Differentials
Ectopic pregnancy
SIGNS / SYMPTOMS
Reproductive-age, sexually active female with missed menses, lower abdominal and pelvic pain, and symptoms of acute abdomen such as diarrhea, nausea, and vomiting.
Presentation may be difficult to distinguish from ovarian torsion.
INVESTIGATIONS
Positive pregnancy test with beta-hCG level >1500 milli-international units/mL and no intrauterine pregnancy on ultrasound raises suspicion of ectopic pregnancy.
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 temperature >101°F (>38°C).
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 periumbilically and localizing to the right lower quadrant.
INVESTIGATIONS
Ultrasound may show a peristaltic or noncompressible structure >6 mm.
CT scan may show abnormal appendix diameter >6 mm with wall thickening, wall enhancement, and inflammatory changes in the surrounding tissues.
Mittelschmerz due to ruptured graafian follicle
SIGNS / SYMPTOMS
Diffuse pain, not localized.
Occurs midcycle, with pelvic pain that resolves.
No fever, chills, or discharge.
INVESTIGATIONS
Clinical diagnosis.
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.
Torsion of a paraovarian cyst or isolated fallopian tube
SIGNS / SYMPTOMS
Clinical picture identical to that of ovarian torsion.
INVESTIGATIONS
Diagnosis may only be available at the time of surgery.
Ovarian cysts
SIGNS / SYMPTOMS
Lower abdominal pain with adnexal fullness on exam.
INVESTIGATIONS
Imaging or laparoscopy may be needed to distinguish from ovarian torsion. Ultrasound shows ovarian cysts and lacks features suggestive of torsion.
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 hematuria.
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