Evaluation of acute pelvic pain in female children and adolescents

INTRODUCTION — This topic will review the differential diagnosis and approach to the adolescent female presenting with acute pelvic pain with an emphasis on gynecologic conditions. The gastrointestinal and urologic causes of abdominal pain are discussed in greater detail separately. (See "Causes of acute abdominal pain in children and adolescents".)

The evaluation of acute pelvic pain in older women is also discussed separately. (See "Acute pelvic pain in nonpregnant adult females: Evaluation".)

DIFFERENTIAL DIAGNOSIS — Pelvic pain most often involves the gastrointestinal or the urinary systems in prepubertal girls. However, gynecologic conditions become more prevalent as etiologies for pelvic pain, especially during late adolescence. The gynecologic causes of acute pelvic pain in adolescent females are listed in the table (table 1).

Important nongynecologic causes of acute pelvic pain include appendicitis, kidney stones, and urinary tract infection. (See 'Appendicitis' below and 'Kidney stones' below and 'Urinary tract infection' below.)

Nongynecologic causes of acute abdominal pain in female children and adolescents and their evaluation is provided separately. (See "Causes of acute abdominal pain in children and adolescents" and "Emergency evaluation of the child with acute abdominal pain".)

Life- or organ-threatening conditions — Complications of pregnancy (eg, ectopic pregnancy, acute abruption, uterine rupture) comprise the most frequent life-threatening gynecologic causes of pelvic pain in adolescent females. Gastrointestinal causes of pelvic pain can be life-threatening if they lead to peritonitis and sepsis. Of these, appendicitis is most common and will be presented briefly here. Other conditions (eg, abscess, bowel obstruction) are reviewed separately. (See "Causes of acute abdominal pain in children and adolescents", section on 'Life-threatening causes'.)

Life-threatening pelvic trauma in female adolescents is usually the result of a high-energy mechanism, such as a fall from a height or motor vehicle crash. Injury patterns and management are similar to the approach in adults and are discussed elsewhere. (See "Pelvic trauma: Initial evaluation and management", section on 'Fracture types' and "Pelvic trauma: Initial evaluation and management", section on 'Initial management'.)

Ectopic pregnancy — Patients usually present with vaginal bleeding and crampy pelvic pain approximately six to eight weeks after the last menstrual period although later presentation is possible, especially if the pregnancy is not in the fallopian tube. Incidence is increased in those with a prior history of ectopic pregnancy, tubal surgery, and pelvic infection, along with those who use an intrauterine device for contraception. Rupture may initially bring temporary relief of pain; however, massive intraperitoneal hemorrhage may ensue with high maternal mortality soon after rupture. (See "Ectopic pregnancy: Epidemiology, risk factors, and anatomic sites", section on 'Risk factors' and "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Clinical presentation'.)

Placental abruption — An acute, clinical abruption classically presents with vaginal bleeding, abdominal and/or back pain, and uterine contractions. Peak incidence is between the 24^th and 26^th week of gestation although placental abruption may occur at any time. The contractions are usually high frequency and low amplitude, but a mild to moderate contraction pattern is also possible. In the presence of a severe abruption (≥50 percent placental separation), both fetal and maternal compromise may occur. Acute disseminated intravascular coagulation (DIC) develops because blood is exposed to large amounts of tissue factor over a brief period of time. This exposure leads to massive generation of thrombin, resulting in the acute triggering of coagulation. The clinical consequence is a profound systemic bleeding diathesis in the mother and due to widespread intravascular fibrin deposition, tissue ischemic injury, and a microangiopathic hemolytic anemia. (See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences".)

Uterine rupture — Signs and symptoms of uterine rupture can include nonreassuring fetal heart rate tracing or fetal death, uterine tenderness, peritoneal irritation, vaginal bleeding, loss of fetal station, and shock. Most uterine ruptures occur in laboring women with a prior cesarean delivery or prior uterine surgery. Rupture of the unscarred uterus during labor is rare. (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients", section on 'Uterine rupture'.)

Appendicitis — Acute appendicitis is the most common cause for emergency abdominal surgery in children; incidence increases with age and peaks in adolescence. Initial periumbilical pain, which later localizes to the area of peritoneal irritation, usually the right lower quadrant, followed by fever, vomiting, and anorexia is the most common presentation. Obstruction of the appendiceal lumen can lead to thrombosis, necrosis, and if untreated, perforation. Complications involve ileus, abscess formation, intestinal obstruction, peritonitis, sepsis, and shock. (See "Acute appendicitis in children: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Ovarian and fallopian tube torsion — Ovarian torsion refers to twisting of the adnexa upon its pedicle and typically presents with an acute onset of sharp, intermittent abdominal pain associated with nausea and vomiting. Formation of ovarian cysts may predispose to torsion, and therefore, torsion has a higher incidence in adolescents than prepubertal girls. This condition requires prompt surgical intervention to prevent necrosis and loss of the ovary. Although typically not life-threatening, ovarian torsion does present a significant risk to the viability of the ovary. (See "Ovarian and fallopian tube torsion", section on 'Clinical presentation'.)

There have been a number of case reports of fallopian tube torsion in both pre- and postmenarchal females [1-8]. Fallopian tube torsion appears to present in a similar manner as ovarian torsion, but with normal imaging of the ovary itself with discovery of the condition during surgical exploration. As with ovarian torsion, prompt consideration of this diagnosis and surgical detorsion may prevent irreversible ischemic damage. (See "Ovarian and fallopian tube torsion", section on 'Isolated fallopian tube torsion'.)

Common conditions — Dysmenorrhea is the most common gynecologic cause of pelvic pain during adolescence. Pelvic inflammatory disease and mittelschmerz are also frequent. Urinary tract infections (cystitis, pyelonephritis) are very common causes of lower abdominal pain. Nephrolithiasis is an increasingly common cause of pelvic pain in adolescents. Other common urologic etiologies (eg, urinary tract infection) as well as gastrointestinal conditions (eg, constipation, gastrointestinal infection, functional abdominal pain) are discussed separately. (See "Causes of acute abdominal pain in children and adolescents", section on 'Common causes' and "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Etiology'.)

Dysmenorrhea — Menstrual pain affects at least two-thirds of postmenarchal females in the United States, some of whom experience severe pain sufficient to affect daily activities. Dysmenorrhea is usually crampy and intermittent. Nausea, vomiting, diarrhea, headache, dizziness, or back pain may accompany the crampy abdominal pain. The pain and associated symptoms typically begin several hours prior to the onset of menstruation and continue for one to three days. The severity of the disorder can be categorized by a grading system based upon the degree of menstrual pain, presence of systemic symptoms, and impact on daily activities (table 2). Dysmenorrhea can be divided into primary causes (absence of any pelvic pathology and the more common form which typically begins during adolescence) or secondary causes (underlying pelvic pathology, such as endometriosis). (See "Primary dysmenorrhea in adolescents", section on 'Clinical manifestations'.)

Mittelschmerz — This ovulatory event causes recurrent midcycle pain in females with regular ovulatory cycles. This pain is caused by normal follicular enlargement just prior to ovulation or to normal follicular bleeding at ovulation. The pain is typically mild and unilateral; it occurs midway between menstrual periods and lasts for a few hours to a couple of days. (See "Evaluation and management of ruptured ovarian cyst", section on 'Differential diagnosis'.)

Pelvic inflammatory disease — Pelvic inflammatory disease (PID) is most commonly caused by C. trachomatis and N. gonorrhoeae, both of which have the highest prevalence in the adolescent/young adult population [9]. PID is an infection of the upper genital tract in females and includes endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

Lower abdominal pain is the cardinal presenting symptom in adolescents with PID, although the character of the pain may be quite subtle. The recent onset of pain that worsens during coitus or with jarring movement may be the only presenting symptom of PID; the onset of pain during or shortly after menses is particularly suggestive. About half of patients with PID have fever. On pelvic examination, the findings of a purulent endocervical discharge and/or acute cervical motion and adnexal tenderness with bimanual examination are strongly suggestive of the diagnosis. Additional nonspecific symptoms may include abnormal vaginal bleeding, dysmenorrhea, vaginal discharge, or gastrointestinal symptoms. (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Clinical features'.)

Ruptured ovarian cyst — In a postmenarchal female, an ovarian cyst that ruptures can cause sudden, severe, unilateral pelvic pain without fever or any gastrointestinal, urinary, or vaginal symptoms. Historically, they occur preceding a menstrual period. The pain often begins during strenuous physical activity, such as exercise or sexual intercourse. Blood from the rupture site may seep into the ovary, which can cause pain from stretching of the ovarian cortex, or it may flow into the abdomen, which has an irritant effect on the peritoneum. Significant hemorrhage leading to shock is rare. (See "Evaluation and management of ruptured ovarian cyst", section on 'Clinical presentation'.)

In prepubertal females, ovarian cysts are typically asymptomatic but can cause acute severe pelvic pain due to torsion, perforation, hemorrhage (intracystic or intra-abdominal), or infarction. (See "Ovarian cysts in infants, children, and adolescents", section on 'Ovarian cysts in infants and prepubertal children'.)

Kidney stones — Kidney stones, an increasingly common cause of pelvic pain in adolescents, typically present with intense, paroxysmal flank pain, which may radiate to the lower abdomen and groin regions. The pain is usually colicky and causes the patient to writhe about because they are unable to find a position of comfort. Nausea, vomiting, and urinary symptoms (dysuria and urgency) may accompany the pain. The diagnosis of kidney stones is initially suspected by the presentation and clinical evaluation (including urinalysis). It is confirmed by the detection of a stone on imaging studies or by retrieval of a passed stone. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Clinical presentation'.)

Urinary tract infection — Symptomatic cystitis causes suprapubic pain and dysuria. Fever, urinary urgency, frequency, and hesitancy may also be present. Pyelonephritis frequently presents with fever, vomiting, flank, and upper back pain. Symptoms of cystitis may also be present. Rapid urine dipstick tests and/or microscopic urinalysis establish the diagnosis. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Older children'.)

Other gynecologic conditions

●Pregnancy – Intrauterine pregnancy is the most common diagnosis for the presentation of secondary amenorrhea. Other common symptoms include morning sickness, breast tenderness, urinary frequency, weight gain, fatigue, and abdominal pain. Pelvic pain is an uncommon primary presenting symptom for pregnancy, although round ligament pain, pubic symphysis separation, or pelvic girdle pain (sacroiliac joint pain) is relatively common. Care must be taken not to miss other causes of pelvic pain (eg, appendicitis, ovarian torsion) in pregnant females. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Diagnosis' and "Maternal adaptations to pregnancy: Musculoskeletal changes and pain", section on 'Pelvic girdle pain'.)

●Spontaneous abortion – Abortion is the outcome of at least 20 percent of all pregnancies, presenting with crampy pelvic pain, vaginal bleeding, and passage of some or all of the products of conception. In the face of a nonsterile abortive procedure or incomplete evacuation of all fetal and placental tissue, sepsis may develop. Clinical findings of a septic abortion include fever, diffuse pelvic pain, and malodorous vaginal discharge. Complications, such as septic shock and rarely, pelvic thrombophlebitis, can occur. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology", section on 'Terminology of pregnancy loss' and "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation" and "Septic abortion: Clinical presentation and management".)

●Developmental anomalies of the Müllerian duct – Anomalies of the Müllerian duct may cause pelvic pain that first presents at puberty. Of these anomalies, imperforate hymen is the most common outflow tract obstruction, and it is most often diagnosed at puberty when menstrual fluid collects. Imperforate hymen can cause primary amenorrhea, a pelvic mass, hydrometrocolpos (dilatation of the uterus and vagina), and pelvic pain. (See "Congenital anomalies of the hymen and vagina", section on 'Anomalies of the hymen'.)

●Endometriosis – Endometrial tissue found outside of the uterus in ectopic locations can cause crampy pelvic pain associated with menses. It has even been known to cause painful defecation and dyspareunia, depending on its location. Though more commonly found in adult women, detection of endometriosis in adolescents is increasing and should be included in the differential. Early diagnosis may impact disease progression and long-term prognosis, especially concerning fertility. (See "Endometriosis in adolescents: Diagnosis and treatment" and "Endometriosis: Clinical features, evaluation, and diagnosis".)

●Ovarian tumors – Ovarian tumors occur in approximately 2 percent of adolescents and young adult women.

Germ cell tumors are the most common histologically, and the most common of these is the dermoid cyst, or mature cystic teratoma, a benign neoplastic cyst. These tumors contain ectodermal, mesodermal, and endodermal tissue (ie, hair, bone, teeth, brain, adipose tissue, skin, etc). They can present with dull abdominal pain or a mass, but they are frequently asymptomatic and found incidentally on imaging due to calcification or increased echogenicity. They may be bilateral in 10-15% percent of adolescents. They may also increase the risk of ovarian torsion, and approximately 1 to 3 percent can rupture. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis", section on 'Mature teratoma (dermoid)'.)

There are numerous other malignancies, and though rare, several peak during adolescence, such as immature teratomas, endodermal sinus tumors, mixed germ cell tumors, and gonadoblastoma. These usually present with pelvic pain, a palpable mass, or abdominal distention. (See "Ovarian germ cell tumors: Pathology, epidemiology, clinical manifestations, and diagnosis".)

●Vaginal foreign bodies – Foreign bodies include "lost" intrauterine devices, contraceptive rings, condoms, tampons, or other objects intentionally placed in the vaginal cavity. Pelvic pain and/or purulent vaginal discharge can ensue, especially if significant vaginal wall irritation or trauma ensues. Complications, such as abscess formation or vaginal or uterine perforation, rarely occur. (See "Vaginitis in adults: Initial evaluation".)

●Chemical irritants – Spermicides, lubricants, douching material, or bath products may cause vaginal irritation and pelvic pain. Douching predisposes to bacterial vaginosis and is not necessary for good vulvovaginal hygiene. (See "Vaginitis in adults: Initial evaluation", section on 'Inflammation or irritation'.)

●Sexual assault – Pelvic pain may indicate vaginal contusions, bruising, laceration or perforation in adolescents who have been sexually assaulted. The breasts, external genitalia, anus, and rectum should also be carefully examined for signs of injury. Detectable trauma is more likely in adolescent females who have never had sexual intercourse or report vaginal or anal penetration. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Physical examination'.)

●Sexual abuse – The possibility of abuse, recent or past, absolutely must be included in any differential of acute or chronic pelvic pain. Previous psychological trauma, such as emotional, physical, or sexual abuse, can manifest itself as chronic functional pelvic pain. Depression and anxiety, as a result of abuse or as separate diseases in themselves, may be associated with chronic pelvic pain as well [10-14].

●Somaticization – Medically unexplained pelvic pain should prompt consideration of psychosocial issues (eg, recent stressors in the family), signs of anxiety and/or depression, as well as consideration of child abuse. (See "Somatic symptom disorder: Epidemiology and clinical presentation", section on 'Clinical presentation'.)

EVALUATION (ADOLESCENT) — The first goal of the evaluation of the adolescent female with acute pelvic pain is to identify life-threatening conditions that require emergent interventions. Once this has been accomplished, other causes of pelvic pain can often be identified through deliberate evaluation with careful attention to the clinical features of the illness (eg, the pain characteristics, sexual history, presence of pregnancy, related symptoms, physical findings, and selected diagnostic studies) (algorithm 1A-D).

The evaluation for gastrointestinal and urologic causes of pelvic pain is discussed in greater detail separately. (See "Emergency evaluation of the child with acute abdominal pain", section on 'Evaluation'.)

History — Pain characteristics, associated symptoms, menstrual status, and sexual history help to differentiate among the various gynecologic causes of pelvic pain [15-17].

●Pain characteristics – The clinician should determine the pain location, quality, radiation, timing, and associated symptoms, including temporal association with the menstrual cycle. Suggestive pain patterns include:

•Ectopic pregnancy – Lower abdominal pain, typically six to eight weeks after the last menstrual period, often lateralizing, with symptoms of pregnancy, syncope and vaginal bleeding; with intraperitoneal bleeding, irritation of the diaphragm with referred pain to the shoulder or pooling of blood in the posterior cul-de-sac (pouch of Douglas) with an urge to defecate may occur (see "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation')

•Ovarian torsion – Moderate to severe abrupt onset of stabbing pain in the lower abdomen, typically lateralizing, with radiation to the back, flank, or groin and associated with nausea and vomiting (see "Ovarian and fallopian tube torsion", section on 'Clinical presentation')

•Ruptured ovarian cyst – Sudden onset of lateralizing pain, especially in association with exercise or sexual intercourse (see "Evaluation and management of ruptured ovarian cyst", section on 'Clinical presentation')

•Pelvic inflammatory disease – Bilateral pain commonly occurring during or just after menses that is worsened by coitus or jarring movement and occasionally associated with a new vaginal discharge, fever, or dysuria (see "Pelvic inflammatory disease: Clinical manifestations and diagnosis", section on 'Clinical features')

•Dysmenorrhea – Midline, cramping or dull pain associated with menstruation and often accompanied by back pain, fatigue, headache, nausea, vomiting, or diarrhea (see "Primary dysmenorrhea in adolescents", section on 'Clinical manifestations')

•Mittelschmerz – Mild to moderate constant lateralizing pain occurring midway between menstrual periods

•Placental abruption– Lower abdominal and/or back pain, typically in the second or third trimester of pregnancy with vaginal bleeding and high frequency and low amplitude contractions (see "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences")

●Menstrual status – It must be ascertained early on whether the adolescent in question is pre or postmenarchal. In postmenarchal females, the timing of the last menstrual period should be determined in relation to the onset of pain and to evaluate for possible pregnancy.

●Sexual history — Sexually active adolescents are at risk for complications of pregnancy and pelvic inflammatory disease. It is important to have a nonjudgmental approach to obtaining a sexual history from the adolescent patient in order to protect confidentiality and to maximize the likelihood that responses will be truthful (see "Sexual development and sexuality in children and adolescents", section on 'Permission, privacy, and confidentiality'):

•Questions regarding sexual activity should only be posed when the patient's parent or caregiver is not present.

•The clinician should introduce these questions with both an assurance that the teenager's confidentiality will be protected and a mention of any exceptions to confidentiality. State and federal laws and regulations in the United States and in other countries can limit confidentiality in specific circumstances, such as pregnancy in a minor, suicidality, and situations in which the teenager is in the legal custody of a state agency. (See "Consent in adolescent health care".)

•For every patient who has had sexual intercourse, questions should include the use of contraceptive methods and adherence to safer sex practices.

•Other key information includes the timing of the last intercourse, any history of sexually transmitted infections (STIs) and/or pelvic inflammatory disease, and any prior pregnancies.

•Any nonconsensual sexual activity should be identified, and patients who disclose recent sexual abuse or assault should ideally have the remainder of the evaluation performed by providers specifically trained to care for such cases. (See "Evaluation and management of adult and adolescent sexual assault victims in the emergency department", section on 'Evaluation'.)

Physical examination — The adolescent female with pelvic pain warrants a complete examination with particular focus on vital signs and examination of the abdomen, genitalia, and pelvis. Hemodynamically unstable patients require resuscitation of shock prior to a comprehensive physical examination (algorithm 2). (See "Shock in children in resource-abundant settings: Initial management", section on 'Clinical and physiologic targets'.)

●Vital signs – Fever suggests the presence of appendicitis, pelvic inflammatory disease (PID), or rarely, a septic abortion. Tachycardia with poor capillary perfusion or hypotension suggests shock in association with acute abruption, ectopic pregnancy, uterine rupture, appendicitis, ruptured hemorrhagic ovarian cyst (rare), or septic abortion.

●Abdomen – Right lower quadrant tenderness may arise from appendicitis, pelvic inflammatory disease, ovarian torsion, ovarian cyst, ectopic pregnancy, or nephrolithiasis. Left lower quadrant tenderness is caused by the same diagnoses, although appendicitis occurs rarely on the left side. Bilateral lower quadrant tenderness suggests PID. Rebound tenderness is found in patients with appendicitis, PID, or any process causing peritonitis. A midline tender mass may be appreciated in adolescent females with imperforate hymen and hydrometrocolpos. Other causes of abdominal pain in the adolescent female are discussed in detail separately. (See "Causes of acute abdominal pain in children and adolescents".)

●Pelvic examination – A pelvic examination is an essential component of a complete physical examination in all sexually active adolescent females with pelvic pain.

Clinicians must demonstrate awareness with regards to patients' gender preferences or nonbinary identification as it relates to female genitalia and associated pelvic pain. Practicing sensitivity in this area will enhance care in a culturally competent manner and guide a pelvic examination as the individual's status dictates. (See "Gender development and clinical presentation of gender diversity in children and adolescents", section on 'Role of the medical provider'.)

First, informed consent to perform the pelvic examination must be obtained from the patient. Clinicians should be cognizant of laws in their state governing adolescent confidentiality/privacy, mandatory notification of legal guardian(s), consent from minors, with regards to special situations and settings (eg, sexually transmitted infections [STIs], emergency care, and pregnancy) [18,19]. (See "The gynecologic history and pelvic examination", section on 'Patient consent'.)

In cases of refusal to perform the pelvic examination, the underlying reasons for refusal should be ascertained and addressed. The patient (and/or caregiver, when applicable) should understand the specific indications for performing the pelvic examination [20], and be made aware of the risks of not obtaining potentially significant clinical information, in their diagnosis and management. (See "Consent in adolescent health care", section on 'Refusal to consent'.)

Depending on the clinical scenario, the patient may consent to certain parts of the pelvic exam, for example, the bimanual but not the speculum examination, which may yield relevant clinical information.

A speculum examination is necessary to assess for cervical bleeding and to evaluate for vaginal injuries or foreign bodies. However, specimens for STI testing may be obtained from vaginal swabs or urine. Nucleic acid amplification tests (NAAT) on both first void (non-clean catch) urine and self-administered vaginal swabs have been shown to be as sensitive as cervical swabs for STI detection [21]. Specimens for C. trachomatis and N. gonorrhoeae should be obtained, and a sample of vaginal discharge collected for microscopic examination. (See "Vaginitis in adults: Initial evaluation", section on 'Test vaginal discharge'.)

Although a vaginal bimanual examination is preferred, a rectal bimanual examination may be substituted in patients who have never had sexual intercourse, although this technique may have a low sensitivity in identifying adnexal, uterosacral or posterior cul-de-sac findings [22].

Important findings on pelvic examination may include:

•Imperforate hymen (hematometrocolpos)

•Vulvar, anal, and/or vaginal trauma (sexual assault)

•Vaginal discharge (PID)

•Vaginal foreign body

•Vaginal bleeding (ectopic pregnancy, acute abruption, spontaneous abortion, normal labor)

•Cervical motion tenderness (PID)

•Uterine tenderness (PID, acute abruption, dysmenorrhea, uterine rupture)

•Adnexal tenderness (PID, ectopic pregnancy, ovarian torsion)

•Adnexal mass (ovarian mass [cyst, abscess, or tumor], ectopic pregnancy, PID, endometriosis)

•Tenderness of the posterior cul-de-sac, rectovaginal septum, or uterosacral ligaments on rectovaginal examination (endometriosis)

Laboratory — The history and physical examination direct the subsequent ancillary testing that should be performed.

●Pregnancy test – Urine pregnancy testing must be done in a menstruating adolescent and may also be appropriate in the ostensibly premenstrual girl in the face of an ambiguous history or clinical picture. Urine beta human chorionic gonadotropin testing is rapid and sensitive for detecting early pregnancy. If the patient is pregnant, quantitative beta hCG testing and Rh(D) typing may be indicated and the status of the pregnancy should be determined (eg, ectopic, intrauterine, threatened abortion). It is important to keep in mind that a positive pregnancy test does not exclude a nongynecologic cause of pelvic pain. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Urine pregnancy test'.)

●Urine tests – After cleansing, a rapid urine dipstick that indicates hematuria or pyuria helps to identify those patients that should have a microscopic urinalysis and/or urine culture. Of note, bladder catheterization may be needed in patients with vaginal bleeding to avoid contamination of the urine specimen.

●Complete blood count and inflammatory markers – Patients with pelvic pain who have vaginal bleeding warrant assessment for anemia and thrombocytopenia. An elevated white blood cell count with immature neutrophil forms on differential is suggestive of an infectious etiology, such as appendicitis, pelvic inflammatory disease and/or sepsis. Erythrocyte sedimentation rates or C-reactive protein levels are nonspecific but may also be increased in patients with these conditions.

●Blood typing – Pregnant patients with spontaneous abortion, ectopic pregnancy or placental abruption should have blood typing to determine Rh (D or Rhesus antigen) status and the potential need for anti-D immune globulin administration to prevent alloimmunization. (See "RhD alloimmunization: Prevention in pregnant and postpartum patients" and "RhD alloimmunization: Prevention in pregnant and postpartum patients", section on 'Selective prophylaxis for pregnancy complications associated with fetomaternal bleeding'.)

●Detection of sexually transmitted infection – Depending upon clinical suspicion, cervical culture (gonorrhea, chlamydia, genital herpes, Trichomonas), serology (herpes simplex virus type 2, syphilis), or cervical NAAT (C. trachomatis, N. gonorrhoeae) or a combination may be obtained. Alternatively, NAAT for C. trachomatis and N. gonorrhoeae may be sent on a spontaneously voided urine obtained before external cleansing in patients for whom pelvic examination is otherwise unnecessary. (See "Sexually transmitted infections: Issues specific to adolescents", section on 'STI clinical patterns'.)

Imaging — Ultrasound is the preferred initial method for evaluating pelvic pathology [4,23,24]. The ultrasound examination is usually initiated transabdominally. The bladder does not have to be full; however, if the ovaries cannot be visualized, it may be necessary to have the patient fill her bladder to a comfortable capacity. This is especially important for those teenagers who have never had sexual intercourse or are unable to tolerate placement of a transvaginal ultrasound probe. Often in these cases, the entire examination can be performed transabdominally. Transabdominal scanning is important for evaluating the upper pelvis and abdomen, and can detect appendicitis, in some cases, nephrolithiasis, ovarian cysts, tumors, and tuboovarian abscess. Doppler flow studies can assist in the urgent diagnosis of ovarian torsion, although a normal study may not rule it out. (See "Acute appendicitis in children: Diagnostic imaging", section on 'Ultrasonography' and "Overview of ultrasound examination in obstetrics and gynecology".)

Transvaginal sonography is best performed with an empty bladder and is helpful in diagnosing ectopic and intrauterine pregnancy and spontaneous abortion.

Computed tomography (CT) of the abdomen and pelvis may be helpful in patients in whom diagnostic uncertainty persists after laboratory and ultrasound evaluation, especially those in whom nephrolithiasis or appendicitis is suspected. Contrast should not be given to patients undergoing CT for the diagnosis of nephrolithiasis. (See "Kidney stones in children: Clinical features and diagnosis", section on 'Non-contrast helical CT' and "Acute appendicitis in children: Diagnostic imaging", section on 'Computed tomography'.)

Magnetic resonance imaging (MRI) is being more frequently utilized as a radiation-free alternative to CT in selected pediatric patients in the evaluation of suspected appendicitis, as well as in pregnant adolescent females [25,26]. (See "Acute appendicitis in children: Diagnostic imaging", section on 'Magnetic resonance imaging'.)

Increasingly, MRI may be helpful in patients with suspected malformations of the genitourinary tract [27-30].

Laparoscopy — Laparoscopy is sometimes indicated in the evaluation of acute pelvic pain, especially when the diagnosis is not clear after less invasive evaluations and the differential diagnoses include potentially life-threatening or organ-threatening disorders. Examples are appendicitis, pelvic inflammatory disease, endometriosis, ovarian and tubal torsion. Laparoscopy also has a role in the treatment of many surgical disorders. On the other hand, most adolescent females with acute pelvic pain, normal imaging and laboratory studies, and a normal physical examination (including absence of vaginal/cervical discharge and abnormal uterine bleeding) will improve without need for intervention. (See "Acute pelvic pain in nonpregnant adult females: Evaluation", section on 'Role of surgical evaluation'.)

ALGORITHMIC APPROACH

Pregnant — The approach to the pregnant adolescent female with pelvic pain is shown in the algorithms (algorithm 1A and algorithm 1B).

Vaginal bleeding — Pregnant patients with vaginal bleeding first should be assessed for hemodynamic stability (algorithm 1A). Shock is associated with a ruptured ectopic pregnancy, acute abruption, and uterine rupture. Patients who are less than 20 weeks gestation and hemodynamically stable may have abruptio placenta or a spontaneous abortion. In addition to these conditions, those patients with vaginal bleeding during late pregnancy may be in normal or premature labor.

No vaginal bleeding — Pregnant patients without vaginal bleeding, but with rhythmic contractions may be in normal or premature labor (late pregnancy by examination or ultrasound) or may have a threatened abortion (algorithm 1B). Patients with sacroiliac joint pain with provocative testing (FABERE sign) may have pelvic girdle pain of pregnancy. Otherwise, the clinician should evaluate for causes unrelated to pregnancy, especially in patients with fever or peritonitis (algorithm 3).

Not pregnant — The approach to pelvic pain in the adolescent female who is not pregnant is shown in the algorithms and varies according to whether the girl has reached normal menstruation or not (algorithm 1C and algorithm 1D). A careful physical examination with selected ancillary studies helps differentiate among the possible causes.

Premenarchal — Key findings for girls who have not yet reached normal menstruation include (algorithm 1C):

●Sexual assault may be determined by history or diagnosed by evidence of vulvovaginal trauma.

●Hydrocolpos with an imperforate hymen is identified on external examination of the vulva.

●Right lower quadrant tenderness with supportive findings on complete blood count and/or imaging suggests appendicitis.

●Flank pain radiating to the pelvis with hematuria is found in patients with nephrolithiasis.

●Flank or suprapubic pain with pyuria suggests pyelonephritis or a urinary tract infection.

●Rarely, a previously premenarchal girl may be pregnant.

Postmenarchal — In females who have reached normal menstruation, the diagnosis is suggested by the following clinical findings (algorithm 1D):

●A vaginal foreign body is typically evident on pelvic examination.

●Vaginal bleeding with pain during menstruation is seen in patients with dysmenorrhea.

●Bilateral adnexal tenderness with cervical discharge and/or cervical motion tenderness supports the diagnosis of pelvic inflammatory disease.

●Patients with unilateral stabbing abdominal pain and decreased blood flow by Doppler ultrasound have ovarian torsion.

●An adnexal mass on pelvic examination and/or ultrasound is seen in patients with ovarian tumor, abscess, or cyst.

●Endometriosis is suggested by recurrent pain, dyspareunia, or typical findings on recto-vaginal examination. (See 'Physical examination' above.)

●Patients who are midcycle and have lateral pain without any other distinguishing features likely have mittelschmerz.

●If the evaluation, including pelvic examination, urinalysis, complete blood count, and imaging fail to establish a diagnosis in a menstruating female, then the clinician should observe for additional signs of appendicitis or PID and pursue other gastrointestinal or urologic causes (algorithm 3).

SUMMARY AND RECOMMENDATIONS

●Differential diagnosis – The gynecologic causes of acute pelvic pain in adolescent females are listed in the table (table 1). (See 'Differential diagnosis' above.)

Important nongynecologic causes of acute pelvic pain include appendicitis, kidney stones, and urinary tract infection. (See 'Appendicitis' above and 'Kidney stones' above and 'Urinary tract infection' above.)

Nongynecologic causes of acute abdominal pain in female children and adolescents and their evaluation are provided separately. (See "Causes of acute abdominal pain in children and adolescents" and "Emergency evaluation of the child with acute abdominal pain".)

●Evaluation – Pain characteristics, associated symptoms, menstrual status, and sexual history help to differentiate among the various gynecologic causes of pelvic pain in the adolescent female. (See 'History' above.)

The adolescent female with pelvic pain warrants a complete examination with particular focus on vital signs and examination of the abdomen, pelvis, and genitalia. Hemodynamically unstable patients require resuscitation of shock prior to a comprehensive physical examination (algorithm 2). A pelvic examination is essential in all sexually active adolescent females with pelvic pain. (See 'Physical examination' above.)

Urine pregnancy testing must be done in a menstruating adolescent and may also be appropriate in the ostensibly premenstrual girl in the face of an ambiguous history or clinical picture. Other ancillary studies are guided by clinical findings. (See 'Laboratory' above and 'Imaging' above.)

●Approach – The algorithms provide a suggested approach to pelvic pain in the pregnant adolescent female (algorithm 1A and algorithm 1B) and premenarchal and nonpregnant postmenarchal females (algorithm 1C and algorithm 1D) according to the presence of key findings and other results of clinical evaluation. (See 'Algorithmic approach' above.)