Pelvic Pain: A Merck Manual of Patient Symptoms podcast
Pelvic pain is discomfort in the lower torso; it is a common complaint in women. It is considered separately from perineal pain, which occurs in the external genitals and nearby perineal skin.
Pelvic pain may originate in reproductive organs (cervix, uterus, uterine adnexa) or other organs. Sometimes the cause is unknown.
Some gynecologic disorders (see Table 1: Symptoms of Gynecologic Disorders: Some Gynecologic Causes of Pelvic Pain) cause cyclic pain (ie, pain recurring during the same phase of the menstrual cycle). In others, pain is a discrete event unrelated to menstrual cycles. Whether onset of pain is sudden or gradual helps discriminate between the two.
Overall, the most common gynecologic causes of pelvic pain include
These disorders (see Acute Abdomen and Surgical Gastroenterology: Acute Abdominal Pain) may be
The most common is difficult to specify.
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Evaluation must be expeditious because some causes of pelvic pain (eg, ectopic pregnancy, adnexal torsion) require immediate treatment. Pregnancy should be excluded in women of childbearing age regardless of stated history.
History of present illness should include gynecologic history (gravity, parity, menstrual history, history of sexually transmitted disease) and onset, duration, location, and character of pain. Severity of pain and its relationship to the menstrual cycle are noted. Important associated symptoms include vaginal bleeding or discharge and symptoms of hemodynamic instability (eg, dizziness, light-headedness, syncope or near-syncope).
Review of systems should seek symptoms suggesting possible causes, including morning sickness, breast swelling or tenderness, or missed menses (pregnancy); fever and chills (infection); abdominal pain, nausea, vomiting, or change in stool habits (GI disorders); and urinary frequency, urgency, or dysuria (urinary disorders).
Past medical history should note history of infertility, ectopic pregnancy, pelvic inflammatory disease, urolithiasis, diverticulitis, and any GI or GU cancers. Any previous abdominal or pelvic surgery should be noted.
The physical examination begins with review of vital signs for signs of instability (eg, fever, hypotension) and focuses on abdominal and pelvic examinations.
The abdomen is palpated for tenderness, masses, and peritoneal signs. Rectal examination is done to check for tenderness, masses, and occult blood. Location of pain and any associated findings may provide clues to the cause (see Table 2: Symptoms of Gynecologic Disorders: Some Clues to Diagnosis of Pelvic Pain).
Pelvic examination includes inspection of external genitals, speculum examination, and bimanual examination. The cervix is inspected for discharge, uterine prolapse, and cervical stenosis or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness.
The following findings are of particular concern:
Interpretation of findings
Acuity and severity of pain and its relationship to menstrual cycles can suggest the most likely causes (see Table 1: Symptoms of Gynecologic Disorders: Some Gynecologic Causes of Pelvic Pain). Quality and location of pain and associated findings also provide clues (see Table 2: Symptoms of Gynecologic Disorders: Some Clues to Diagnosis of Pelvic Pain).
All patients should have
If a patient is pregnant, ectopic pregnancy is assumed until excluded by ultrasonography or, if ultrasonography is unclear, by other tests (see Symptoms During Pregnancy: Pelvic Pain During Early Pregnancy). If a suspected pregnancy may be < 5 wk, a serum pregnancy test should be done; a urine pregnancy test may not be sensitive enough to rule out pregnancy that early in gestation.
Other testing depends on which disorders are clinically suspected. If a patient cannot be adequately examined (eg, because of pain or inability to cooperate) or if a mass is suspected, pelvic ultrasonography is done. If the cause of severe or persistent pain remains unidentified, laparoscopy is done.
Pelvic ultrasonography using a vaginal probe can be a useful adjunct to pelvic examination; it can better define a mass or help diagnose a pregnancy after 5 wk gestation. For example, free pelvic fluid and a positive pregnancy test plus no evidence of an intrauterine pregnancy help confirm ectopic pregnancy.
The underlying disorder is treated when possible.
Pain is initially treated with oral NSAIDs. Patients who do not respond well to one NSAID may respond to another. If NSAIDs are ineffective, other analgesics or hypnosis may be tried. Musculoskeletal pain may also require rest, heat, physical therapy, or, for fibromyalgia, injection of tender points with 0.5% bupivacaine or 1% lidocaine.
For patients with intractable pain due to dysmenorrhea or another disorder, uterosacral nerve ablation or presacral neurectomy can be tried. If all measures are ineffective, hysterectomy can be done, but it may be ineffective or even worsen the pain.
Pelvic pain symptoms in elderly women may be vague. Careful review of systems with attention to bowel and bladder function is essential.
A sexual history should be obtained; clinicians often do not realize that many women remain sexually active throughout their life. Whether a woman's partner is living should be determined before inquiring about sexual activity. In elderly women, vaginal irritation, itching, urinary symptoms, or bleeding may occur secondary to sexual intercourse. Such problems often resolve after a few days of pelvic rest.
Acute loss of appetite, weight loss, dyspepsia, or a sudden change in bowel habits may be signs of ovarian or uterine cancer and requires thorough clinical evaluation.
Last full review/revision July 2012 by David H. Barad, MD, MS