Mittelschmerz

Background

• Lower abdominal or pelvic pain during ovulation
• From German for "middle pain."

Clinical Features

• Pain occurs roughly halfway of menstrual cycle
• Should not have any additional symptoms
• Abdominal/pelvic exam benign

Differential Diagnosis

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervical Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

RLQ Pain

• GI
  • Appendicitis
    • Perforated appendicitis
  • Peritonitis
  • Crohn's disease (terminal ileitis)
  • Diverticulitis (cecal, Asian patients)
  • Inguinal hernia
  • Mesenteric ischemia
  • Ischemic colitis
  • Meckel's diverticulum
  • Neutropenic enterocolitis (typhlitis)
• GU
  • Ectopic
  • Endometriosis
  • Kidney stone
  • Mittelschmerz
  • Ovarian cyst
  • Ovarian torsion
  • PID
  • Pyelonephritis
• Other
  • Abdominal aortic aneurysm
  • Epiploic appendagitis
  • Mesenteric lymphadenitis
  • Herpes zoster
  • Psoas abscess
  • Testicular torsion

LLQ Pain

• Diverticulitis
• Kidney stone
• UTI
• Pyelonephritis
• Ectopic pregnancy
• Infectious colitis
• Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
• Inguinal hernia
• Mesenteric ischemia
• Epiploic appendagitis
• Mittelschmerz
• Ovarian cyst
• Ovarian torsion
• PID
• Psoas abscess
• Testicular torsion
• Appendicitis
• Abdominal aortic aneurysm
• Herpes zoster
• Endometriosis
• Colon cancer
• Irritable bowel syndrome
• Small bowel obstruction

Evaluation

A gray-scale sonogram shows a dominant follicle with a much smaller, cystic-appearing structure at the periphery of the follicle, the cumulus oophorus (arrow). This is indicative of imminent ovulation.

• Frequently a diagnosis of exclusion

Management

• Benign, analgesia as needed

Disposition

• Outpatient

See Also

• Abdominal pain