Maria, a 14-year-old girl, came to the office late one Friday morning with a chief complaint of right lower abdominal pain.

 

Mom was concerned that she might have an appendicitis. Maria said the pain woke her up at 6 AM and was sharp and constant. It did not radiate to her back or elsewhere in her abdomen. She denied any discomfort when urinating. Her last period was two weeks ago and has been very regular. There has been no sexual active. She had no fever, nor vomiting or diarrhea although she was somewhat nauseated because of the pain. She did manage to eat some breakfast but wasn’t too hungry.

 

Her temperature was 98.7 and she had normal vital signs.

 

With the exception of her abdomen the exam was completely normal (throat, ears, heart and lungs). She had normal bowel sounds and the abdomen was soft. It is written in old literature that when examining a normal abdomen, one should be able to “knead the abdomen like dough”. Maria’s abdomen was just like that. She did have tenderness when I palpated the lower right side. She winced and said that it hurt, about 7 out of 10 for pain.
 

When pressing the right lower quadrant and then quickly releasing my hand, this did not exacerbate the pain.

 

This meant there was no rebound tenderness which is often common in appendicitis. When pressing on the left lower quadrant it did not cause pain on the right side which tests for Rovsing sign, also common in appendicitis. I had her stand up and then bend down like a baseball catcher. She could do this multiple times with no pain. Then she jumped up and down a few times and again no problem. Both of these maneuvers are often positive in appendicitis. They are manifestations of rebound tenderness which is the result of the intra-abdominal inflammation from the infected appendix.

 

After the history and examination, I was certain that Maria did NOT have appendicitis or any intra-abdominal surgical problem.

 

I told mom and Maria that I thought she had Mittleschmerz. Before I could say “let me explain”, they both simultaneously said, “Mittle-what”??
 

Mittleschmerz is a German word meaning mid-cycle.

 

It refers to the pain that can affect 20-40% of women of ovulatory age. When a woman is mid-cycle the ovum, or egg, matures and is surrounded by follicular fluid. At ovulation the egg essentially pushes through the ovarian wall and is released to be picked up by the Fallopian tube. Then begins its migration down to the uterus where it is primed and ready for conception. When the egg is released the follicular fluid, along with blood, may trickle down the pelvic gutter where it settles. Blood can be an irritant when it occurs outside the blood vessels. The main theory for the mid-cycle pain is that the blood sitting in the pelvic gutter is what causes the pain. Another theory is that at the time of ovulation there are increased levels of Lutenizing Hormone (LH). This may cause spasms and contractions of the smooth muscle of the ovary. Regardless, the pain with Mittleschmerz usually lasts from hours to a couple of days. But it is self-resolving and a benign condition. However, It can mimic acute appendicitis or other intra-abdominal issues. These MUST unequivocally be ruled out.
 

Mom and Maria were both confident with this diagnosis.

 

She should use a heating pad and take NSAID’s such as Motrin or Advil. If she spiked a fever or developed worsening pain that was crampy and severe (concern for a twisted or torsed ovarian cyst), or if the pain changed, she must call ASAP and be prepared to be told to go to the ER for an ultrasound.

 

I was certain of my diagnosis but she was on my mind all night.

 

The next morning I called mom to see how it was going. Maria had slept all night, got up feeling great and did not have ANY pain. She was actually at her volleyball game.