3-42
disease or a non-GYN cause such as appendicitis. All of these situations require close observation for
possible surgical intervention or transfer to an acute care facility.
Subjective: Symptoms
Abrupt onset of abdominal/pelvic pain. Character of pain and other symptoms vary depending on the cause.
Ruptured ovarian cyst: acute lower pelvic pain, often mid-cycle (day 12-16); occasional postcoital onset of
pain due to disruption of cyst during intercourse; should not have associated fever; may present acutely and
improve over 8-12 hours; minimal blood loss.
Torsion of the ovary: intermittent severe pelvic pain initially localized in right or left lower quadrant then
becoming more diffuse as the ovary necroses. The ovary will often torse and de-torse prior to a final torsion
so the patient will describe this same pain lasting for shorter intervals prior to the event that brings the
patient in for care. Not initially associated with fever; pain often radiates down inner thigh on affected side;
hematologically stable. Fever and elevated white blood cell count are seen if the ovary has become necrotic
(prolonged torsion - usually greater than 8 hours although no good data is available on exact time).
Ectopic pregnancy: late, short or missed menses; suddenly worsening abdominal pain which may radiate to
a shoulder due to irritation of the diaphragm; circulatory collapse due to internal bleeding; history of vaginal
bleeding, infertility, prior PID or pelvic surgery to include infertility procedures; increased risk if prior ectopic
pregnancy.
Pelvic Infection: See PID section.
Objective: Signs
Using Basic Tools:
Ruptured ovarian cyst: tender adnexa, normal ovaries after rupture. Fullness in posterior cul-de-sac may
suggest blood in pelvis. Localized guarding but no rebound until rupture, no abnormal vaginal discharge,
normal uterine exam, afebrile, normal vitals.
Torsion of the ovary: Very tender mass in right or left lower quadrant; rebound and guarding; afebrile early
with normal WBC, but both elevated later; nausea and vomiting; rare anorexia; NO leg numbness or weakness
to accompany pain (consider disc herniation if present); hemodynamically stable.
Ectopic pregnancy: If ruptured: acute abdomen with peritonitis; nausea and vomiting; hemodynamically
unstable with tachycardia, hypotension and anxiety; slightly enlarged, tender uterus with severe cervical
motion tenderness. If not ruptured: unilateral, palpable, tender mass without peritonitis; early ectopic will not
be palpable and may have intermittent, severe, cramping pain; mild spotting through a closed cervical os (open
os with significant vaginal bleeding is a miscarriage).
Pelvic Infection: Lower abdominal tenderness, bilateral adnexal tenderness (see PID section).
NOTE: Perform rectal examination with Hemocult for blood. Change gloves before rectal/ Hemocult exam if
the patient is having vaginal bleeding. Positive Hemocult does not occur with the above diagnoses without
co-existing GI disease.
Using Advanced Tools: Lab: WBC count (elevated in later torsion and in PID), urine HCG (ectopic), CBC
(anemia due to hemorrhage), stool Hemocult (guaiac), cervical cultures for gonorrhea, type blood (pending
transfusion if needed).
Assessment:
Differential Diagnosis (see Symptom: Abdominal Pain and GI chapter)
Appendicitis- frequently confused with gynecological acute pathology. Appendicitis begins in the epigastrium,
migrates to the periumbilical region and then settles in the right lower quadrant (RLQ) after 6 to 8 hours, with
rebound tenderness and RLQ tenderness to palpation (most common finding). Anorexia, nausea and vomiting
are common. Prodromal symptoms include indigestion and irregularity of the bowels. The WBC count is often
NOT elevated until the patient has had symptoms for over 24 hours.
Diverticulitis- pain due to infected diverticulum is usually left lower quadrant. Past history includes diarrhea
and bloody stools, low-grade fever, elevated WBC counts and age over 40.
Severe Constipation- acute cramping pain; anorexia and nausea or vomiting; common in the second and third
trimesters; treatment with fluids and fiber will be sufficient for many pregnant women. Acute constipation can
indicate underlying disease.