Differentials
Endometriosis
SIGNS / SYMPTOMS
High abdominal and cervical tenderness.
Urethral pain/hematuria.
Dysfunctional menstrual bleeding.
Pain increases during menstrual cycle.
Absence of anterior vaginal wall tenderness over urethra or bladder neck on bimanual exam.[38]
INVESTIGATIONS
Laparoscopy demonstrates sites of ectopic endometrial implantation. Cystoscopy can show implants if cyclic hematuria present.
Irritable bowel syndrome (IBS)
SIGNS / SYMPTOMS
Fecal urgency and frequency.
Excessive straining on defecation.
Alternating constipation and diarrhea.
Pain on digital rectal exam.
Almost 50% of patients may have symptoms related to IBS.[39] Symptoms/signs may be similar due to overlapping spinal cord innervation.
INVESTIGATIONS
Colonoscopy is usually normal, but mucosal inflammation or ulceration suggests IBS.
Urinary tract infection
SIGNS / SYMPTOMS
Fever and hematuria.
Absence of pain with palpation of levator ani (pelvic diaphragm) on bimanual exam.
May coexist with IC/bladder pain syndrome (BPS).
INVESTIGATIONS
Positive urine cultures.
Positive response to antibiotic therapy.
Pelvic organ prolapse
SIGNS / SYMPTOMS
Prolapse seen on exam.
Obstructive urinary symptoms.
Defecatory dysfunction.
INVESTIGATIONS
Physical exam can show position of anterior, apical, and posterior walls of the vagina during the Valsalva maneuver.
Pelvic congestion syndrome
SIGNS / SYMPTOMS
Pain worsens with menstruation/physical activity.
History of multiparity and latent onset of symptoms.
INVESTIGATIONS
Pelvic MRI or pelvic venogram will show large tortuous veins of the ovaries and broad ligaments.
Bacterial vaginosis, atrophic vaginitis
SIGNS / SYMPTOMS
Vaginal itching, burning, or discharge. Vaginal odor.
Recurrent use of spermicide or douching.
INVESTIGATIONS
Vaginal exam and wet prep.
Specific sexually transmitted infection culture or ribonucleic acid (RNA) probe testing.
Clue cells on potassium hydroxide wet prep and elevated pH (>4.5), respectively.
Pelvic floor dysfunction (levator myalgia)
SIGNS / SYMPTOMS
Pain with intercourse; urinary hesitancy or constipation.
Myofascial trigger points, levator spasm on exam.
INVESTIGATIONS
Vaginal exam with spastic and tender levator ani muscles.
Overactive bladder
SIGNS / SYMPTOMS
Absence of pain with palpation of the urethra, bladder neck, and levator ani (pelvic diaphragm) on bimanual exam.
INVESTIGATIONS
No glomerulations and/or Hunner ulcers with cystoscopic hydrodistention.
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