Diagnostic Approach to Sharp, Intermittent Right Pelvic Pain

Gynecologic Causes

The American College of Radiology recommends considering ovarian cysts, ovarian torsion, pelvic inflammatory disease, and endometriosis as potential causes of sharp, intermittent right pelvic pain in reproductive-age women 1, 2, 3, 4
Ovarian torsion presents with asymmetrically enlarged ovary with twisted pedicle, often requiring urgent surgical intervention, with a high degree of suspicion needed for timely diagnosis 3, 4
Pelvic inflammatory disease manifests with tubal wall thickening, pyosalpinx, or tubo-ovarian abscess, and should be considered in the differential diagnosis 3, 4

Appendicitis remains the most common surgical emergency and must always be considered in right lower quadrant pain, with CT sensitivity of 95% and specificity of 94% 1, 2
Right colonic diverticulitis accounts for 8% of right lower quadrant pain cases, and should be considered in the differential diagnosis 1, 2
Ureteral calculi cause colicky right-sided pain radiating to the pelvis, and should be considered in patients with severe pain 5, 1

Transvaginal ultrasound is the first-line imaging modality for suspected gynecologic etiology, due to superior sensitivity for ovarian pathology and lack of radiation 3, 6
CT abdomen and pelvis with IV contrast is the preferred initial imaging for nonspecific right lower quadrant pain, due to high diagnostic yield for both appendicitis and alternative diagnoses 5, 1, 2
The American College of Radiology recommends obtaining β-hCG in all reproductive-age women before imaging decisions to avoid missing ectopic pregnancy 6