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    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.

    Physical examination

    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.


    Next: Tests and differential diagnosis >>

    Kate C Arnold, MD
    Dr Arnold is a resident in obstetrics and gynecology, University of Oklahoma Health Sciences Center, Oklahoma City.


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    • Dr. DaftPunk
      Pelvic muscle spasm needs to always be in the differential for pelvic pain, particularly in the ER. Too many patients have been convinced their pain is coming from their 2cm functional cyst.
    • I appreciate this article regarding the differential diagnosis of pelvic pain. However, I do take significant exception regarding management. Why would anyone go straight to an exploratory LAPAROTOMY on a healthy nulliparous patient? The obvious choice would be diagnostic LAPAROSCOPY. In this situation the fibroids could easily be amputated with laparoscopic instruments, and the pathology removed through a small minilaparotomy or (if God willing its return) a morcellator. I understand the need for resident experience in open cases, but in this case the patient was definitely harmed with a big incision. Since a retractor and packing the intestine obviously occurred, the risk of adhesions, And pain are compounded on top of the surgical removal of the fibroids. If you don't start laparoscopically, no case can be done laparoscopically. There are few cases, IMHO, that warrant primary laparotomy in our day and age.


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