Differentials
Endometriosis
SIGNS / SYMPTOMS
Cyclical pain in early endometriosis, progressing to continuous pain.[40] Diagnosed based on the presence of endometrial glands and stroma outside of the uterine cavity.
INVESTIGATIONS
Laparoscopy and biopsy: endometrial glands and stroma.
Adenomyosis
SIGNS / SYMPTOMS
Initially cyclic pain, typically beginning after pregnancy.[41] Requires pathologic examination of the excised uterus for definitive diagnosis.
INVESTIGATIONS
Ultrasound may be suggestive, definitively diagnosed on pathologic examination of removed uterus.
Chronic pelvic inflammatory disease
SIGNS / SYMPTOMS
Suggested by a history of previous infection or multiple sexual partners with tenderness on manipulation of the uterus or adnexa.[42]
INVESTIGATIONS
Diagnosed at laparoscopy.
Interstitial cystitis
SIGNS / SYMPTOMS
Elevated bladder pain or the presence of irritative voiding symptoms.
INVESTIGATIONS
Suggested by questionnaire and a response to alkalinized lidocaine instillation, definitively diagnosed at cystoscopy with hydrodistension.
Vulvodynia
SIGNS / SYMPTOMS
Pain with insertion at intercourse.
INVESTIGATIONS
Diagnosed by physical exam. Tenderness limited to areas of the vestibule only.
Levator ani syndrome (pelvic floor tension myalgia)
SIGNS / SYMPTOMS
Only a portion of the levator muscle may be generating pain.
INVESTIGATIONS
Diagnosed by physical exam.
Hemorrhagic ovarian cysts
SIGNS / SYMPTOMS
Typically causes severe, acute pain but may evolve into chronic pain. Will frequently resolve with time. Persistent, larger (>3 cm) cysts may need to be excised.
INVESTIGATIONS
Ultrasound may demonstrate fine fibrinous strands suggestive of clot formation within the cystic mass.
Irritable bowel syndrome (IBS)
SIGNS / SYMPTOMS
Abdominal pain is associated with altered bowel habit. May be a family history of IBS.
INVESTIGATIONS
Rome IV criteria, no specific diagnostic test.
Fibromyalgia
SIGNS / SYMPTOMS
Tenderness to palpation of individual muscles. In pelvic pain, these typically include the lower, lateral borders of the rectus sheath.
INVESTIGATIONS
Diagnosed by physical exam.
Central pain syndrome
SIGNS / SYMPTOMS
Pain at multiple locations. Spread of pain from one location to another without an obvious etiology.
INVESTIGATIONS
Pinprick testing reveals increased sensation toward the anterior midline compared with the back, or allodynia (feeling a pinprick when touched with a cotton swab).
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