Prepubertal pelvic pain: Difference between revisions
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(Expanded with concise EM-focused content: age-appropriate DDx, constipation/UTI as common causes, ovarian torsion, abuse screening, disposition) |
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==Background== | ==Background== | ||
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]] | [[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]] | ||
*Pelvic pain in prepubertal children has a different differential than in post-pubertal/adult patients | |||
*Pregnancy-related causes are not applicable (but always consider the possibility of sexual abuse) | |||
*Most common causes: [[UTI]], [[constipation]], [[appendicitis]] | |||
*Key EM concerns: [[ovarian torsion]] (can occur at any age), [[appendicitis]], sexual abuse, incarcerated hernia | |||
==Clinical Features== | ==Clinical Features== | ||
* | ===History=== | ||
*Onset, location, duration, character | |||
*Urinary symptoms (UTI) | |||
*Bowel habits (constipation is a very common cause) | |||
*Vaginal discharge or bleeding (foreign body, vulvovaginitis, abuse) | |||
*Fever (UTI, appendicitis, abscess) | |||
*Vomiting (appendicitis, ovarian torsion) | |||
*Any concern for abuse — screen carefully | |||
===Physical Exam=== | |||
*Abdominal exam: tenderness, guarding, peritoneal signs | |||
*External genital exam: discharge, bleeding, irritation, foreign body, signs of trauma | |||
*Internal/speculum exam is generally NOT indicated in prepubertal children | |||
*Rectal exam if necessary (appendicitis) | |||
===Red Flags=== | |||
*Severe acute unilateral pain (ovarian torsion) | |||
*Peritoneal signs (appendicitis, perforated viscus) | |||
*Vaginal bleeding in prepubertal child (foreign body, abuse, precocious puberty, tumor) | |||
*Signs of sexual abuse (genital trauma, STI symptoms, behavioral changes) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Prepubertal pelvic pain DDX}} | {{Prepubertal pelvic pain DDX}} | ||
===GI=== | |||
*'''[[Constipation]]''' (most common benign cause) | |||
*'''[[Appendicitis]]''' | |||
*Mesenteric lymphadenitis | |||
*[[Intussusception]] | |||
*Meckel diverticulum | |||
===GU=== | |||
*'''[[UTI]]''' | |||
*'''[[Ovarian torsion]]''' (can occur even without ovarian mass) | |||
*Ovarian cyst (functional — rare prepubertally but can occur) | |||
*Labial adhesions (can cause urinary retention) | |||
===Gynecologic=== | |||
*Vaginal foreign body | |||
*Vulvovaginitis (nonspecific irritation, poor hygiene) | |||
===Other=== | |||
*'''Inguinal hernia''' (incarcerated) | |||
*Musculoskeletal (hip pathology, muscle strain) | |||
*'''Abuse''' — always consider | |||
==Evaluation== | ==Evaluation== | ||
*[[Urinalysis]] + culture | |||
*Abdominal X-ray if constipation suspected (to confirm or rule out fecal loading) | |||
*Pelvic/abdominal ultrasound if ovarian torsion, mass, or appendicitis suspected | |||
*CT abdomen/pelvis if appendicitis high on differential and US nondiagnostic | |||
*STI testing if concern for abuse | |||
==Management== | ==Management== | ||
*'''Constipation''': enema/disimpaction, stool softeners, dietary counseling | |||
*'''UTI''': age-appropriate antibiotics (see [[UTI (peds)]]) | |||
*'''Appendicitis''': surgical consultation | |||
*'''Ovarian torsion''': emergent surgical consultation for detorsion | |||
*'''Vaginal foreign body''': removal (may require sedation) | |||
*'''Suspected abuse''': child protective services notification, forensic exam per local protocol | |||
==Disposition== | ==Disposition== | ||
*Admit: appendicitis, ovarian torsion, incarcerated hernia, severe infection | |||
*Discharge: constipation, UTI with ability to take oral antibiotics, resolved pain | |||
*Return precautions: worsening pain, fever, vomiting, vaginal bleeding | |||
==See Also== | ==See Also== | ||
*[[Pelvic Pain]] | *[[Pelvic Pain]] | ||
*[[Abdominal pain (peds)]] | |||
*[[Ovarian torsion]] | |||
*[[UTI (peds)]] | |||
*[[Non-accidental trauma]] | |||
==References== | ==References== | ||
Revision as of 00:43, 21 March 2026
This page is for pediatric patients. For adult patients, see: Pelvic pain
Background
- Pelvic pain in prepubertal children has a different differential than in post-pubertal/adult patients
- Pregnancy-related causes are not applicable (but always consider the possibility of sexual abuse)
- Most common causes: UTI, constipation, appendicitis
- Key EM concerns: ovarian torsion (can occur at any age), appendicitis, sexual abuse, incarcerated hernia
Clinical Features
History
- Onset, location, duration, character
- Urinary symptoms (UTI)
- Bowel habits (constipation is a very common cause)
- Vaginal discharge or bleeding (foreign body, vulvovaginitis, abuse)
- Fever (UTI, appendicitis, abscess)
- Vomiting (appendicitis, ovarian torsion)
- Any concern for abuse — screen carefully
Physical Exam
- Abdominal exam: tenderness, guarding, peritoneal signs
- External genital exam: discharge, bleeding, irritation, foreign body, signs of trauma
- Internal/speculum exam is generally NOT indicated in prepubertal children
- Rectal exam if necessary (appendicitis)
Red Flags
- Severe acute unilateral pain (ovarian torsion)
- Peritoneal signs (appendicitis, perforated viscus)
- Vaginal bleeding in prepubertal child (foreign body, abuse, precocious puberty, tumor)
- Signs of sexual abuse (genital trauma, STI symptoms, behavioral changes)
Differential Diagnosis
Prepubertal pelvic pain
Gynecologic
- Trauma
- Laceration
- Hematoma
- Sexual abuse
- Vaginal foreign body
- Vaginal infection
- Contact Vulvovaginitis
- Outflow-tract obstruction
- Imperforate hymen
- Labial adhesions
- Congenital abnormalities
Gastrointestinal
Musculoskeletal
- Muscle tendon injury
- Growth-plate injury
- Ligamentous injury
- Avulsion fracture
- Inguinal hernia
- Intervertebral disc herniation
Urologic
Other
- Diabetic ketoacidosis
- Sickle cell crisis
- Neoplasms
GI
- Constipation (most common benign cause)
- Appendicitis
- Mesenteric lymphadenitis
- Intussusception
- Meckel diverticulum
GU
- UTI
- Ovarian torsion (can occur even without ovarian mass)
- Ovarian cyst (functional — rare prepubertally but can occur)
- Labial adhesions (can cause urinary retention)
Gynecologic
- Vaginal foreign body
- Vulvovaginitis (nonspecific irritation, poor hygiene)
Other
- Inguinal hernia (incarcerated)
- Musculoskeletal (hip pathology, muscle strain)
- Abuse — always consider
Evaluation
- Urinalysis + culture
- Abdominal X-ray if constipation suspected (to confirm or rule out fecal loading)
- Pelvic/abdominal ultrasound if ovarian torsion, mass, or appendicitis suspected
- CT abdomen/pelvis if appendicitis high on differential and US nondiagnostic
- STI testing if concern for abuse
Management
- Constipation: enema/disimpaction, stool softeners, dietary counseling
- UTI: age-appropriate antibiotics (see UTI (peds))
- Appendicitis: surgical consultation
- Ovarian torsion: emergent surgical consultation for detorsion
- Vaginal foreign body: removal (may require sedation)
- Suspected abuse: child protective services notification, forensic exam per local protocol
Disposition
- Admit: appendicitis, ovarian torsion, incarcerated hernia, severe infection
- Discharge: constipation, UTI with ability to take oral antibiotics, resolved pain
- Return precautions: worsening pain, fever, vomiting, vaginal bleeding