Puzzler: An unusual cause of pelvic pain
Dr Arnold is a resident in obstetrics and gynecology, University of Oklahoma Health Sciences Center, Oklahoma City.
A 47-year-old nulliparous woman presented to an emergency department (ED) for 3 days of nausea and 1 day of abdominal pain. She reported feeling well prior to this episode. There were no signs consistent with an acute abdomen. A transvaginal ultrasound showed 2 ovaries with normal blood flow. No fibroids were noted. On arrival, the patient received 1 mg of hydromorphone and did not require further dosing for approximately 4 hours, but she continued to complain of nausea.
The patient denied fevers/chills, changes in bowel or bladder function, or contacts who were ill, and reported that she was generally in good health. Her medical and surgical histories were noncontributory. The patient also denied using cigarettes, alcohol, or drugs. She had no family history of cancer.
The patient was up to date on and had normal Pap smears, reported regular menses and had a normal menstrual period 1 week before. Despite her age, she used oral contraceptives.
The patient’s blood pressure was 142/84 mmHg; pulse 72 bpm; respiratory rate 19; and temperature 36.9o C. She was in no apparent distress; her abdomen was soft and nontender to palpation in upper quadrants. Inferiorly, a firm mass was palpated in the suprapubic region, also nontender to palpation. No rebound/guarding was present but the right lower quadrant was mildly tender to palpation although no mass was palpable.
On bimanual examination, the uterus was nontender to palpation at midline, and the anterior mass was felt to be connected to the uterus. A firm mass was palpated through the posterior fornix, which was tender to palpation immediately laterally to the right of the uterus. The cervix was normal to palpation and inspection.