What is the appropriate urgent evaluation and management for a reproductive‑age woman presenting with acute pelvic pain that started during intercourse and is accompanied by nausea and vomiting?

Urgent Evaluation and Management of Acute Pelvic Pain During Intercourse with Nausea and Vomiting

Immediately obtain serum β-hCG and perform transvaginal ultrasound with Doppler imaging, as this presentation suggests ovarian torsion, ruptured hemorrhagic cyst, or ectopic pregnancy—all time-sensitive emergencies requiring urgent surgical consultation. 1, 2

Immediate Laboratory Assessment

• Serum β-hCG is mandatory as the first test in all reproductive-age women with acute pelvic pain, as it fundamentally determines the entire diagnostic pathway and imaging strategy. 1, 2
• A positive β-hCG immediately prioritizes ectopic pregnancy, spontaneous abortion, or other pregnancy complications and eliminates CT as an option due to fetal radiation exposure. 1, 2
• A negative β-hCG essentially excludes pregnancy-related causes (becomes positive ~9 days post-conception) and allows consideration of CT imaging if non-gynecological causes are suspected. 1
• Obtain urine culture even with negative urinalysis to detect clinically significant bacteria not identifiable on dipstick. 1

Critical Clinical Features to Document

• Pain onset during intercourse strongly suggests ovarian torsion (from sudden movement) or ruptured hemorrhagic ovarian cyst. 3, 4
• Nausea and vomiting accompanying acute pelvic pain indicate peritoneal irritation from hemorrhage, torsion, or rupture—these are red flag symptoms requiring urgent imaging. 1, 5
• Assess for fever (suggests pelvic inflammatory disease or tubo-ovarian abscess), vaginal bleeding (suggests ectopic pregnancy or placental abruption if pregnant), and hemodynamic instability (suggests hemorrhage). 2, 5
• Document pain severity, laterality, and radiation pattern to differentiate adnexal pathology from gastrointestinal or urinary causes. 1, 6

Imaging Algorithm Based on β-hCG Result

If β-hCG is Positive:

• Transvaginal AND transabdominal ultrasound with Doppler is mandatory as first-line imaging—CT is contraindicated due to fetal radiation exposure. 1, 2, 5
• Ultrasound findings: adnexal mass without intrauterine pregnancy has a positive likelihood ratio of 111 for ectopic pregnancy; endometrial thickness <8mm virtually excludes normal intrauterine pregnancy. 2
• If ultrasound is nondiagnostic and severe pain persists, MRI abdomen/pelvis without IV contrast is preferred over CT (100% sensitivity and 93.6% specificity for appendicitis in pregnancy). 2, 5
• Gadolinium contrast is pregnancy category C and should be avoided unless absolutely necessary, as it is excreted in amniotic fluid for indeterminate periods. 1, 5

If β-hCG is Negative:

• Transvaginal ultrasound with Doppler imaging remains first-line for suspected gynecological causes (ovarian torsion, hemorrhagic cyst, tubo-ovarian abscess, pelvic inflammatory disease). 1, 2
• Ultrasound has 93% sensitivity and 98% specificity for tubo-ovarian abscess; specific findings include thick walls (>5mm), cogwheel sign, incomplete septa, and cul-de-sac fluid. 7, 2
• For ovarian torsion, ultrasound shows enlarged ovary with decreased or absent Doppler flow, but normal vasculature does NOT exclude torsion—if clinical suspicion is high with severe pain, proceed directly to surgical consultation. 3
• If ultrasound is nondiagnostic or non-gynecological causes are suspected (appendicitis, diverticulitis, urinary calculi), CT abdomen/pelvis with IV contrast is indicated (89% sensitivity vs. 70% for ultrasound in urgent abdominopelvic diagnoses). 1, 2

Urgent Gynecological Diagnoses to Rule Out

• Ovarian torsion: Sudden onset during intercourse, severe unilateral pain, nausea/vomiting; ultrasound shows enlarged ovary ± decreased Doppler flow; requires immediate surgical consultation for detorsion within 4-8 hours to preserve ovarian function. 3, 4
• Ruptured hemorrhagic ovarian cyst: Sudden onset during intercourse, unilateral pain, nausea/vomiting; ultrasound shows complex cystic mass with internal echoes and free pelvic fluid; most managed conservatively unless hemodynamically unstable. 8, 4
• Ectopic pregnancy (if β-hCG positive): Unilateral pain, vaginal bleeding, nausea; ultrasound shows adnexal mass without intrauterine pregnancy; requires immediate obstetric consultation for methotrexate vs. surgical management. 2, 6
• Tubo-ovarian abscess: Fever, bilateral pain, nausea; ultrasound shows thick-walled complex adnexal mass with septations and cul-de-sac fluid; requires immediate broad-spectrum antibiotics covering N. gonorrhoeae, C. trachomatis, anaerobes, and gram-negative bacteria. 7, 2

Management Based on Diagnosis

• For suspected ovarian torsion with ultrasound showing enlarged ovary or high clinical suspicion despite normal Doppler, obtain immediate surgical consultation—do not delay for additional imaging. 3
• For pelvic inflammatory disease/tubo-ovarian abscess, initiate empiric broad-spectrum antibiotics immediately when minimum criteria are met (uterine + adnexal + cervical motion tenderness), even before culture results. 2
• Coverage must include N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci; obtain cervical cultures but do not delay treatment. 2
• For ruptured hemorrhagic cyst with hemodynamic stability, manage conservatively with analgesia and serial hemoglobin monitoring; surgical consultation if unstable. 4

Critical Pitfalls to Avoid

• Never rely on normal Doppler flow to exclude ovarian torsion—torsion can occur despite normal vasculature on ultrasound, and patients with severe pain or risk factors may require exploratory laparotomy. 3
• Do not skip β-hCG testing in reproductive-age women—failure to obtain this test can result in missed ectopic pregnancy, inappropriate radiation exposure, or delayed diagnosis. 1, 2
• Do not require multiple criteria before treating suspected pelvic inflammatory disease—requiring two or more findings reduces sensitivity and misses cases that can cause permanent reproductive damage. 2
• Never order CT pelvis alone for generalized pain—it provides insufficient coverage and must be combined with abdominal imaging. 2
• Do not use plain radiographs for pelvic pain evaluation, as they have extremely limited utility. 1
• Do not perform CT as first-line imaging when gynecological causes are suspected—ultrasound has equivalent or superior diagnostic accuracy without radiation exposure. 1, 2