A 25-year-old woman was admitted to the emergency department with a complaint of pain in her right iliac fossa. The pain had developed rapidly over approximately 40 minutes and was associated with cramps and vomiting. The surgical intern made an initial diagnosis of appendicitis.
The typical history for appendicitis is a central abdominal, colicky (intermittent waxing and waning) pain, which over a period of hours localizes to become a constant pain in the right iliac fossa. The central colicky pain is typical for a poorly localized visceral type of pain. As the parietal peritoneum becomes inflamed, the pain becomes localized. Although this patient does have right iliac fossa pain, the history is not typical for appendicitis (although it must be remembered that patients may not always have a classical history for appendicitis).
The surgical intern asked a more senior colleague for an opinion.
The senior colleague considered other anatomical structures that lie within the right iliac fossa as a potential cause of pain. These include the appendix, the cecum, and the small bowel. Musculoskeletal pain and referred pain could also be potential causes. In women, pain may also arise from the ovary, fallopian tube, and uterus. In a young patient, diseases of these organs are rare. Infection and pelvic inflammatory disease may occur in the younger patient and need to be considered.
The patient gave no history of these disorders.
Upon further questioning, however, the patient revealed that her last menstrual period was 6 weeks before this examination. The senior physician realized that a potential cause of the abdominal pain was a pregnancy outside the uterus (ectopic pregnancy). The patient was rushed for an abdominal ultrasound, which revealed no fetus or sac in the uterus. She was also noted to have a positive pregnancy test. The patient underwent surgery and was found to have a ruptured fallopian tube caused by an ectopic pregnancy.
Whenever a patient has apparent pelvic pain, it is important to consider the gender-related anatomical differences. Ectopic pregnancy should always be considered in women of childbearing age.
A 35-year-old woman visited her family practitioner because she had a “bloating” feeling and an increase in abdominal girth. The family practitioner examined the lower abdomen, which revealed a mass that extended from the superior pubic rami to the level of the umbilicus. The superior margin of the mass was easily palpated, but the inferior margin appeared to be less well defined.
This patient has a pelvic mass.
When examining a patient in the supine position, the observer should uncover the whole of the abdomen.
Inspection revealed a bulge in the lower abdomen to the level of the umbilicus. Palpation revealed a hard and slightly irregular mass with well-defined superior and lateral borders and a less well-defined inferior border, giving the impression that the mass continued into the pelvis. The lesion was dull to percussion. Auscultation did not reveal any abnormal sounds.
The doctor pondered which structures this mass may be arising from. When examining the pelvis, it is important to remember the sex differences. Common to both men and women are the rectum, bowel, bladder, and musculature. Certain pathological states are also common to both sexes, including the development of pelvic abscesses and fluid collections.
In men, the prostate cannot be palpated transabdominally, and it is extremely rare for it to enlarge to such an extent in benign diseases. Aggressive prostate cancer can spread throughout the whole of the pelvis, although this is often associated with bowel obstruction and severe bladder symptoms.
In women, a number of organs can develop large masses, including the ovaries (solid and cystic tumors), the embryological remnants within the broad ligaments, and the uterus (pregnancy and fibroids).
The physician asked further questions.
It is always important to establish whether the patient is pregnant (occasionally, pregnancy may come as a surprise to the patient).