Differential Diagnosis for Pelvic Pressure and Pain

The patient presents with constant pressure and pain in her lower pelvis for the last 5 days, with a recent transvaginal ultrasound showing a fibroid uterus. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Fibroid-related symptoms: Given the patient's recent ultrasound showing a fibroid uterus, it is likely that the fibroids are causing the pelvic pressure and pain. Fibroids can cause a range of symptoms, including pelvic pain, pressure, and heavy menstrual bleeding.
• Other Likely Diagnoses
  • Urinary tract infection (UTI): Although the patient's urine test is negative, a UTI could still be present, especially if the test was not a urine culture. UTIs can cause pelvic pain and pressure.
  • Ovarian cyst: An ovarian cyst could be causing the patient's symptoms, especially if it is large or ruptured. The transvaginal ultrasound may not have detected an ovarian cyst, especially if it is small or not visible.
  • Endometriosis: Endometriosis is a condition in which tissue similar to the lining of the uterus grows outside the uterus, causing pain and pressure. The patient's symptoms could be related to endometriosis, especially if she has a history of heavy menstrual bleeding or infertility.
• Do Not Miss Diagnoses
  • Ectopic pregnancy: Although the patient is 49 years old, an ectopic pregnancy is still possible, especially if she is not using birth control. An ectopic pregnancy can cause severe pelvic pain and pressure, and is a life-threatening condition if not treated promptly.
  • Ovarian torsion: Ovarian torsion is a condition in which the ovary twists around its blood supply, causing severe pain and pressure. This is a medical emergency that requires prompt treatment.
  • Appendicitis: Appendicitis is a condition in which the appendix becomes inflamed, causing severe abdominal pain and pressure. Although the patient's pain is localized to the pelvis, appendicitis can cause referred pain to the pelvis.
• Rare Diagnoses
  • Uterine sarcoma: Uterine sarcoma is a rare type of cancer that can cause pelvic pain and pressure. Although it is unlikely, it is still possible, especially if the patient has a history of cancer or is postmenopausal.
  • Pelvic inflammatory disease (PID): PID is a condition in which the reproductive organs become inflamed, causing pelvic pain and pressure. Although it is unlikely, it is still possible, especially if the patient has a history of sexually transmitted infections or multiple sexual partners.

Next Steps

The patient should undergo a thorough physical examination, including a pelvic exam, to assess for any abnormalities. Additional testing, such as a complete blood count (CBC) and blood cultures, may be ordered to rule out infection or other conditions. Imaging studies, such as a pelvic MRI or CT scan, may be ordered to further evaluate the patient's symptoms and rule out other conditions. Referral to a gynecologist or other specialist may be necessary for further evaluation and treatment.