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.

Etiology

Pelvic pain may originate in reproductive organs (cervix, uterus, uterine adnexa) or other organs. Sometimes the cause is unknown.

Gynecologic disorders

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

• Dysmenorrhea
• Ovulation (mittelschmerz)
• Endometriosis

Nongynecologic disorders

These disorders (see Acute Abdomen and Surgical Gastroenterology: Acute Abdominal Pain) may be

• GI (eg, gastroenteritis, inflammatory bowel disease, appendicitis, diverticulitis, tumors, constipation, intestinal obstruction, perirectal abscess, irritable bowel syndrome)
• Urinary (eg, cystitis, interstitial cystitis, pyelonephritis, calculi)
• Musculoskeletal (eg, diastasis of the pubic symphysis due to previous vaginal deliveries, abdominal muscle strains)
• Psychogenic (eg, somatization; effects of previous physical, psychologic, or sexual abuse)

The most common is difficult to specify.

Table 1
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Some Gynecologic Causes of Pelvic Pain Cause Suggestive Findings Diagnostic Approach* Related to menstrual cycle Dysmenorrhea Sharp or crampy pain a few days before or at onset of menses, often with headache, nausea, constipation, diarrhea, or urinary frequency Symptoms usually peaking in 24 h but sometimes persisting for 2–3 days after onset of menses Clinical evaluation Endometriosis Sharp or crampy pain before and during early menses, often with dysmenorrhea, dyspareunia, or painful defecation May eventually cause pain unrelated to the menstrual cycle In advanced stages, sometimes uterine retroversion, tenderness, decreased mobility Sometimes a fixed pelvic mass (possibly an endometrioma) or tender nodules noted during bimanual vaginal and rectovaginal examination Clinical evaluation Sometimes laparoscopy Mittelschmerz Sudden onset of severe, sharp pain, most intense at onset and abating over 1–2 days Often accompanied by light spotty vaginal bleeding Occurring midcycle (during ovulation), caused by mild, brief peritoneal irritation due to a ruptured follicular cyst Clinical evaluation Diagnosis of exclusion Unrelated to menstrual cycle Pelvic inflammatory disease Gradual onset of pelvic pain, mucopurulent cervical discharge Sometimes fever, dysuria, dyspareunia Typically, marked cervical motion tenderness and adnexal tenderness Rarely, an adnexal mass (eg, abscess) Clinical evaluation Cervical culture Sometimes pelvic ultrasonography (if abscess is suspected) Ruptured ovarian cyst Sudden onset of pain, most severe at onset and often rapidly decreasing over a few hours Sometimes with slight vaginal bleeding, nausea, vomiting, and peritoneal signs Clinical evaluation Sometimes pelvic ultrasonography Ruptured ectopic pregnancy Sudden onset of localized, constant (not crampy) pain, often with vaginal bleeding and sometimes syncope or hemorrhagic shock Closed cervical os Sometimes acute abdominal distention or tender adnexal mass Quantitative β-hCG measurement Pelvic ultrasonography Sometimes laparoscopy or laparotomy Acute degeneration of uterine fibroid Sudden onset of pain, vaginal bleeding Most common during the first 12 wk of pregnancy or after delivery or termination of a pregnancy Pelvic ultrasonography Adnexal torsion Sudden onset of severe, unilateral pain, occasionally colicky (because of intermittent torsion) Often with nausea, vomiting, peritoneal signs, and cervical motion tenderness Presence of risk factors (eg, pregnancy, induction of ovulation, ovarian enlargement to > 4 cm) Pelvic ultrasonography with color Doppler flow studies Sometimes laparoscopy or laparotomy Uterine or ovarian cancer Gradual onset of pain, vaginal discharge (which precedes bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia) Rarely, a palpable pelvic mass Pelvic ultrasonography Biopsy Adhesions Gradual onset of pelvic pain (often becoming chronic) or dyspareunia in patients who have had abdominal surgery or sometimes pelvic infections No vaginal bleeding or discharge Sometimes nausea and vomiting (suggesting intestinal obstruction) Clinical evaluation Diagnosis of exclusion Sometimes abdominal obstruction series (flat and upright abdominal x-rays) Spontaneous abortion Vaginal bleeding associated with crampy lower abdominal pain or back pain during early pregnancy and accompanied by other symptoms of early pregnancy, such as breast tenderness, nausea, and delayed menses Clinical evaluation Pregnancy test Pelvic ultrasonography to assess viability of pregnancy *Pelvic examination, urinalysis, and a urine or serum pregnancy test should be done. Most patients with acute or significant recurrent symptoms require pelvic ultrasonography. β-hCG = β subunit of human chorionic gonadotropin. Some Gynecologic Causes of Pelvic Pain Cause Suggestive Findings Diagnostic Approach* Related to menstrual cycle Dysmenorrhea Sharp or crampy pain a few days before or at onset of menses, often with headache, nausea, constipation, diarrhea, or urinary frequency Symptoms usually peaking in 24 h but sometimes persisting for 2–3 days after onset of menses Clinical evaluation Endometriosis Sharp or crampy pain before and during early menses, often with dysmenorrhea, dyspareunia, or painful defecation May eventually cause pain unrelated to the menstrual cycle In advanced stages, sometimes uterine retroversion, tenderness, decreased mobility Sometimes a fixed pelvic mass (possibly an endometrioma) or tender nodules noted during bimanual vaginal and rectovaginal examination Clinical evaluation Sometimes laparoscopy Mittelschmerz Sudden onset of severe, sharp pain, most intense at onset and abating over 1–2 days Often accompanied by light spotty vaginal bleeding Occurring midcycle (during ovulation), caused by mild, brief peritoneal irritation due to a ruptured follicular cyst Clinical evaluation Diagnosis of exclusion Unrelated to menstrual cycle Pelvic inflammatory disease Gradual onset of pelvic pain, mucopurulent cervical discharge Sometimes fever, dysuria, dyspareunia Typically, marked cervical motion tenderness and adnexal tenderness Rarely, an adnexal mass (eg, abscess) Clinical evaluation Cervical culture Sometimes pelvic ultrasonography (if abscess is suspected) Ruptured ovarian cyst Sudden onset of pain, most severe at onset and often rapidly decreasing over a few hours Sometimes with slight vaginal bleeding, nausea, vomiting, and peritoneal signs Clinical evaluation Sometimes pelvic ultrasonography Ruptured ectopic pregnancy Sudden onset of localized, constant (not crampy) pain, often with vaginal bleeding and sometimes syncope or hemorrhagic shock Closed cervical os Sometimes acute abdominal distention or tender adnexal mass Quantitative β-hCG measurement Pelvic ultrasonography Sometimes laparoscopy or laparotomy Acute degeneration of uterine fibroid Sudden onset of pain, vaginal bleeding Most common during the first 12 wk of pregnancy or after delivery or termination of a pregnancy Pelvic ultrasonography Adnexal torsion Sudden onset of severe, unilateral pain, occasionally colicky (because of intermittent torsion) Often with nausea, vomiting, peritoneal signs, and cervical motion tenderness Presence of risk factors (eg, pregnancy, induction of ovulation, ovarian enlargement to > 4 cm) Pelvic ultrasonography with color Doppler flow studies Sometimes laparoscopy or laparotomy Uterine or ovarian cancer Gradual onset of pain, vaginal discharge (which precedes bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia) Rarely, a palpable pelvic mass Pelvic ultrasonography Biopsy Adhesions Gradual onset of pelvic pain (often becoming chronic) or dyspareunia in patients who have had abdominal surgery or sometimes pelvic infections No vaginal bleeding or discharge Sometimes nausea and vomiting (suggesting intestinal obstruction) Clinical evaluation Diagnosis of exclusion Sometimes abdominal obstruction series (flat and upright abdominal x-rays) Spontaneous abortion Vaginal bleeding associated with crampy lower abdominal pain or back pain during early pregnancy and accompanied by other symptoms of early pregnancy, such as breast tenderness, nausea, and delayed menses Clinical evaluation Pregnancy test Pelvic ultrasonography to assess viability of pregnancy *Pelvic examination, urinalysis, and a urine or serum pregnancy test should be done. Most patients with acute or significant recurrent symptoms require pelvic ultrasonography. β-hCG = β subunit of human chorionic gonadotropin.

Evaluation

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

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.

Physical examination

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.

Red flags

The following findings are of particular concern:

• Syncope or hemorrhagic shock (eg, tachycardia, hypotension)
• Peritoneal signs (rebound, rigidity, guarding)
• Postmenopausal vaginal bleeding
• Fever or chills
• Sudden severe pain with nausea, vomiting, diaphoresis, or agitation

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).

Table 2
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Some Clues to Diagnosis of Pelvic Pain Finding Possible Diagnosis Syncope or hemorrhagic shock Ruptured ectopic pregnancy Possibly ovarian cyst Vaginal discharge, fever, bilateral pain and tenderness Pelvic inflammatory disease Severe, intermittent colicky pain (sometimes with nausea), which may develop and reach peak intensity within seconds or minutes Adnexal torsion Renal colic Nausea followed by anorexia, fever, and right-sided pain Appendicitis Constipation, diarrhea, relief or worsening of pain during defecation GI disorder Left lower quadrant pain in women > 40 Diverticulitis Generalized abdominal tenderness or peritoneal signs Peritonitis (eg, due to appendicitis, diverticulitis, another GI disorder, pelvic inflammatory disease, adnexal torsion, or rupture of an ovarian cyst or ectopic pregnancy) Tenderness in the anterior vaginal wall Lower urinary tract disorder (causing bladder or urethral pain) Uterine fixation detected by bimanual examination Adhesions Endometriosis Late-stage cancer Tender adnexal mass or tenderness with cervical motion Ectopic pregnancy Pelvic inflammatory disease Ovarian cyst or tumor Adnexal torsion Tenderness of the pubic bone in parous women, particularly if pain occurs during ambulation Diastasis of the pubic symphysis Acute, painful defecation plus localized, tender, fluctuant mass felt during internal or external rectal examination; with or without fever Perirectal abscess Gross or microscopic rectal blood GI disorder Chronic painful defecation plus localized, firm woody mass felt during internal or external rectal examination; without fever Severe endometriosis Late-stage cervical cancer Some Clues to Diagnosis of Pelvic Pain Finding Possible Diagnosis Syncope or hemorrhagic shock Ruptured ectopic pregnancy Possibly ovarian cyst Vaginal discharge, fever, bilateral pain and tenderness Pelvic inflammatory disease Severe, intermittent colicky pain (sometimes with nausea), which may develop and reach peak intensity within seconds or minutes Adnexal torsion Renal colic Nausea followed by anorexia, fever, and right-sided pain Appendicitis Constipation, diarrhea, relief or worsening of pain during defecation GI disorder Left lower quadrant pain in women > 40 Diverticulitis Generalized abdominal tenderness or peritoneal signs Peritonitis (eg, due to appendicitis, diverticulitis, another GI disorder, pelvic inflammatory disease, adnexal torsion, or rupture of an ovarian cyst or ectopic pregnancy) Tenderness in the anterior vaginal wall Lower urinary tract disorder (causing bladder or urethral pain) Uterine fixation detected by bimanual examination Adhesions Endometriosis Late-stage cancer Tender adnexal mass or tenderness with cervical motion Ectopic pregnancy Pelvic inflammatory disease Ovarian cyst or tumor Adnexal torsion Tenderness of the pubic bone in parous women, particularly if pain occurs during ambulation Diastasis of the pubic symphysis Acute, painful defecation plus localized, tender, fluctuant mass felt during internal or external rectal examination; with or without fever Perirectal abscess Gross or microscopic rectal blood GI disorder Chronic painful defecation plus localized, firm woody mass felt during internal or external rectal examination; without fever Severe endometriosis Late-stage cervical cancer

Testing

All patients should have

• Urinalysis
• Urine pregnancy test

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.

Treatment

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.

Geriatrics Essentials

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.

Key Points

• Pelvic pain is common and may have a gynecologic or nongynecologic cause.
• Pregnancy should be ruled out in women of childbearing age.
• Quality, acuity, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes.
• Dysmenorrhea is a common cause of pelvic pain but is a diagnosis of exclusion.

Last full review/revision July 2012 by David H. Barad, MD, MS