Chapter 25: Assessment of Pelvic Pain

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You know, usually when we talk about a medical diagnosis, there's this expectation of clinical precision.

I mean, it's almost like engineering.

If someone breaks their arm, the x -ray shows that jagged white line, the doctor points to it and says, well, there's the problem.

Yeah.

And it is incredibly satisfying when medicine works like that.

Yeah.

You know, it's binary.

The bone is either broken or it is intact.

The whole treatment path is just laid out right in front of you.

Right.

And it's comforting.

Like for both the provider and the patient, we just like things to be visible.

But then you step into the clinical reality of women's health, specifically when a patient presents with pelvic pain and suddenly that x -ray machine feels completely useless.

Oh, totally.

You're looking at a diagnostic landscape that is honestly incredibly murky.

Exactly.

So welcome to today's Deep Dive.

If you are a nursing or advanced practice student tuning in or, you know, just someone fascinated by how complex the human body is, consider this your mental shortcut.

Right.

Because today we are tackling Chapter 25, Assessment of Pelvic Pain from Advanced Health Assessment of Women.

Yeah.

Our mission today is to master this clinical assessment.

We are going to translate these dense diagnostic pathways into plain, retainable language, moving strictly in the chapter's order from the very first question you ask a patient to the final management plan.

And to do that, we first need to define what we are actually talking about because pelvic pain is technically a geographical definition.

It's not a strictly anatomical one.

Right.

So it's an area, not a specific thing.

Exactly.

Generally, it refers to pain in the region of a woman's internal reproductive organs.

So the uterus, ovaries, fallopian tubes, cervix, or vagina.

It is a vital flashing red light indicating a potential reproductive issue.

But, and this is the kicker, because of how closely packed the female pelvis is, that exact same pain could easily be stemming from, like, the pelvic bone, the bladder, or the lower colon.

Yeah.

It's a crowded neighborhood in there.

OK, let's unpack this.

If the pain can literally be coming from a reproductive organ, a bone, a bladder, or a bowel, how on earth do you figure out what's causing it?

Well, the best analogy, I think, is that the clinician really have to adopt the mindset of a detective.

I love that.

Like, your initial history taking is getting the witness testimony.

Right.

And that testimony tells you exactly where to look during the physical exam, which is, you know, gathering your physical evidence.

And once you have the evidence, you move to clinical interpretation, basically naming the suspect.

Exactly.

And you cannot skip steps.

You can't gather physical evidence without a good witness testimony first.

But to get that testimony without overwhelming the patient, clinicians use a structured symptom framework.

According to Box 25 .1, it's the Colder Pneumonic.

C -O -L -D -E -R -R.

OK, so let's walk through how that actually sounds in a clinic.

So it starts with character.

Like, what does the pain actually feel like?

Is it a sharp, stabbing sensation, a dull ache, or is it crampy?

Because the mechanism of the pain dictates the feeling.

Right.

So a cramp usually means a hollow organ, like the uterus or bowel, is contracting.

Yeah, exactly.

And a sharp pain might mean something is ruptured.

Then next is onset.

Did this hit them like a lightning bolt, or has it been gradually a building for weeks?

Is it tied to the cycle of their menses, or is it constant?

Right.

Then you look at location.

Is the patient pointing to one very specific spot on their lower right side, or are they waving their hand vaguely across their entire lower abdomen?

Which leads right into duration, like how long has this been going on?

Has it changed?

Exactly.

Then we get to the modifiers, which are exacerbation and relief, basically what makes it worse and what makes it better.

So if, say, coughing or jumping makes the pain unbearable, we start thinking about peritoneal inflammation, right?

Yeah, it means the lining of the abdomen is irritating.

Or if eating makes it worse, maybe we're looking at the bowel instead.

Okay, and the final R is radiation.

Does the pain shoot somewhere else?

Right, and this is a big one.

Pain originating in the pelvis that shoots up to the shoulder is a classic sign of internal bleeding.

Wait, really?

The shoulder?

Yeah, because blood pooling in the abdomen irritates the phrenic nerve, and that nerve shares a pathway with the shoulder.

See, that is fascinating.

The pain is in the shoulder, but the bleeding is in the pelvis.

But the history doesn't stop at just colder, right?

No, not at all.

Our sources emphasize that you have to expand outward.

You have to ask about urinary and gastrointestinal symptoms.

You need to know about any vaginal bleeding or discharge.

And you have to ask really detailed questions about their sexual history, like changes in partners, STI exposure, unprotected sex, and even the use of sex toys.

Right, plus any contraception changes.

And crucially, you need to know about any abdominal or pelvic surgery, especially within the last 12, 24 months.

I have to admit, if I come in complaining of lower belly pain, being asked about a surgery I had two years ago feels like a stretch, or, you know, being asked about sex toys.

Why is that so relevant?

I mean, it feels like ancient history to the patient.

But to the clinician, it is a massive clue.

Any time the peritoneum, that protective membrane lining the abdominal cavity, is penetrated during surgery, the body heals by creating scar tissue.

OK, that makes sense.

Yeah.

And sometimes,

that scar tissue forms webs or bands called adhesions.

These adhesions act like internal glue, binding organs together that should normally just slide past one another.

Oh, wow.

So a year or two later, as those organs move during digestion or physical activity, they pull on those adhesions, which causes severe pain.

Wow.

So the tissue is literally tethering their organs together.

And what about the sexual history?

Why the focus on sex toys or new partners?

Because it completely alters your risk profile for an infectious suspect.

Introducing new bacteria into the vaginal canal increases the risk of an ascending infection.

Meaning the bacteria travel up through the cervix into the uterus and fallopian tubes.

Exactly.

Knowing the sexual history tells the detective how heavily to weigh infections like povic inflammatory disease in their investigation.

All right.

So our witness testimony has given us a solid suspect list.

Now we transition to the physical exam to gather our physical evidence.

And the assessment moves from the outside in.

Precisely.

You start with the abdominal assessment.

First, you inspect.

You are literally using your eyes to look for those surgical scars we just talked about.

Right.

Then you auscultate.

You listen.

You want to hear normal bowel sounds.

Because if the bowel sounds are absent or altered, you might be dealing with a paralytic elias or an obstruction.

Paralytic elias, which is what?

Exactly.

It's a condition where the normal muscle contractions of the intestines just stop.

The bowel essentially freezes up, usually due to inflammation or infection nearby, so things just aren't moving through.

That sounds like a major red flag.

Oh it is.

Then, after listening, you percuss.

You're tapping on the abdomen.

If you hear a hollow, drum -like sound timpani, you know you are tapping over trapped air.

Which could mean a bowel obstruction.

But if it's a dull thud, you're tapping over something solid or fluid -filled.

Like a distended bladder, an enlarged organ, like the liver or spleen, or pregnancy, or a tumor.

Exactly.

Then comes palpation.

You start with light palpation.

If the patient's abdominal muscles rigidly spasm when you touch them and they can't control it, that's called involuntary guarding.

Which means the abdominal lining is severely inflamed, right?

Like an acute abdomen.

Yes.

Which is often a surgical emergency.

Then deep palpation is used to feel for specific masses, like a tumor or a pregnant uterus.

Our sources also brought up this concept of pain mapping with figure 25 .1, which honestly sounds like drawing a treasure map of discomfort with the patient.

That is a brilliant way to visualize it.

It is literally a geographical map of the patient's abdomen.

The patient and provider work together to document the exact coordinates of the pain.

Right, so right -sided pain might point your compass toward the appendix, while bilateral pain pain on both sides often points toward an infection spreading through both fallopian tubes like PID or endometriosis.

Exactly.

It's so useful that providers often have patients do this mapping at home when they experience flare -ups.

So after the abdomen, the clinician moves to the pelvic and rectal exam.

Visualizing the vagina and cervix, assessing the size and mobility of the uterus, and checking the ovaries.

But there is a massive clinical pearl here regarding the ovaries, isn't there?

Oh, a huge one.

A rule you cannot ignore.

Ovaries should not be palpable in postmenopausal women.

Period.

Wait, really?

You shouldn't feel them at all, because they shrink.

Exactly.

After menopause, without the constant stimulation of estrogen, the ovaries atrophy.

They become very small.

So if you can physically feel an ovary during a bimanual exam in a postmenopausal patient, you have to assume it is an abnormal mass or tumor until proven otherwise.

Okay, here's where it gets really interesting for me.

Let's talk about the infamous chandelier sign.

In a lot of early nursing or medical training, you hear that the chandelier sign automatically equals Pelvic Inflammatory Disease or PID.

Yes, and that is a major clinical myth that needs to be shattered.

But first, let's explain what it actually is.

The clinical term is cervical motion tenderness.

When the provider inserts their fingers and gently moves the cervix from side to side, the pain is so excruciating that the patient figuratively jumps off the exam table and reaches for the chandelier.

That pain's quite the picture.

But why does simply moving the cervix cause that much pain?

Because the cervix is connected to the uterus, which is connected to the fallopian tubes and the broad ligament.

If the pelvic cavity is full of severe inflammation,

moving the cervix stretches all that highly inflamed, angry tissue at once.

So it's like pulling on a rope that's attached to a sunburn.

That's a perfect analogy.

And while it is strongly associated with PID, which is usually bilateral,

it is absolutely not exclusive to it.

Really?

Yeah, think about it.

If the appendix is about to burst, that surrounding tissue is inflamed.

Moving the cervix will pull on that area too.

In fact, 28 % of patients with appendicitis, usually right -sided, will have a positive chandelier sign.

Wow, 28%.

Yeah.

You will also see it with ectopic pregnancies, endometriosis, ruptured cysts, and ovarian torsion.

It is a sign of severe pelvic inflammation, not one specific disease.

Okay, so we've gathered all our physical evidence.

Now we have to interpret it, name the suspect, and rule out the immediate dangers.

In clinical terms, we are moving into the differential diagnosis for acute pelvic pain, or APP.

Right.

This is pain that hits fast, is incredibly severe, short -lived, and often follows trauma or surgery.

Yeah.

And your absolute first priority, the prime suspect you must rule out first in any patient of childbearing age,

is a pregnancy -related emergency.

Let's break this down.

Spontaneous abortion or miscarriage is a major one, but the text categorizes five distinct types of how this presents physically.

Right.

The terminology describes exactly what is physically happening.

An inevitable abortion means the cervix has started to dilate, there is heavy bleeding, and intense cramping.

The process has started and cannot be stopped.

And an incomplete abortion means the body is actively passing the products of conception, but some tissue remains inside.

So the cervix stays open and the bleeding is heavy.

Exactly.

Then there's a complete abortion, that's when all the tissue has passed, so the cramping and bleeding decrease, and the cervix closes back up.

But what about a missed abortion?

That is when the pregnancy is no longer viable, but the body hasn't recognized it yet.

The only symptom is amenorrhea, a missed period.

There is no bleeding, no cramping, and the cervix is totally closed.

And we also have to watch for a septic abortion, right, which is any of these complicated by a severe upper general tract infection.

Yes, absolutely.

And for all of these, your labs are going to include serial beta HCG, RH typing, a CBC, and an ultrasound.

Now the other massive pregnancy emergency is the ectopic pregnancy.

Our sources stress this must always be on every single differential list for acute pain.

It has to be.

In an ectopic pregnancy, the fertilized egg implants outside the uterus, most commonly in the celopian tube.

As that embryo grows, the tube stretches, causing immense pain.

If it ruptures, it's a life -threatening hemorrhage.

And previous trauma to the area plays a big role here, like prior PID, tubal surgery, or IUC use, right?

Huge.

If a patient has had one ectopic pregnancy before, their chance of having a second one jumps to 10 to 20 percent, because that structural damage is already there.

You diagnose this by looking for a gestational sac visible at five and a half weeks and checking if the beta HCG is between 1 ,500 and 2 ,400 and increasing by 50 percent every two days.

So once we rule out pregnancy, we pivot to gynecologic infectious causes.

We mentioned PID, and table 25 .1 breaks it down.

Aside from that chandelier sign, how are clinicians definitively spotting PID?

You are looking for physical signs of aggressive bacterial invasion.

You'll see cervical, uterine, and ednexal tenderness.

You might see cervical mucopis.

Mucopis.

Yeah, thick discharge of mucus and pus.

You might also see friability, meaning the tissue bleeds easily when touched, at a temp over 101 degrees Fahrenheit.

But the real key finding is the presence of white blood cells leukocytes in the vaginal secretions, right?

Exactly.

The body sends them to fight infection.

If they're completely absent, it strongly argues against PID.

An outpatient treatment for PID per table 25 .1 is an aggressive combo.

It's ceftriaxone, 250 milligrams IM, plus doxycycline, 100 milligrams orally, twice a day for 14 days, plus metronidazole, 500 milligrams twice a day for 14 days.

Yep.

You are hitting it hard to prevent permanent scarring, and you hospitalize if a surgical emergency is suspected, if they're pregnant, or if the oral meds are failing.

Oh, and interestingly, routine IUD removal is not currently recommended by the CDC.

Good to know.

What about a tubo -ovarian abscess?

That occurs in 15 to 34 percent of PID cases.

It absolutely requires a surgical referral.

Okay, then we have endometritis.

How does that contrast with PID?

Endometritis is pregnancy -related.

It happens post -delivery, usually causing a fever within 36 hours, uterine tenderness, and foul -smelling lochia.

But unlike PID, it's not associated with infertility or chronic pain.

Let's round out the other gynecologic causes.

You have dysmenorrhea, which is suprapubic pain, during menses driven by prostaglandins.

Box 25 .2 says treatment is NSAs like 800 -milligram ibuprofen, oral contraceptives, heat, and exercise.

Right.

Then there are uterine fibroids.

Pain usually hits after age 35, feels like chronic pressure, and the uterus feels firm and irregularly enlarged.

And medically,

per table 25 .2, you treat fibroids with NSAs, contraceptives, progestin, or GnRH agonists like Luperlide.

Exactly.

Then you have ovarian cysts.

Physiologic cysts usually resolve in one to two months, but a rupture causes sudden pain that resolves in 24 to 48 hours, whereas a hemorrhage is highly vascular and mimics an ectopic pregnancy.

But the really scary one is adnexal torsion.

Oh, torsion requires an acute referral.

It presents a sudden unilateral colic -y pain with severe nausea and vomiting.

Like twisting a garden hose.

Exactly like that.

It cuts off its own blood supply.

And of course, we have to quickly mention GI causes like appendicitis and gastroenteritis and urinary causes like pylonephritis and nephrolithiasis or kidney stones.

Right.

Table 25 .3 outlines stones, analgesics like NSAs or chitterolac, plus Tamselocin to help the stone pass.

It's a massive amount of information, which is why box 25 .3 summarizes how to mentally organize these lists by quality crampy versus colic -y, by age monarch versus menopausal, by onset seconds versus days, and by associated symptoms like nausea versus bleeding.

It's a great roadmap for the student listener.

But why do we transition from acute to chronic pelvic pain?

Because once the immediate life -threatening emergencies like an ectopic pregnancy or torsion are ruled out, we have to address the lingering pain that severely impacts the patient's quality of life.

Right.

Chronic pelvic pain, or CPP, is defined as pain lasting for six or more months.

And box 25 .4 lists the risk factors, and this is crucial.

Shockingly, 40 to 50 % of women with CPP have a history of physical or sexual abuse.

That statistic is just, wow, it's jarring.

It really is.

Other risks include prior PID, endometriosis, interstitial cystitis, and IBS.

Let's talk about endometriosis.

The number one cause of gynecologic pelvic pain.

Yeah, so ectopic endometrial tissue responds to hormonal cycling.

It literally bleeds wherever it sits.

And the chapter details that these implants can be found in the nasal mucosa, the spinal canal, and the spleen.

Does more tissue mean more pain?

You would think so, but no.

Uniquely, the amount of ectopic tissue has absolutely no correlation with symptom severity.

On exam, the uterus is fixed and retroverted with nodularity in the cul -de -sac.

And the treatment is identical to fibroid management, right?

Table 25 .2.

Correct.

Then we briefly have adenomyosis, which is tissue inside the myometria making the uterus diffusely enlarged and soft.

Povik adhesions, which are those webs of scar tissue restricting bowel mobility.

And pelvic congestion, which is varicosities of the pelvic veins causing bilateral pain.

But what about GI and GU causes of chronic pain?

Well, IBS irritable bowel syndrome accounts for 60 % of pelvic pain referrals.

Box 25 .5 and table 25 .5 say it's diagnosed via the Roan criteria.

Which is recurrent pain at least three days a month linked to defecation or stool changes.

Treatment is a low FODMAP diet, PEG -3 350 for constipation, lopramide for diarrhea, and dicyclamine for pain.

And for the urinary system, we have interstitial cystitis, or IC.

If we connect this to the bigger picture, IC is the main GU cause of chronic pelvic pain.

It's characterized by the leaky bladder theory, marked by urinary frequency, more than eight times normal, and flares with intercourse.

And it's diagnosed by exclusion.

Box 25 .6 says initial treatments are heat, avoiding trigger foods like caffeine, citrus, and spicy foods, and doing pelvic PT.

Exactly.

So we have all these overlapping chronic issues, endometriosis, IBS, IC.

How are these actually managed in practice?

It takes a village.

Table 25 .4 outlines this massive interdisciplinary approach.

Options range from pharmacologic -like analgesics or neuropathic agents like gabapentin and SNRIs.

To cognitive behavioral therapy and pelvic floor physical therapy using biofeedback and manual manipulation.

And non -invasive procedures like Botox for muscle spasms or nerve blocks.

And only as an absolute last resort do you look at opioids or invasive surgery like a hysterectomy or destroying bladder nerves.

It's a massive clinical puzzle.

We've traced the entire assessment pathway of Chapter 25 today, but I know you have a final provocative thought for us to mull over.

I do.

Consider how intertwined our bodily systems are.

When treating chronic pelvic pain, you aren't just treating a reproductive organ.

You are treating a complex web of gastrointestinal, urinary, musculoskeletal, and nervous systems, heavily influenced by a patient's psychological and trauma history.

How might you change your questioning knowing that the source of the pain might not even be in the pelvis?

That is the exact mindset you need.

To everyone listening, you've now traced the exact clinical pathways of Chapter 25, turning a dense textbook chapter into a mental roadmap.

Good luck on your clinicals and exams, and a warm, encouraging thank you, specifically from the Last Minute Lecture team.

See you next time.