Деякі гінекологічні причини тазового болю

Cause

Suggestive Findings

Diagnostic Approach*

Cyclic pain, related to menses

Primary dysmenorrhea

Crampy or dull pain a few days before or at onset of menses, sometimes with headache, nausea, constipation, diarrhea, or urinary frequency

Symptoms usually peaking in 24 hours but sometimes persisting for 2–3 days after onset of menses

History and physical examination

Transvaginal ultrasound to exclude other causes

Endometriosis

Dysmenorrhea or pelvic pain not related to menses; pain can be mild to severe

Classic triad of dysmenorrhea, dyspareunia, and infertility; sometimes painful defecation

In advanced disease, pelvic examination with cervical or uterine malposition, tender nodules in the posterior cul de sac, immobile uterus or adnexa, or fixed adnexal mass (endometrioma)

Pelvic examination

Laparoscopic biopsy (gold standard)

Transvaginal ultrasound or MRI prior to laparoscopy or if laparoscopy is not possible (due to lack of facility or surgeon)

Infrequently, laparotomy, sigmoidoscopy, or cystoscopy

Uterine adenomyosis

Dysmenorrhea or pelvic pain not related to menses; pain can be mild to severe

Transvaginal ultrasound

MRI if ultrasound is inconclusive

Pathology after hysterectomy

Mittelschmerz

Sudden onset of severe, sharp pain lasting 1–2 days in midcycle (during ovulation)

Sometimes light spotty vaginal bleeding

History and physical examination

Transvaginal ultrasound to exclude other causes

Constant or intermittent pain, unrelated to menses

Adnexal mass (benign or malignant tumor or other type of mass)

Dull, persistent unilateral pain

Palpable pelvic mass

Transvaginal ultrasound

Additional tests such as tumor markers or abdominal and pelvic CT or MRI, if needed

Ruptured ovarian cyst

Acute onset of pelvic pain, most severe at onset and often decreasing over a few hours, may be associated with sexual intercourse

Associated with vaginal bleeding, nausea, vomiting, or peritoneal signs

Transvaginal ultrasound

CBC (if significant bleeding is suspected)

Adnexal torsion

Sudden onset of severe, unilateral pain, occasionally colicky (intermittent torsion)

Often with nausea, vomiting, peritoneal signs, and cervical motion tenderness

Usually an ovary enlarged > 5 cm due to a mass or ovarian stimulation

Transvaginal ultrasound with color Doppler flow studies

Laparoscopy

Pelvic inflammatory disease

Gradual onset of pelvic pain; sometimes dyspareunia

Sometimes fever

Cervical motion tenderness, uterine, and adnexal tenderness, and mucopurulent cervical discharge

Rarely, adnexal mass (tubo-ovarian abscess)

Pelvic examination

Testing for gonorrhea and chlamydia, CBC, and urinalysis or urine culture

Transvaginal ultrasound

Acute degeneration of uterine fibroid

Sudden onset of moderate to severe pain

Sometimes vaginal bleeding

Most common during the first 12 weeks of pregnancy or after delivery or termination of a pregnancy

Transvaginal ultrasound

If diagnosis is unclear, MRI

Pelvic adhesions

Gradual onset of pelvic pain (often becoming chronic) or dyspareunia in patients with a history of abdominal surgery or pelvic infection

Rarely nausea and vomiting (if intestinal obstruction occurs)

Laparoscopy, sometimes laparotomy

Myofascial pelvic pain

Chronic or recurring pain in one or more genital tract (vulva, vagina) or other pelvic structures (bladder, rectum, buttocks, hips, abdomen)

Physical examination with evaluation of trigger points and Carnett sign

Pregnancy-related

Ectopic pregnancy

Pelvic pain and vaginal bleeding during early pregnancy

Adnexal mass with or without tenderness

If rupture occurs, sudden onset of localized, severe, sharp pain, often with vaginal bleeding and acute abdomen, and with or without hemodynamic instability

Pregnancy test, serial quantitative beta-hCG

Transvaginal ultrasound

Sometimes laparoscopy or laparotomy

* Pregnancy should be excluded in all patients of reproductive age regardless of menstrual or sexual history.

Beta-hCG = beta subunit of human chorionic gonadotropin; CBC = complete blood count.