Differentials
Ectopic pregnancy
SIGNS / SYMPTOMS
Reproductive-age, sexually active female with missed menses, lower abdominal and pelvic pain, vaginal bleeding, and symptoms of acute abdomen such as diarrhoea, nausea, and vomiting.
Presentation may be difficult to distinguish from ovarian torsion.
INVESTIGATIONS
Ultrasound and positive pregnancy test.
Mittelschmerz due to ruptured graafian (dominant) follicle
SIGNS / SYMPTOMS
Sudden severe, localised pain that subsequently becomes diffuse. The pain may take a few days to resolve.
Occurs mid-cycle or in the luteal phase. May be low-grade pyrexia.
INVESTIGATIONS
Ultrasound.
Urolithiasis
SIGNS / SYMPTOMS
Associated with colic pain, usually in the flank initially and migrating anteriorly and inferiorly as the stone migrates down the ureter.
INVESTIGATIONS
Ultrasound and CT scan may show hydronephrosis or hydroureter.
Urinalysis may show haematuria.
Functional ovarian cysts
SIGNS / SYMPTOMS
Lower abdominal pain with adnexal fullness on examination.
INVESTIGATIONS
Imaging or laparoscopy may be needed to distinguish from ovarian torsion. Ultrasound may show ovarian cyst and no features suggestive of torsion.
Pelvic inflammatory disease (PID)
SIGNS / SYMPTOMS
Sexually active female with lower abdominal pain, cervical motion tenderness, and adnexal tenderness.
Abnormal vaginal and cervical discharge may be noted, as well as a raised temperature.
INVESTIGATIONS
Cervical cultures may show Neisseria gonorrhoeae or Chlamydia trachomatis, the most common causes of PID.
Ultrasound may show tubo-ovarian abscess.
Appendicitis
SIGNS / SYMPTOMS
Acute pain, classically beginning peri-umbilically and localising to the right lower quadrant.
INVESTIGATIONS
Ultrasound may show a peristaltic or non-compressible structure >6 mm.
CT scan may show abnormal appendix diameter >6 mm with wall thickening, wall enhancement, and inflammatory changes in the surrounding tissues.
Endometriosis
SIGNS / SYMPTOMS
Cyclic pain exacerbated by onset of menses and occurring during the luteal phase.
Pelvic or adnexal mass may be noted, as well as lateral displacement of the uterus.
May have chronic pelvic pain.
INVESTIGATIONS
Definitive diagnosis is surgical.
Ultrasound may show ovarian endometrioma (homogeneous, low-level echoes) or deep pelvic endometriosis such as uterosacral ligament involvement (hypoechoic linear thickening).
Urinary tract infection
SIGNS / SYMPTOMS
Pain and tenderness in the suprapubic area commonly associated with burning on micturition.
Pyelonephritis may present with fever, chills, and pain at the costovertebral angle.
INVESTIGATIONS
Urinalysis and urine cultures show presence of bacteria.
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