Acute Pelvic Pain

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Misplaced IUCD (Perforated Uterus)
  • Referred (e.g. Spinal Tumour, Bowel Spasm)
  • Proctitis
  • Invasive Carcinoma of Ovaries or Cervix
  • Fibroid Degeneration
  • Strangulated Femoral or Inguinal Hernia

Ready Reckoner

Key distinguishing features of the most common diagnoses

PIDUTIMiscarriage EctopicOvarian Cyst
Abnormal Vaginal Bleeding PossibleNoYes PossibleNo
Purulent Discharge PVYesNoNoNoNo
FeverYesYesNoNoNo
Palpable MassNoNo PossibleNo Possible
Tender Uterus PVYesNo PossibleNoNo

Possible Investigations

Likely:HVS, cervical swab, urinalysis, MSU, pregnancy test.

Possible:FBC, ESR/CRP, ultrasound, laparoscopy (all usually arranged by hospital admitting team).

Small Print:None.

  • Urinalysis: Look for nitrites and pus cells to make diagnosis of UTI
  • MSU will confirm UTI and guide antibiotic treatment.
  • HVS for bacteria including gonococcus and endocervical swab for Chlamydia if purulent discharge present
  • ESR/CRP: Elevated in PID.
  • Pregnancy test: Positive in ectopic and miscarriage
  • FBC: Raised WCC helps confirm PID and UTI if not being admitted. Also elevated in pelvic abscess
  • Urgent ultrasound helpful if miscarriage or ectopic pregnancy suspected.
  • Cases referred to hospital may undergo laparoscopy.

Top Tips

  • In miscarriage, pain follows bleeding. In ectopic pregnancy, the sequence is usually reversed.
  • Remember that there may be no bleeding with an ectopic pregnancy – or that the vaginal loss may be a light, blackish discharge.
  • PV bleeding will cause haematuria on urinalysis. Only diagnose UTI if the symptoms are suggestive and urinalysis also shows nitrites and pus cells.

Red Flags

  • Severe unilateral pain in very early pregnancy suggests ectopic pregnancy, even with no bleeding. Admit urgently.
  • If PID does not settle within 48 hours of appropriate antibiotic treatment, consider abscess formation.
  • Don’t forget to check femoral and inguinal canals for a possible strangulated hernia.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.