CRACKCast E033 – Acute Pelvic Pain in Women

In CRACKCast, Podcast by Adam Thomas2 Comments

This episode of CRACKCast cover’s Rosen’s Chapter 33, Acute pelvic pain in women. This common presentation in the ED has a wide differential and having a solid approach will always keep you considering the life threatening causes.

Link to the show notes – HERE


Rosen’s in Perspective

A patient presenting with acute pain from pelvic pathology is common, manifesting as:

  • Diffuse pain
  • Lower abdominal pain
  • Pelvic pain
  • Low back pain

It is important to recognize that a patient with chronic pelvic pain may also have an acute process, either related to the chronic condition or arising de novo. The female pelvis contains:

  • Vagina
  • Uterus
  • Fallopian tubes and Ovaries
  • Ureters and Urinary bladder
  • Sigmoid colon and rectum

Inflammation, distention, ischemia of these organs or the spillage of blood, pus, or other material into the pelvis can drive pain. This is often difficult to localize because the pain is often visceral from the common afferents supplying the organs.[bg_faq_end]


1) List the 8 diagnoses of pelvic pain in (non-pregnant) women that are of reproductive tract origin?

Reproductive Tract

MechanicalInfectiousNeoplasticDx of Exclusion
Ovarian Torsion

Ovarian Cyst

Uterine Perforation




Tubo-ovarian abscess




[bg_faq_end] [bg_faq_start]

2) List 3 causes of pelvic pain in the pregnant patient <20 weeks or >20 weeks that is pregnancy related

1st trimester

  • Ectopic pregnancy
  • Threatened abortion / non-viable pregnancy
  • Ovarian hyper stimulation syndrome (think if IVF)

2nd-3rd trimester

  • Placenta previa
  • Placental abruption
  • Round ligament pain
  • Braxston hicks[bg_faq_end]



1) List 6 life threatening causes of acute pelvic pain in women

Life threatening diagnoses NOT to miss:

  • PID
  • Tubo-ovarian abscess
  • Ectopic pregnancy
  • Hemorrhagic ovarian cyst (ruptured)
  • Appendicitis
  • Bowel/uterine perforation[bg_faq_end]

2) Outline a systematic approach to acute pelvic pain in women


  • Reproductive tract / urinary tract / intestines / PREGNANCY
  • Hx and physical are insufficient to rule in or out pathology
    • ask about high risk sexual features
    • use of fertility treatments or surgery
    • Most acute serious pathologies have less than 48 hrs of pain
  •  Symptoms
    • Lateral pain = ovary or tube pathology
    • may also be appendix, diverticulitis or colic
    • benign: mittelschmerz, luteum cyst
    • Central pain = uterus or bladder pathology
      • PID, endometritis, dysmenorrhea, fibroids
    • Pain radiating to rectum = pooling of blood in the cul de sac
    • Diffuse pain = PID / infection / bowel pathology
    • LNMP hx is useful
  •  Signs
    • Abdominal and pelvic exam on all
    • Women > 20 weeks pregnant should have a recent U/S FIRST before pelvic

Multiple Etiologies to Consider **think anatomically**

Reproductive tract

  • Ovarian torsion / cyst / TOA / PID / Salpingitis / endometritis
  • endometriosis / uterine perforation / fibroids / dysmenorrhea / neoplasm

Pregnancy related

  • 1st trimester
    • ectopic pregnancy/ovarian hyperstimulation syndrome
    • threatened abortion/non-viable pregnancy
  • 2nd-3rd trimester
    • placenta previa
    • placental abruption
    • round ligament pain/braxston hicks

Intestinal tract

  • Appendicitis / ischemic bowel / perforated viscous / IBS/IBD / etc.

Urinary Tract

  • Pyelonephritis / cystitis / ureteral stone


  • Septic pelvic thrombophlebitis / ovarian vein thrombosis / sickle cell disease


  • Muscular strain/sprain / hernia / abdominal wall hematoma Neuro / Psych

Neuro / Psych

  • Abdominal migraine / herpes zoster / depression

Lab tests and imaging

  • Pregnancy test!
  • Urine-analysis
  • Hob, Hot, Rh status
  • Ultrasound
  • +/- CT scan (appendicitis / colic)

Diagnostic algorithm

  • See Rosen’s pg. 270, but basically goes systematically through the various systems

Empirical management

  • ABCs MOVIE etc.
  • Life threatening hemorrhage caused by:
    •  ECTOPIC
    • Placental abruption
    • Hemorrhagic ovarian cyst[bg_faq_end]

3) List 6 risk factors for ectopic pregnancy

  • PID history
  • Smoker
  • Pelvic / tubal / ovarian surgery
  • Prior ectopic pregnancy
  • IUD
  • Undergoing reproductive technology
  • Heterotopic pregnancy:
    • 1:8000
    • 1:100 in women with IVF/ Fertility treatment [bg_faq_end]

This post was copyedited and uploaded by Rob Carey (@_RobCarey)



Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..