identify the site of tenderness and rebound tenderness, and any abdominal or pelvic masses. The pelvis should be examined by speculum (preferably bivalve type) and bimanual palpation.

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   Proper assessment can be difficult if the patient cannot relax or overreacts, if there is abdominal scarring or obesity, or if extreme tenderness is present. It is therefore important, especially in the younger and apprehensive patient, to conduct a gentle, caring vaginal examination with appropriate explanation and reassurance.

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Key investigations

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  • FBE/ESR/CRP

  • Urine MC

  • Chlamydia PCR

  • Cervical swabs MC

  • Serum β-HCG

  • Vaginal and/or pelvic ultrasound

  • Laparoscopy if appropriate

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Diagnostic tips

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  • Think of endometriosis and ovarian cysts in any woman with lower abdominal pain.

  • Recurrent pain related to menstruation is typical of dysmenorrhoea or endometriosis.

  • Ectopic pregnancy remains a potentially lethal condition so always be ‘ectopic minded’.

  • A position β-HCG plus an empty uterus and an adnexal mass are the classic diagnostic features of ectopic pregnancy.

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