Pelvic pain is discomfort in the lower abdomen and is a common complaint. It is considered separately from vaginal pain and from vulvar or perineal pain, which occurs in the external genitals and nearby perineal skin. The pelvic cavity also contains intestines, bladder, and lower ureters and is surrounded by muscles, connective tissue, and bones. Pelvic pain may originate from any of these structures.
Pelvic pain may be acute or chronic; pain that persists for 3 to 6 months is considered chronic.
Etiology of Pelvic Pain
Pelvic pain may originate in female reproductive organs (cervix, uterus, ovaries, fallopian tubes) or other structures in the abdomen (intestines, urinary tract, pelvic floor).
Gynecologic disorders
Some gynecologic disorders (see table Some Gynecologic Causes of Pelvic Pain Some Gynecologic Causes of Pelvic Pain 
) cause cyclic pelvic pain (ie, pain recurring during the same phase of the menstrual cycle). In others, pain is a unrelated to menses. Also, onset of pain (sudden or gradual) and type of pain (eg, sharp, crampy) may help identify the cause.
Overall, the most common gynecologic causes of pelvic pain include
Ovarian mass, sometimes with rupture or torsion
Uterine fibroids Uterine Fibroids Uterine fibroids (leiomyomas) are benign smooth muscle tumors of the uterus. Fibroids frequently cause abnormal uterine bleeding and pelvic pressure and sometimes urinary or intestinal symptoms... read more 
do not usually cause pain, but pain is possible if they put pressure on surrounding structures, contribute to dysmenorrhea, or degenerate.
Nongynecologic disorders
Nongynecologic disorders that can cause pelvic pain may occur in any system located in the pelvis:
Gastrointestinal (eg, tumors, constipation Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more , inflammatory bowel disease Overview of Inflammatory Bowel Disease Inflammatory bowel disease (IBD), which includes Crohn disease and ulcerative colitis, is a relapsing and remitting condition characterized by chronic inflammation at various sites in the gastrointestinal... read more , high perirectal abscess)
Urinary (eg, cystitis Cystitis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more , interstitial cystitis Interstitial Cystitis Interstitial cystitis is noninfectious bladder inflammation that causes pain (suprapubic, pelvic, and abdominal), urinary frequency, and urgency with incontinence. Diagnosis is by history and... read more , calculi Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more )
Musculoskeletal (eg, myofascial pain, abdominal muscle strains)
Vascular (rapid expansion or rupture of aortic aneurysm)
Evaluation of Pelvic Pain
Evaluation of acute pelvic pain must be expeditious because some causes (eg, ectopic pregnancy Ectopic Pregnancy Ectopic pregnancy is the implantation of a pregnancy in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal... read more , adnexal torsion Adnexal Torsion Adnexal torsion is twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia. Symptoms include severe pelvic pain, often with nausea and vomiting... read more ) require immediate treatment.
Pregnancy should be excluded in all patients of reproductive age regardless of menstrual or sexual history.
History
History of present illness should include onset, duration, location, severity, and character of pain. Relationship of pain to the menstrual cycle is noted. Important associated symptoms include vaginal bleeding Vaginal Bleeding Abnormal vaginal or uterine bleeding includes Menses that are excessive in frequency (amenorrhea, oligomenorrhea, polymenorrhea), volume, or duration (menorrhagia, or heavy menstrual bleeding)... read more or discharge Vaginal Itching and Discharge Vaginal itching (pruritus), discharge, or both result from infectious or noninfectious inflammation of the vaginal mucosa ( vaginitis), often with inflammation of the vulva (vulvovaginitis)... read more , dyspareunia, fever, and symptoms of hemodynamic instability (eg, dizziness, light-headedness, syncope).
Review of systems should include the following:
Amenorrhea, morning sickness, or breast swelling or tenderness: Pregnancy
Fever, chills, or vaginal discharge: Infection
Abdominal pain, change in stool habits, or rectal bleeding: Gastrointestinal disorders
Urinary frequency, urgency, dysuria, or hematuria: Urinary disorders
Past medical history should note obstetric and gynecologic history (gravidity, parity, menstrual history, sexual history, history of sexually transmitted infections, infertility, ectopic pregnancy, pelvic inflammatory disease) and history of urinary calculi, diverticulitis, and other gastrointestinal or genitourinary conditions or cancers. Any previous abdominal or pelvic surgery should be noted.
Physical examination
The physical examination begins with review of vital signs for fever or signs of hemodynamic instability (eg, hypotension, rapid pulse) 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 Some Clues to Diagnosis of Pelvic Pain 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 or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness. If ectopic pregnancy is suspected, pressure should not be applied to an adnexal mass because pressure may cause rupture.
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, or diaphoresis
Interpretation of findings
Acuity and severity of pelvic pain and its relationship to menstrual cycles can suggest the most likely causes (see table Some Gynecologic Causes of Pelvic Pain Some Gynecologic Causes of Pelvic Pain ). Quality and location of pain and associated findings also provide clues (see table Some Clues to Diagnosis of Pelvic Pain Some Clues to Diagnosis of Pelvic Pain ). However, findings may be nonspecific. For example, endometriosis Some Clues to Diagnosis of Pelvic Pain can result in a wide variety of findings.
Testing
All patients with pelvic pain should have
Pregnancy test
Urinalysis
If a patient is pregnant and has pain or bleeding, ectopic pregnancy is assumed until excluded by ultrasonography or, if ultrasonography is unclear, by other tests Testing Pelvic pain is common during early pregnancy and may accompany serious or minor disorders. Some conditions causing pelvic pain also cause vaginal bleeding. In some of these disorders (eg, ruptured... read more . If a suspected pregnancy may be < 5 weeks, a serum pregnancy test should be done; a urine pregnancy test may not be sensitive enough to rule out pregnancy that early in gestation. If urinary symptoms are present, urinalysis is a fast, simple test done to rule out many common causes of pelvic pain (eg, cystitis, urinary calculi).
Other testing depends on which disorders are clinically suspected. If a patient cannot be adequately examined (eg, because of pain) or if a mass is suspected, pelvic ultrasonography is done. If the cause of severe or persistent pain remains unidentified and a serious cause (eg, ruptured ectopic pregnancy, peritonitis) is suspected, laparoscopy or laparotomy may be done.
Transvaginal pelvic ultrasonography can be a useful adjunct to pelvic examination; it can better define a mass or help diagnose a pregnancy after 5 weeks gestation (ie, 1 week after a missed menstrual period). For example, a positive pregnancy test plus no evidence of an intrauterine pregnancy support a diagnosis of ectopic pregnancy.
Treatment of Pelvic Pain
Treatment for pain during pregnancy is based on maternal and fetal considerations.
The underlying disorder is treated when possible.
Pelvic pain in nonpregnant patients is initially treated with oral nonsteroidal anti-inflammatory drugs (NSAIDs). Patients who do not respond well to one NSAID may respond to another.
Pain related to the menstrual cycle (eg, dysmenorrhea, endometriosis) may be treated with hormonal contraceptives.
Musculoskeletal or myofascial pain requires rest, heat, physical therapy, analgesics or other drugs.
If patients have intractable pain unresponsive to any of the above measures, hysterectomy may be offered as a last option.
Geriatrics Essentials
Pelvic pain symptoms in older women may be vague. Careful review of systems with attention to bowel and bladder function is essential.
In older women, common causes of pelvic pain may be different because some disorders that cause pelvic pain or discomfort become more common as women age, particularly after menopause. These disorders include
Cancers of the reproductive tract Introduction to Gynecologic Tumors Gynecologic cancers often involve the uterus, ovaries, cervix, vulva, vagina, fallopian tubes, or the peritoneum. Gestational trophoblastic disease is a group of proliferative disorders originating... read more , including cancers of the uterus and ovaries
A general medical history and obstetric and gynecologic history should be obtained. A sexual history should also be obtained; clinicians often do not realize that many women remain sexually active throughout their life.
Acute loss of appetite, weight loss, dyspepsia, bloating, 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 all patients of reproductive age.
Quality, acuity, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes.
