Prepubertal pelvic pain
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