Differential Diagnosis for Pelvic Pain in Patients with Hysterectomy and Negative CT and Transvaginal Ultrasound

• Single Most Likely Diagnosis
  • Adhesions or scar tissue formation: This is a common cause of pelvic pain in patients who have undergone hysterectomy. Adhesions can form between the bowel, bladder, and abdominal wall, or between these structures and the pelvic sidewall, leading to chronic pain.
• Other Likely Diagnoses
  • Ovarian remnant syndrome: Even after hysterectomy, remnants of ovarian tissue can cause cyclic pelvic pain if they produce hormones.
  • Endometriosis: Although less likely if the patient has had a hysterectomy, endometriosis can still occur, especially if the ovaries were left intact during the surgery.
  • Interstitial cystitis: A condition causing bladder pressure, bladder pain, and sometimes pelvic pain.
  • Irritable Bowel Syndrome (IBS): Can cause abdominal and pelvic pain, bloating, and changes in bowel movements.
• Do Not Miss Diagnoses
  • Ovarian torsion: Although the CT and ultrasound are negative, ovarian torsion can be a late or intermittent occurrence and might not always be visible on initial imaging.
  • Appendicitis: Especially if the appendix was not visualized clearly on the CT scan, appendicitis can present with pelvic pain and should not be missed due to its potential for serious complications.
  • Ectopic pregnancy: Although rare in patients who have undergone hysterectomy, it's not impossible, especially if there was a failure of the procedure or an undiagnosed ectopic pregnancy at the time of surgery.
• Rare Diagnoses
  • Pelvic congestion syndrome: A condition characterized by chronic pelvic pain associated with ovarian and pelvic varices.
  • Nerve entrapment or neuropathic pain: Damage to nerves during the hysterectomy can lead to chronic pain.
  • Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis): Can cause chronic pelvic pain among other symptoms.
  • Malpositioned or eroded intrauterine device (IUD) fragments (if an IUD was placed before the hysterectomy and not removed): Although rare, it can cause chronic pelvic pain.