CASE: ACUTE PELVIC PAIN
Naomi is a 29 yo African American female who walks into the ED alone complaining of abdominal pain. She appears in acute
pain, hunched over holding her lower abdomen. The clerk puts Naomi in a wheelchair and notifies the triage nurse to come
and do an immediate triage. It is a Saturday morning, and you are at a large ED with full laboratory and radiologic services
available. On-call OB/GYN via the affiliated teaching hospital is available for consultation. POC pregnancy test is available.
Naomi endorses sudden lower right abdominal/pelvic pain that came on while exercising strenuously this morning about 2
hours ago and has become progressively worse. While her friend was driving her to the ED, she began feeling nauseous, but
has not vomited. She denies dizziness, lightheadedness, chest pain, palpitations, SOB, vaginal or any other bleeding. Her
LMP was two weeks ago and was normal. She denies current pregnancy, stating she “doesn’t think” she could be pregnant.
Naomi screens negative for violence or trauma. She is able to give a clean catch urine sample.
VS: T 98.7, HR 105, BP 123/72, RR 20, 100% on room air
Pain: past two hours, severe, stabbing with radiation into the right groin, 7/10, constant
Naomi was quickly helped into a gown. She was placed on a monitor and one 18 gauge IV was placed in her right antecubital
region and labs were drawn. She is in obvious pain, continuing to clutch her right lower abdomen. She is more comfortable in
the fetal position. Naomi continues to deny dizziness and is able to answer questions in 2-3 word responses.
On additional questioning, she has never been pregnant, is sexually active with one male partner and uses condoms most of
the time. She denies STIs. She has had her appendix removed, but has never had a GYN procedure.
VS reassessment reveals
HR 102, BP 128/75, R 22
Pain 7/10
POC pregnancy testing is negative
The provider walks into Naomi’s room and finds her curled up on the exam table in the fetal position in pain. She is verbal, but
using only 2-3 word responses because of pain. VS are HR 102, BP 128/75, R 22, Pain 7/10.
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Appropriate questions to ask for abdominal/pelvic pain history:
1. Pain characteristics
2. ROS – fevers/chills, nausea/vomiting, diarrhea/constipation, back/flank pain, dysuria, hematuria, BRBPR or tarry stools,
dizziness/lightheadedness/syncope, chest pain, SOB?
3. LMP? Was it normal? Are your periods regular?
4. OB history: G___ (# of pregnancies, vaginal or C/S) P___ (#live births) AB____(# abortions – spontaneous/elected)
5. Vaginal discharge, characteristics?
6. Vaginal bleeding, onset, duration, amount, pad/tampon use?
7. History of STI?
8. Method of contraception? Used consistently? Attempting to get pregnant/fertility treatment?
9. Sexually active? With men, women or both? When was last sexual activity? How many recent partners? Vaginal or anal?
10. Any past GYN conditions (i.e. abnormal paps, endometriosis, cyst, etc.)? GYN surgeries or procedures?
11. Any past GI conditions (i.e. Crohn’s, diverticulosis, etc.)? Abdominal surgeries (i.e. appendectomy)?
12. Medications?
13. Allergies?
14. Last meal?
15. Any recent trauma? Have you been physically or sexually assaulted in the past? MST?
As the nurse gets and administers the IV narcotic, Naomi succinctly answers the provider’s questions. Her HPI is confirmed
and ROS is largely negative apart from nausea. Her LMP was about 2 weeks ago, her menses are regular, she is sexually
active with one male partner for about 2 years and they use condoms “most of the time”. She has never been pregnant. She
has never had any gynecological issues and denies any prior STIs. Naomi has no medical conditions, takes no medications
regularly and is not allergic to anything. She confirms her history of prior appendectomy. She denies recent trauma, or history
of sexual or physical abuse. Her family history is non-contributory. She denies smoking or drug use, and reports alcohol use
twice per week. She admits to working out “all the time”.
Naomi gives verbal consent for pelvic exam. She reports the pain medication has begun to help a bit.
VS reassessment reveals
HR 95, BP 117/62, RR 18, 98% on room air
Pain 5/10
Naomi’s privacy is assured, the mobile GYN cart has been placed in the room, and the provider and female nurse chaperone
enter to perform the exam.
Physical exam (provide elements requested)
GEN: A&O, relatively comfortable lying, but increased pain with movement
HEENT: normal
PULM: CTAB
CV: RRR, no m/r/g
ABD: well-healed open appendectomy scar, normal BS, soft, ND, significant tenderness RLQ with voluntary guarding, no
rebound
PELVIC:
External inspection: normal external genitalia
Speculum: normal vagina and cervix, no blood or discharge, closed cervical os
Bimanual: no CMT, mild uterine tenderness, involuntary guarding in the area of the right adnexa, exquisite tenderness in right
adnexa causing inability to fully palpate for mass as patient unable to tolerate deep palpation
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Naomi’s pain continued as 5/10 and she was provided more IV narcotic and taken to radiology for stat TVUS. Lab results are:
WBC 12.8
INR 0.9
K 3.8
LFTs normal
Hgb 15
Na 140
BUN/Cr 17/1.1
UA: negative blood, LE, nitrates
Hct 47
Cl 110
Glucose 98
Plt 398
HCO3 22
T&S O+
The radiologist calls the provider with TVUS results: enlarged, multicystic right ovary 6 x 4 x 4cm; doppler reveals flow to right
ovary; the left ovary is normal; here is minimal amount of free fluid in pelvis
The provider informs Naomi of the lab and TVUS results as well as the concern for ovarian torsion or impending ovarian cyst
or TOA rupture. She is aware of the GYN consultation and is awaiting their arrival. On nurse reassessment, Naomi
verbalizes increasing pain despite the IV narcotics and vomits the contents of her stomach with no blood or bile noted.
VS reassessment reveals
T 99.1, HR 110, BP 101/50, RR 24, 99% on room air
Pain 8/10
The nurse alerts the provider to Naomi’s deteriorating status and contacts the gynecologist who is in the parking lot. The GYN
consultant arrives to the ED and performs an abbreviated history, brief abdominal and bimanual exam and reviews the TVUS
all of which confirms an acute abdominal process. GYN discusses with Naomi and the ED provider. GYN contacts the OR
nurse manager and anesthesia staff to prepare for emergent exploratory laparoscopy. Naomi provides verbal and written
consent for the surgery and is wheeled to the surgical holding area.
Naomi’s mother is now present with her at the bedside. Naomi is transferred to holding area and taken back to the OR one
hour later. Laproscopic evaluation reveals right ovary torsed twice. The ovary is found to be viable after untorsing and a 4cm
dermoid cyst is removed with approximately 2cm of viable ovary left. The left ovary has no evidence of a dermoid cyst.
Naomi is discharged after an uncomplicated recovery the next day with gynecology follow-up a month later.
KEY LEARNING POINTS – ACUTE PELVIC PAIN
 Unstable patients should be identified immediately, triaged appropriately and placed in a resuscitative bed
 All female patients with abdominal pain, pelvic pain, and/or vaginal bleeding who are <52 years of age should have
pregnancy assessed at triage
 It is important to acknowledge and treat pain
 Emergency providers should perform a pelvic exam prior to specialty consultation in case of lower abdominal/pelvic pain
 The pelvic exam should be performed adhering to patient dignity, privacy and appropriate female chaperone requirements
 Adequate pelvic exam supplies, equipment and set-up should be ensured prior to pelvic exam
 Life and fertility threatening causes of pelvic pain (i.e. ectopic pregnancy, ovarian torsion, ruptured TOA or hemorrhagic
cyst) must be recognized
 Gynecological consultation is indicated for all patients with potential for life or fertility threatening conditions
 Transvaginal ultrasound is indicated in the case of pelvic pain with concern for an ovarian/adnexal abnormality
 While the absence of blood flow to the ovary on TVUS is diagnostic for torsion, a normal doppler flow study does not
exclude ovarian torsion
 A change in patient status needs to be communicated between nurse and provider immediately
 The plan of care should be effectively communicated to the patient, family and among ED staff throughout the encounter
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