Clinical: Case Study: Pelvic Pain

Original materials created in October 1998 by Barbara Levy, M.D.

History
Ms. DB is a 40 y/o woman with a two day history of increasingly severe LLQ pain. The morning of evaluation she awakened with severe pain, unable to stand up straight. She called her family physician and stated that she felt exactly as she had two years ago with an unruptured ectopic pregnancy. Her last menstrual period was exactly two weeks previously. She had had no abnormal spotting or bleeding.

On assessment by her FP, a urine pregnancy test was negative, urinalysis was normal, CBC was normal with a WBC of 6,800 and normal differential. The pelvic ultrasound demonstrated a left ovary twice the size of the right ovary and almost completely replaced by a solid/hemorrhagic area with no blood flow identified. The patient was immediately referred to me for evaluation and probable surgery for ovarian torsion.

When I first saw her, she appeared clearly uncomfortable but not acutely ill, walking with a slightly doubled-over stance. She reported that the pain was deep and constant with a secondcomponent consisting of waves of sharp pains that came on suddenly and lasted seconds. She had normal bladder function, and had had three stools that morning. The pain was relieved somewhat after the first two stools but seemed unchanged after the third. She had been hungry for breakfast and had eaten cereal with milk. There was no nausea. She denied any recent change in physical activity or stressors.

She used no contraception, was recently married, and anxious for a pregnancy. She was clearly distressed that these symptoms could represent a failed pregnancy, and was relieved at a negative pregnancy test. Past medical history was remarkable for bilateral inguinal hernias repaired as a young child, and an unruptured ectopic pregnancy treated laparoscopically in 1996.

Exam
A thin 40 year old in moderate distress. Afebrile, pulse 80, BP 107/70, RR 12. The abdomen was soft, non-distended with normal bowel sounds. No guarding or rebound present except in the LLQ. Superficial palpation over the left hernia scar elicited extreme tenderness which increased when she raised her head off the exam table. On single digit pelvic examination (vaginal without abdominal palpation) there was minimal cervical motion tenderness, no peritoneal irritation, and moderate uterine and LLQ pain. No mass was appreciated.

Discussion
Abdominal and pelvic pain may have many etiologies, including trigger points in the abdominal wall. Sequential and careful physical examination can distinguish extraperitoneal from intraperitoneal sources of pain. While the presentation and high-tech imaging suggested the possibility of an acute, surgically emergent condition, the physical examination and much of the history was incompatible with ovarian torsion. People with peritonitis generally are not hungry, and the classic peritoneal signs of guarding and rebound are most often obvious. Once peritonitis and an acute surgical emergency have been eliminated, the patient may be treated conservatively and monitored.

Plan
Treat the pain with IM ketrolac and have the patient return in several hours for reevaluation. Review the ultrasound with the radiologist and discuss the confidence with which they can determine blood flow to the ovary.

Follow Up
Films were reviewed with the radiologist. The right ovary was 2 cm. The left ovary was only 5 cm but the rim of normal ovary was compressed by a hemorrhagic cyst. The radiologist stated that there may have been some doppler signal in the normal portion of the ovary but it was hard to tell. He could not see laterally to the ovarian blood vessels themselves.

Two hours later the patient returned with significant pain relief and wanted to return to work. She had eaten some lunch, but stated that the waves of pain returned somewhat as she was eating. She was given prescriptions for sublingual hyoscyamine 0.125 mg and oral naproxen and asked to return the next morning. She was advised to go home and rest.

The next morning, she reported remarkable relief of her pain and had slept well for the first time in weeks. She revealed that perhaps her stress levels had been increased because her husband was being evaluated for a brain tumor. On exam, her abdomen was soft with no guarding or rebound, but a definite trigger point was present over the hernia scar on the left. This was treated with local ice, massage, and anti-inflammatory medications.

Conclusion
Proper evaluation of patients complaining of acute or chronic pelvic pain requires a systematic approach and an appreciation for the limitations of high tech medicine. It is essential to trust in the art of medicine, i.e. in the consistency of the history and physical examination of the patient before deciding that what we happen to see with sophisticated imaging devices is the etiology of the patient’s problem.

'''OVARIES MAKE CYSTS FOR A LIVING! THEY ARE RARELY THE CAUSE OF ACUTE OR CHRONIC PELVIC PAIN.'''