[Management of acute and chronic anal pain]. / Prise en charge des douleurs anales aiguës et chroniques.

Anal pain can be acute (most commonly related to anal fissure, perianal abcess or fistula, perianal vein thrombosis) or chronic (functional or neuropathic) including levator ani syndrome, proctalgia fugax, pudendal nevralgia and coccygodynia. History and clinical examination are keys to diagnose acute causes. Diagnosis of chronic anal pain on the other hand is more challenging and based on thorough history and analysis of symptoms. The aim of this article is to discuss the main etiologies and treatments of acute and chronic anal pain, including an update on the management and treatment of hemorrhoidal disease and postoperative pain management.

La douleur anale peut être de survenue aiguë (le plus fréquemment en lien avec une fissure anale, un abcès ou fistule anale, ou une thrombose des veines périanales) ou chronique (fonctionnelle ou neuropathique), comportant le syndrome du releveur de l'anus, la proctalgia fugax, la névralgie du pudendal et les coccygodynies. Le diagnostic d'une douleur anale aiguë est rapidement posé grâce à l'anamnèse et surtout l'examen clinique. Les causes chroniques sont en revanche plus difficiles à diagnostiquer et nécessitent un interrogatoire détaillé avec une analyse approfondie des symptômes. Le but de cet article est d'explorer le traitement des étiologies de douleur anale aiguë, de pouvoir reconnaître une grande part des douleurs anales chroniques, sans oublier une mise à jour sur la maladie hémorroïdaire avec la prévention et gestion des douleurs postopératoires.

Challenges of acute pain management in older patients.

Adequate management of acute pain in the older population is crucial. However, it is inherently complex because of multiple physiological changes that significantly impact both the pharmacokinetics and pharmacodynamics of medications. Current guidelines promote paracetamol as the first-line analgesic for acute pain in older adults, whereas opioids are advised cautiously for moderate to severe acute pain. However, opioids come with a significant array of side effects, which can be more pronounced in older individuals. Ketamine administered via intranasal (IN) and nebulised inhalation in the emergency department for managing acute pain in older patients shows promising potential for improving pain management and reducing opioid reliance Kampan, Thong-on, Sri-on (2024, Age Ageing, 53, afad255). Nebulised ketamine appears superior in terms of adverse event incidence. However, the adoption of IN or nebulised ketamine in older adult acute pain management remains unclear because of the lack of definitive conclusions and clear guidelines. Nevertheless, these modalities can be valuable options for patients where opioid analgesics are contraindicated or when intravenous morphine titration is impractical or contraindicated. Here, we review these concepts, the latest evidence and propose avenues for research.

The acute pain crisis in sickle cell disease: What can be done to improve outcomes?

The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.

A Prospective Cohort Study of Acute Pain and In-Hospital Opioid Consumption After Cardiac Surgery: Associations With Psychological and Medical Factors and Chronic Postsurgical Pain.

BACKGROUND: Understanding the association of acute pain intensity and opioid consumption after cardiac surgery with chronic postsurgical pain (CPSP) can facilitate implementation of personalized prevention measures to improve outcomes. The objectives were to (1) examine acute pain intensity and daily mg morphine equivalent dose (MME/day) trajectories after cardiac surgery, (2) identify factors associated with pain intensity and opioid consumption trajectories, and (3) assess whether pain intensity and opioid consumption trajectories are risk factors for CPSP. METHODS: Prospective observational cohort study design conducted between August 2012 and June 2020 with 1-year follow-up. A total of 1115 adults undergoing cardiac surgery were recruited from the preoperative clinic. Of the 959 participants included in the analyses, 573 completed the 1-year follow-up. Main outcomes were pain intensity scores and MME/day consumption over the first 6 postoperative days (PODs) analyzed using latent growth mixture modeling (GMM). Secondary outcome was 12-month CPSP status. RESULTS: Participants were mostly male (76%), with a mean age of 61 ± 13 years. Three distinct linear acute postoperative pain intensity trajectories were identified: "initially moderate pain intensity remaining moderate" (n = 62), "initially mild pain intensity remaining mild" (n = 221), and "initially moderate pain intensity decreasing to mild" (n = 251). Age, sex, emotional distress in response to bodily sensations, and sensitivity to pain traumatization were significantly associated with pain intensity trajectories. Three distinct opioid consumption trajectories were identified on the log MME/day: "initially high level of MME/day gradually decreasing" (n = 89), "initially low level of MME/day remaining low" (n = 108), and "initially moderate level of MME/day decreasing to low" (n = 329). Age and emotional distress in response to bodily sensations were associated with trajectory membership. Individuals in the "initially mild pain intensity remaining mild" trajectory were less likely than those in the "initially moderate pain intensity remaining moderate" trajectory to report CPSP (odds ratio [95% confidence interval, CI], 0.23 [0.06-0.88]). No significant associations were observed between opioid consumption trajectory membership and CPSP status (odds ratio [95% CI], 0.84 [0.28-2.54] and 0.95 [0.22-4.13]). CONCLUSIONS: Those with moderate pain intensity right after surgery are more likely to develop CPSP suggesting that those patients should be flagged early on in their postoperative recovery to attempt to alter their trajectory and prevent CPSP. Emotional distress in response to bodily sensations is the only consistent modifiable factor associated with both pain and opioid trajectories.

Patient Values and Preferences for Managing Acute Dental Pain Elicited through Online Deliberation.

INTRODUCTION: Patient values and preferences (PVP) are among multiple sources of information panelists synthesize when developing clinical practice guidelines (CPG). Patient and public involvement (PPI) can be critical for learning PVP; however, the methodology for engaging patients in CPG development is lacking. Deliberative engagement is effective for obtaining public views on complex topics that require people to consider ethics, values, and competing perspectives. OBJECTIVE: Elicit comprehensive understanding of PVP concerning oral analgesics for managing acute dental pain consecutive to toothache and simple and surgical dental extractions, with consideration of associated outcomes, both desirable and undesirable. METHODS: Multistage engagement involving 2 electronic surveys and a 90-min online small group deliberative engagement. Adults who have experienced acute dental pain deliberated about 3 hypothetical scenarios stratified according to expected pain intensity, completed a postdeliberation survey, and validated a PVP statement developed by researchers based on review of qualitative data from deliberations and quantitative data from surveys. RESULTS: Participants affirmed the PVP statement reflected their small group deliberations and their individual views. Most indicated that pain relief is critical to deciding which pain relief medicine they would want regardless of expected pain level. Most also identify as critical concerns about substance abuse or misuse, although many believe it unlikely that they will experience these outcomes over the brief prescription timeframe for acute dental pain. Participants identified agency in decision-making, consultation including "better communication" of options, and treatment actions tailored to life circumstances as key values. CONCLUSIONS: Participants preferred nonprescription and nonopioid pain relief options. As expected pain levels increased, more participants expressed willingness to accept opioids, but more also mentioned rescue analgesia as a third outcome critical to decision-making. Online deliberative method provided opportunities for obtaining informed perspectives. Guideline developers and policymakers may find online deliberations useful for eliciting PVP related to health outcomes. KNOWLEDGE TRANSFER STATEMENT: Study results informed the US Food and Drug Administration-funded clinical practice guideline on the management of acute dental pain. Findings may be a resource for clinicians in decision-making conversations with patients regarding expectations for pain relief and positive and negative outcomes of differing pain relief medications. Further research should pursue applicability of online deliberative engagement as a method to elicit patient values and preferences.

Acute pain management after trauma: What you need to know.

ABSTRACT: Effective acute pain control is mandatory after injury. Opioids continue to be a pillar acute pain management of strategies despite not being as effective as some nonnarcotic alternatives. An acute pain management strategy after trauma should be thoughtful, effective, and responsible. A thoughtful approach includes managing a patient's expectations for acute pain control and ensuring that interventions purposefully and rationally affect the domain of pain that is uncontrolled. An effective pain management strategy includes a multimodal approach using acetaminophen, nonsteroidal anti-inflammatory drugs, and regional anesthesia. A responsible acute pain management approach includes knowing the relative strengths of the opioids prescribed and standardized approach to opioid prescribing at discharge to minimize diversion. Acute pain management is quite understudied, and future considerations include a reliable objective measurement of pain and the evaluation of nonmedication acute pain interventions.

National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA. METHODS: A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics. RESULTS: Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions. CONCLUSIONS: Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored.

Development of an Acute Pain Assessment Tool for Patients in Post-anesthesia Care Units.

BACKGROUND: Post-operative pain is a common form of acute pain. Objective pain assessment in post-anesthesia care units after surgery is useful regardless of the patient's condition. AIMS: This study aimed to develop and evaluate an acute pain assessment tool for patients in post-anesthesia care units. DESIGN: This was a cross-sectional observational study comprising two stages: scale development and psychometric evaluation. SETTINGS:  . PARTICIPANTS/SUBJECTS:  . METHODS: Scale items were developed based on a literature review and content validity by experts. The validity and interrater reliability of the pain scale were evaluated using data from 218 patients admitted to the post-anesthesia care unit at a university hospital. A receiver operating characteristic curve was used to identify the sensitivity and specificity for determining the cutoff point for acute pain. RESULTS: We developed an objective acute pain scale, called the APA5, which ranges from 0-10 and comprises behavioral (facial and verbal expressions and body movement) and physiological (changes in heart rate and blood pressure) responses. The APA5 is valid and reliable for assessing acute pain in the recovery room. Sensitivity and specificity were acceptable when the cutoff was 2 out of 10 points. CONCLUSIONS: The APA5 is an easy and simple tool for measuring pain in patients in post-anesthesia care units who have difficulties with self-reporting.

Study protocol for a randomised controlled trial to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: 2 (TOPIC 2).

BACKGROUND: Thoracotomy is considered one of the most painful surgical procedures and can cause debilitating chronic post-surgical pain lasting months or years postoperatively. Aggressive management of acute pain resulting from thoracotomy may reduce the likelihood of developing chronic pain. This trial compares the two most commonly used modes of acute analgesia provision at the time of thoracotomy (thoracic epidural blockade (TEB) and paravertebral blockade (PVB)) in terms of their clinical and cost-effectiveness in preventing chronic post-thoracotomy pain. METHODS: TOPIC 2 is a multi-centre, open-label, parallel group, superiority, randomised controlled trial, with an internal pilot investigating the use of TEB and PVB in 1026 adult (≥ 18 years old) patients undergoing thoracotomy in up to 20 thoracic centres throughout the UK. Patients (N = 1026) will be randomised in a 1:1 ratio to receive either TEB or PVB. During the first year, the trial will include an integrated QuinteT (Qualitative Research Integrated into Trials) Recruitment Intervention (QRI) with the aim of optimising recruitment and informed consent. The primary outcome is the incidence of chronic post-surgical pain at 6 months post-randomisation defined as 'worst chest pain over the last week' equating to a visual analogue score greater than or equal to 40 mm indicating at least a moderate level of pain. Secondary outcomes include acute pain, complications of regional analgesia and surgery, health-related quality of life, mortality and a health economic analysis. DISCUSSION: Both TEB and PVB have been demonstrated to be effective in the prevention of acute pain following thoracotomy and nationally practice is divided. Identification of which mode of analgesia is both clinically and cost-effective in preventing chronic post-thoracotomy pain could ameliorate the debilitating effects of chronic pain, improving health-related quality of life, facilitating return to work and caring responsibilities and resulting in a cost saving to the NHS. TRIAL REGISTRATION: NCT03677856 [ClinicalTrials.gov] registered September 19, 2018. https://clinicaltrials.gov/ct2/show/NCT03677856 . First patient recruited 8 January 2019.

Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine.

BACKGROUND: More than half of all emergency department patients seek help for acute pain, which is usually of musculoskeletal origin. Acute pain is often inadequately treated even today, particularly in children and in older patients. In this study, we assess the potential role of regional anesthetic methods in improving the treatment of pain in the preclinical and clinical emergency setting. METHODS: Pain-related reasons for admission were identified and quantified from emergency admission data. A structured literature search was carried out for clinical studies on the treatment of pain in the emergency setting, and a before-and-after comparison of the pain relief achieved with established vs. newer regional anesthetic methods was performed. RESULTS: 43% of emergency patients presented with acute musculoskeletal pain. The literature search yielded 3732 hits for screening; data on entity-specific pain therapy spectra were extracted from 153 studies and presented for the main pain regions. The degree of pain relief obtained through regional anesthetic procedures, on a nominal rating scale from 0 to 10, was 4 to 7 points for acute back and chest wall pain, >6 for shoulder pain, 5 to 7 for hand and forearm injuries, and >4 for hip fractures. These results were as good as, or better than, those obtained by analgesia/sedation with strong opioids. CONCLUSION: Modern regional anesthetic techniques can improve acute pain management in the emergency department and, to some extent, in the pre-hospital setting as well. Pain relief with these techniques is quantifiably better than with strong opioids in some clinical situations; moreover, there is evidence of further advantages including process optimization and fewer complications. Data for comparative study remain scarce because of a lack of standardization.

Effectiveness of Intranasal Analgesia in the Emergency Department.

In the Emergency Department (ED), pain is one of the symptoms that are most frequently reported, making it one of the most significant issues for the emergency physician, but it is frequently under-treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondly, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a narrative review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library, and Controlled Trials Register, finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia, showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. Intravenous is simple to administer, non-invasive, rapid onset, and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors.

PURPOSE OF REVIEW: Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases). RECENT FINDINGS: Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated. SUMMARY: This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

[Acute vulvar pain after covid-19]. / Acute vulvaire pijn na covid-19.

This case describes a 36-year-old woman who presents with acute painful ulcers of the vulva four days after a covid-19 infection. Extensive additional examination ruled out sexually transmitted diseases and auto-immune diseases, leaving acute vulvar ulcers, triggered by a covid-19 infection, as likely diagnosis. The ulcers healed spontaneously without scarring.

An ethogram of acute pain behaviors in cats based on expert consensus.

An improved understanding of behaviors reflecting acute pain in cats is a priority for feline welfare. The aim of this study was to create and validate a comprehensive ethogram of acute pain behaviors in cats that can discriminate painful versus non-painful individuals. An inventory of behaviors (ethogram) with their respective descriptors was created based on a literature review of PubMed, Web of Science and CAB Abstracts databases. The ethogram was divided into ten behavior categories that could be evaluated by duration and/or frequency: position in the cage, exploratory behaviors, activity, posture and body position, affective-emotional states, vocalization, playing (with an object), feeding, post-feeding and facial expressions/features. Thirty-six behaviors were analyzed independently by four veterinarians with postgraduate qualifications in feline medicine and/or behavior as (1) not relevant, (2) somewhat relevant, (3) quite relevant or (4) highly relevant and used for content (I-CVI) and face validity. Items with I-CVI scores > 0.67 were included. Twenty-four behaviors were included in the final ethogram. Thirteen items presented full agreement (i.e., I-CVI = 1): positioned in the back of the cage, no attention to surroundings, feigned sleep, grooming, attention to wound, crouched/hunched, abnormal gait, depressed, difficulty grasping food, head shaking, eye squinting, blepharospasm and lowered head position. Seven descriptors were reworded according to expert suggestions. The final ethogram provides a detailed description of acute pain behaviors in cats after content and face validity and can be applied to the characterization of different acute painful conditions in hospitalized cats.

Acute Pain in Perspective.

KEY TAKEAWAYS: Acute pain is a common and nearly universal experience that usually has a sudden onset and is limited in duration. It is a normal physiologic response to a noxious stimulus that can become pathologic if untreated or not treated effectively. Acute pain has a limited duration (<1 month) and often is caused by injury, trauma, or medical treatments such as surgery. Primary care practitioners (PCPs) who encounter patients with acute pain can help preserve function and quality of life and prevent progression to chronic pain by implementing appropriate management strategies. PCPs in rural settings may bear greater responsibility for acute pain management because of the lack of accessible specialists. All current guidelines support using a multimodal approach to pain management and reserving use of opioids for patients with severe pain that cannot be managed with other agents. There are several new agents and formulations recently approved or in development for the treatment of acute pain. The recently approved co-crystal formulation of celecoxib and tramadol hydrochloride provides an additional option for acute pain management and utilizes a single-medication multimodal approach.

Demystifying Acute Pain Management in the Emergency Department: A Case-Based Approach.

Introduction: Acute pain is one of the most common complaints that presents to the emergency department. Despite its ubiquity, oligoanalgesia, or the undertreatment of pain, remains a problem in medicine, possibly due to minimal dedicated pain teaching for senior medical students transitioning to residency. Methods: We designed a 2.5-hour interactive seminar for senior medical students transitioning into residency. The seminar included a chalk talk and case-based discussion, reviewed pain physiology, revisited pain assessment, and introduced pain management strategies using a novel acute pain plan to organize an analgesic approach from presentation through disposition from the emergency department. The didactic chalk talk was interwoven with a case of acute pain. Seminar materials promoted a near-peer teaching opportunity for future facilitators. Learners completed open-ended pre-/postsession knowledge assessments. Results: Data were obtained from 19 fourth-year medical students enrolled in three iterations of a preinternship course at Harvard Medical School. Prior to the seminar, learners scored an average of 23.0 out of 53.0 points (SD = 9.0) on the knowledge assessment, which improved to 36.6 out of 53.0 points (SD = 6.7) following the seminar (paired t test p < .001). Learner satisfaction data revealed a positive response to the seminar: Learners felt more confident managing pain and highly recommended the seminar's continuation in the future. Discussion: Initial data from this seminar suggest a need for and benefit of targeted pain education for senior medical students. Seminar materials can easily be adapted for learners in other departments or in early graduate medical education.

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis.

BACKGROUND: Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients. METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids. RESULTS: From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42). CONCLUSIONS: For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.

Evaluation of Acute Pelvic Pain in Women.

Acute pelvic pain is defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months. Signs and symptoms are often nonspecific. The differential diagnosis is broad, based on the patient's age and pregnancy status and gynecologic vs. nongynecologic etiology. Nongynecologic etiologies include gastrointestinal, urinary, and musculoskeletal conditions. Urgent gynecologic conditions include ectopic pregnancy, ruptured ovarian cyst, adnexal torsion, and pelvic inflammatory disease. Approximately 40% of ectopic pregnancies are misdiagnosed at the presenting visit. Urgent nongynecologic conditions include appendicitis and pyelonephritis. Less urgent etiologies include sexually transmitted infections, pelvic floor myofascial pain, dysmenorrhea, and muscle strain. Approximately 15% of untreated chlamydia infections lead to pelvic inflammatory disease. History and physical examination findings guide laboratory testing. Questions should focus on the type, onset, location, and radiation of pain; timing and duration of symptoms; aggravating and relieving factors; and associated symptoms. Performing a urine pregnancy test or beta human chorionic gonadotropin test is an important first step for sexually active, premenopausal patients. Imaging options should be considered, with transvaginal ultrasonography first, followed by computed tomography. Magnetic resonance imaging can be useful if ultrasonography and computed tomography are nondiagnostic.