Intestinal obstruction is heralded by the onset of colicky abdominal pain followed by abdominal distention, vomiting, constipation, and obstipation. Higher and more acute obstruction results in early vomiting. Colonic obstruction presents with a greater degree of abdominal distention and obstipation. Vomiting first consists of gastric contents, followed by bile, then material with feculent odor, depending on the level of obstruction.
Fever is often present in the late stages. At the onset of mechanical obstruction, bowel sounds are high pitched and maximal during an episode of colicky pain. As the obstruction progresses, bowel sounds decrease and, when absent, suggest ischemic bowel. Marked abdominal distention often ensues.
An upright abdominal x-ray series shows a characteristic gas pattern, distended loops of bowel, and air ﬂuid levels; and it helps to determine whether obstruction is partial or complete (no colonic gas seen). CT can be useful. White blood cell count will be elevated in patients with ischemic bowel. Complete obstruction requires surgical management, whereas partial obstruction often can be managed with intravenous ﬂuids, bowel rest, and selective use of nasogastric suction. The cause of the obstruction should be determined and treated if possible. Underlying GI or reproductive tract malignancy may be present.
Urinary Tract Causes of Acute Pelvic Pain
Ureteral colic due to ureteral lithiasis is caused by a sudden increase in intraluminal pressure and associated inﬂammation. Urinary tract infections producing acute pain include cystitis and pyelonephritis. The most common microbes causing urinary tract infections are Escherichia coli followed by Proteus, Klebsiella, and Pseudomonas (31).
The pain of lithiasis is typically severe and crampy; it can radiate from the costovertebral angle to the groin. Hematuria is often present. Urinary tract infection (UTI) comprises bladder or kidney infection. Cystitis is associated with dull suprapubic pain, urinary frequency, urgency, dysuria, and occasionally hematuria. Pyelonephritis is associated with ﬂank and costovertebral angle (CVA) pain, although lateralizing lower abdominal pain occasionally is present. Urethritis due to chlamydia or gonorrhea infection can have similar symptoms to those of a UTI. These infections must be ruled out if relevant.
Acute Pelvic Pain: Summary
Diagnosis of stone can be made by urinalysis revealing red blood cells and demonstration of the stone via abdominal ultrasound, CT urography, or intravenous pyelography (uric acid stones may not be detected by CT). There is pain with firm pressure over the costovertebral angle in the case of lithiasis or pyelonephritis. Peritoneal signs are absent. Suprapubic tenderness may accompany cystitis.
The diagnosis of UTI is based on RUA revealing bacteria and leukocytes with or without leukocyte esterase and nitrites, in the absence of squamous epithelial cells. Findings can subsequently be confirmed by culture. The diagnostic thresholds for white blood cell count (WBC) and vaginal squamous cells vary with each laboratory. An elevated number of squamous cells in the urinary specimen suggests contamination of the urine specimen with vaginal secretions and can result in false-positive urine analysis and culture.