Initial Workup and Management for Right Lower Quadrant Pain in a Female Near Groin with No Abdominal Tenderness
CT of the abdomen and pelvis is the recommended initial imaging modality for females with right lower quadrant pain near the groin with no abdominal tenderness, due to its high diagnostic yield with a sensitivity of 95% and specificity of 94% for detecting appendicitis and other etiologies. 1
Diagnostic Approach
Initial Assessment
- Focus on specific pain characteristics:
- Location: Right lower quadrant near groin
- Radiation: To back, groin, or thigh
- Timing: Onset (sudden vs. gradual), duration, progression
- Aggravating/alleviating factors: Movement, position changes
- Associated symptoms: Fever, nausea, vomiting, urinary symptoms, vaginal discharge
Key Physical Examination Elements
- Vital signs with attention to fever and tachycardia
- Focused abdominal examination:
- Inspect for distension, scars from previous surgeries
- Palpate for masses, hernias, or point tenderness
- Check for rebound tenderness and guarding
- Perform pelvic examination to assess for cervical motion tenderness, adnexal masses
- Evaluate for inguinal hernias and lymphadenopathy
Laboratory Testing
- Complete blood count (CBC) to assess for leukocytosis
- Basic metabolic panel
- Urinalysis to rule out urinary tract infection
- Pregnancy test (β-hCG) in all women of reproductive age 1
- Consider C-reactive protein (CRP) to assess inflammation severity
Imaging Recommendations
First-Line Imaging
- CT abdomen and pelvis with IV contrast: Highest diagnostic yield for right lower quadrant pain in adults with 97% sensitivity and 94% specificity 1
- Can identify appendicitis, diverticulitis, bowel obstruction, ovarian pathology, and other causes
Special Populations
Pregnant patients:
- Ultrasound abdomen and pelvis as first-line imaging
- If inconclusive, MRI abdomen and pelvis without gadolinium
- CT only if absolutely necessary and other modalities are inconclusive 2
Premenopausal women with suspected gynecologic etiology:
- Transvaginal ultrasound to evaluate for ovarian torsion, tubo-ovarian abscess, or ectopic pregnancy 1
Differential Diagnosis for Right Lower Quadrant Pain Near Groin
Gastrointestinal Causes
- Appendicitis (even without classic abdominal tenderness)
- Terminal ileitis
- Cecal diverticulitis
- Inflammatory bowel disease
- Small bowel obstruction (adhesions most common cause, 55-75% of cases) 2
Gynecological Causes
- Ovarian torsion
- Ruptured ovarian cyst
- Tubo-ovarian abscess
- Pelvic inflammatory disease
- Ectopic pregnancy
Urological Causes
- Ureteral stone
- Pyelonephritis
Musculoskeletal/Other Causes
- Inguinal hernia
- Iliopsoas abscess
- Lymphadenopathy
- Sports hernia/athletic pubalgia
Management Approach
Initial Management
- Intravenous fluid resuscitation if signs of dehydration
- Pain management: Multimodal analgesia with scheduled acetaminophen and NSAIDs as first-line 1
- NPO status if surgical intervention is anticipated
Condition-Specific Management
- Appendicitis: Surgical consultation for appendectomy; consider antibiotics-first approach in uncomplicated cases 1
- Diverticulitis: Antibiotics covering gram-negative aerobes and anaerobes; percutaneous drainage for abscesses >3cm 1
- Ovarian torsion: Immediate gynecologic consultation for surgical intervention 3
- Bowel obstruction: Nasogastric decompression, IV fluids, surgical consultation 2
Potential Pitfalls
- Missing gynecologic causes in women of reproductive age
- Inadequate pain control affecting diagnostic accuracy
- Overlooking inguinal hernias or sports hernias in active females
- Attributing pain to musculoskeletal causes without adequate imaging
- Delaying surgical consultation when indicated
By following this algorithmic approach with appropriate imaging and early specialist consultation when indicated, the diagnosis and management of right lower quadrant pain near the groin in female patients can be optimized to improve outcomes.