Vital signs are usually normal, although a low-grade temperature and mild tachycardia can be present with degeneration. Abdominal or bimanual examination and ultrasound reveal an irregular solid mass or masses arising from the uterus. If degeneration occurs, the inﬂammation can cause abdominal tenderness in response to palpation and mild localized rebound tenderness.
With degeneration there is usually leukocytosis. Ultrasound can distinguish adnexal from uterine etiology of an eccentric mass. If diagnosis is still uncertain, a pelvic MRI is more accurate (27). The fibroid can be excised laparoscopically; however, surgery is not mandatory. A submucous leiomyoma with pain and hemorrhage should be excised transcervically with hysteroscopic guidance.
In women with endometriosis, endometrial glands and stroma implant outside the uterine cavity, most commonly at the cul-de-sac, ovaries, or pelvic visceral and parietal peritoneum. Each menstrual cycle potentially results in further proliferation, causing inﬂammation, scarring, fibrosis, and adhesion formation. Women with endometriosis often experience dysmenorrhea, dyspareunia, and dyschezia, irregular bleeding, or subfertility. Acute pain attributable to endometriosis is usually premenstrual and menstrual; if nonmenstrual acute generalized pain occurs, a ruptured endometrioma (chocolate endometriotic cyst within the ovary) should be considered. The management of endometriosis is discussed under dysmenorrhea and chronic pelvic pain (see also Chapter 17).
The abdomen is often tender in one or both the lower quadrants. Significant distention or rebound tenderness may be present if there is there is a ruptured endometrioma. Bimanual and rectovaginal examinations can reveal a fixed, retroverted uterus with tender nodules in the uterosacral region or thickening of the cul-de-sac. An adnexal mass, if present, usually is fixed to the broad ligament and cul-de-sac. The clinical diagnosis of endometriosis is accurate approximately 50% of the time. Definitive diagnosis is made by laparoscopy or laparotomy. In the setting of chronic pain symptoms, as noted above, with an acute exacerbation a leaking endometrioma should be suspected. If there is a characteristic mass on ultrasound, laparoscopy is indicated.
Gastrointestinal Tract Causes of Acute Pelvic Pain
Appendicitis The most common intestinal source of acute pelvic pain in women is appendicitis. Lifetime incidence in the United States is 7%, and it is the most common cause of emergent abdominal surgery (28). The symptoms and signs of appendicitis can be similar to those of PID, but the nausea and emesis are often more prominent with appendicitis.
The first symptom of appendicitis is typically diffuse abdominal pain, periumbilical pain, followed by anorexia, nausea, and vomiting. Within a matter of hours, the pain generally shifts to the right lower quadrant. Fever, chills, emesis, and obstipation (no ﬂatus or stool per rectum) may ensue. However, this classic symptom pattern is often absent. Atypical abdominal pain can occur when the appendix is retrocecal or entirely within the true pelvis (which occurs in 15% of the population). In this setting, tenesmus and diffuse suprapubic pain may occur.