What are the differential diagnoses for abnormal findings on pelvic examination, grouped by discharge, lesions, bleeding, pain, or masses?

Differential Diagnoses for Abnormal Pelvic Examination Findings

Organized by Clinical Presentation

Vaginal Discharge

White adherent plaques indicate Candida species, while thin homogeneous discharge with pH >4.5, clue cells, and amine odor suggests bacterial vaginosis. 1

• Candida vaginitis: White adherent plaques on vaginal walls 1
• Bacterial vaginosis: Thin, homogeneous discharge with pH >4.5, presence of clue cells on microscopy, and amine odor after base addition (Amsel criteria have 69% sensitivity, 93% specificity) 1
• Cervicitis: Mucopurulent cervical discharge, often with elevated WBCs on saline microscopy 1
• "Strawberry cervix": Punctate hemorrhages suggesting trichomoniasis 1

Lesions and Skin Findings

External genital lesions require careful characterization to distinguish infectious from neoplastic etiologies.

External Genitalia 1

• Condyloma acuminata (genital warts): HPV-related warty lesions
• Condylomata lata: Papular lesions from secondary syphilis
• Genital ulcers/fissures: Consider herpes, syphilis, or trauma
• Molluscum contagiosum: Umbilicated papules
• Bartholin gland abscess: Tender, fluctuant mass at 4 or 8 o'clock position
• Skene gland infection: Periurethral inflammation
• Urethral prolapse: Circumferential red mass at urethral meatus
• Folliculitis: Inflamed hair follicles
• Hidradenitis suppurativa: Chronic inflammatory nodules in apocrine gland areas
• Vulvitis: Generalized vulvar inflammation
• Pigmentary changes: May indicate lichen sclerosus or malignancy
• Papillomatosis: Benign vestibular papillae

Cervical Lesions 1

• Cervical ectropion: Columnar epithelium visible on ectocervix (benign)
• HPV/condyloma: Warty growths on cervix
• Cervical polyp: Smooth, pedunculated mass protruding from os
• Cervical ulcers: Consider malignancy, infection, or trauma

Vaginal Lesions 1

• Vaginal ulcers: Infectious or traumatic etiology
• Vaginal condyloma acuminata: HPV-related lesions

Abnormal Bleeding

Abnormal bleeding unresponsive to medical therapy or causing severe anemia warrants gynecologic referral. 1

• Cervical polyp: Visible pedunculated lesion causing contact bleeding 1
• Cervical ulcers: May indicate malignancy or severe infection 1
• Endometrial pathology: Requires further evaluation with imaging or biopsy
• Uterine fibroids: Palpable irregular uterine contour, especially if causing acute degeneration 1

Pain on Examination

Cervical motion tenderness indicates pelvic infection or inflammation and is the minimum criterion for diagnosing PID in sexually active women at risk. 1

Acute Pain Etiologies

In reproductive-age women:

• Pelvic inflammatory disease (PID): Cervical motion tenderness, uterine tenderness, or adnexal tenderness with mucopurulent discharge or elevated WBCs on wet prep 1, 2
  • Lower abdominal pain and/or dyspareunia have 100% sensitivity for PID diagnosis 2
  • Additional supportive findings: fever >101°F, elevated ESR/CRP, documented cervical infection 1
• Ectopic pregnancy: Adnexal mass with positive pregnancy test (approximately 40% misdiagnosed initially) 3
• Ovarian torsion: Enlarged, tender adnexal mass 1
• Ruptured ovarian cyst: Acute onset pain with free fluid 1
• Tubo-ovarian abscess: Tender adnexal mass with fever 1

In postmenopausal women: 1

• Ovarian cysts: Account for one-third of gynecologic pain cases
• Uterine fibroids: Second most common cause, from torsion, prolapse, or degeneration
• Pelvic infection: 20% of cases, including TOA, endometritis (may be related to cervical stenosis)
• Ovarian neoplasm: 8% of acute pain cases

Chronic/Subacute Pain 1

• Endometriosis: Dysmenorrhea and deep dyspareunia, especially with posterior cul-de-sac or uterosacral ligament involvement 4
  • Pain severity correlates with lesion depth, not disease stage 4
  • Deep infiltrating disease causes more severe, persistent pain 4
• Pelvic venous disorders (pelvic congestion syndrome) 1
• Hydrosalpinx: Tubular cystic adnexal mass 1
• Chronic inflammatory disease 1
• Cervical stenosis 1
• Vaginal atrophy, vaginismus, vulvodynia, pelvic myofascial pain 1

Palpable Masses

Any adnexal mass requires gynecologic referral for further evaluation. 1

Cystic Masses 1

• Simple ovarian cyst: Unilocular, thin-walled (<0.4% malignancy risk in premenopausal women)
• Hemorrhagic cyst: Spiderweb-appearing or retracting clot with peripheral vascularity
• Endometrioma: Low-level internal echoes, mural echogenic foci
• Teratoma/dermoid: Echogenic attenuating component
• Hydrosalpinx: Tubular cystic mass with or without folds
• Peritoneal inclusion cyst: Cystic mass surrounding functioning ovary
• Bartholin gland cyst: Lateral vaginal wall mass 1

Solid Masses 1

• Pedunculated leiomyoma (fibroid): Most common solid adnexal mass in women >30 years (20-30% prevalence)
  • Irregular uterine contour on bimanual exam 1
  • Blood supply from uterine vessels helps distinguish from ovarian mass 1
• Ovarian neoplasm: Requires characterization with imaging 1

Pregnancy-Related Findings 1

• Gravid uterus: Soft cervix (vs. firm nonpregnant cervix), enlarged globular uterus
  • Grapefruit-sized at 10-12 weeks, starting to protrude from pelvis
  • Becomes larger and softer between 8-10 weeks

Key Examination Pitfalls

• Adolescents commonly mistake pressure for pain, making true cervical motion tenderness difficult to assess 1
• Normal ovaries are barely palpable on bimanual exam; easily palpable ovaries suggest pathology 1
• Absence of mucopurulent discharge and WBCs on wet prep makes PID unlikely, prompting search for alternative diagnoses 1

Indications for Gynecologic Referral 1

• Adnexal mass of any type
• Vulvar or cervical lesion of undetermined etiology
• Possible genital tract anomaly
• Abnormal Pap requiring colposcopy
• Acute pelvic pain with suspected torsion, ectopic pregnancy, or TOA
• PID (if primary provider uncomfortable with management)
• Chronic pelvic pain or dysmenorrhea unresponsive to NSAIDs
• Abnormal vaginal bleeding unresponsive to therapy or with severe anemia