Appropriate Workup for Pelvic Pain
The appropriate workup for pelvic pain should begin with transvaginal and transabdominal ultrasound as first-line imaging, followed by targeted laboratory tests including pregnancy test, serum CA-125, and CBC, with advanced imaging reserved for non-diagnostic cases. 1
Initial Evaluation
History
- Pain characteristics: onset, location, radiation, quality, severity, timing, aggravating/relieving factors 2, 3
- Associated symptoms: vaginal discharge, bleeding, urinary symptoms, gastrointestinal symptoms
- Menstrual history: last menstrual period, cycle regularity, dysmenorrhea
- Sexual history: activity, contraception, STI risk factors
- Obstetric history: pregnancies, deliveries, complications
- Past medical/surgical history: focus on gynecologic, gastrointestinal, urologic conditions
Physical Examination
- Vital signs: fever may indicate infection
- Abdominal examination: tenderness, guarding, masses, rebound
- Pelvic examination:
- External genitalia: lesions, discharge
- Speculum exam: cervical discharge, lesions
- Bimanual exam: cervical motion tenderness, uterine/adnexal tenderness, masses
- Rectovaginal exam: nodularity, masses
- Musculoskeletal assessment: lumbosacral spine, sacroiliac joints, pelvic floor 2
Laboratory Testing
First-line Tests
- Pregnancy test (urine or serum β-hCG) for all reproductive-age women 1, 3
- Complete blood count (CBC) 1
- Urinalysis 1
- Cervical cultures for gonorrhea and chlamydia if PID suspected 3
Additional Tests Based on Clinical Suspicion
- Serum CA-125 if ovarian pathology suspected 1
- Comprehensive metabolic panel 1
- Inflammatory markers (ESR, CRP) 1
- STI testing 3
Imaging Studies
First-line Imaging
- Pelvic ultrasound (transvaginal and transabdominal) 1, 4, 3
- Evaluate: uterus (size, endometrial thickness), ovaries (size, cysts, masses), free fluid
- Assess vascular flow with Doppler if torsion suspected
- Look for specific findings: wall thickness >5mm, cogwheel sign, incomplete septa
Advanced Imaging (if ultrasound non-diagnostic)
- CT abdomen/pelvis with IV contrast 1, 3
- Indicated for suspected complications or broader differential
- Non-contrast CT "stone protocol" for suspected urolithiasis (sensitivity 92-99%)
- MRI pelvis without and with IV contrast 1, 5
- For indeterminate adnexal masses
- Suspected endometriosis or adenomyosis
- Pelvic venous disorders
- Pelvic floor dysfunction
Specialized Testing Based on Duration and Suspected Etiology
For Acute Pelvic Pain (<3 months)
- Focus on ruling out urgent conditions: ectopic pregnancy, ovarian torsion, PID, appendicitis 4, 3
- Apply O-RADS US Risk Stratification system for ovarian/adnexal findings 1
For Chronic Pelvic Pain (>6 months)
- Consider laparoscopy if endometriosis suspected 6
- Evaluate for comorbid conditions: irritable bowel syndrome, interstitial cystitis 6
- Consider nerve conduction studies/EMG for suspected neuropathic pain 5
- Assess for mental health disorders (depression, PTSD) 6
Common Pitfalls and Caveats
- Missed ectopic pregnancy: Approximately 40% are misdiagnosed at initial presentation. Always perform pregnancy testing in reproductive-age women 3
- Overlooking non-gynecologic causes: Consider gastrointestinal, urologic, and musculoskeletal etiologies 4, 3
- Inadequate imaging: Transvaginal ultrasound should be combined with transabdominal views for comprehensive evaluation 1
- Delayed diagnosis of PID: Approximately 15% of untreated chlamydia infections progress to PID 3
- Cancer consideration: Always consider malignancy in postmenopausal women with pelvic pain 4
Management Considerations
- Immediate gynecology consultation for suspected torsion, significant cyst rupture, or large symptomatic cysts 1
- Non-pharmacological approaches as first-line treatment 1
- Appropriate analgesics based on pregnancy status (NSAIDs for non-pregnant patients) 1
- Consider surgical intervention for persistent symptoms or failed conservative management 1