Pelvic Pain
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 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
Uterine fibroids can cause pelvic pain if they are degenerating or if their location in the uterus results in excessive bleeding or cramping. Most uterine fibroids do not cause pain.
Some Gynecologic Causes of Pelvic Pain
Cause |
Suggestive Findings |
Diagnostic Approach* |
Related to menstrual cycle |
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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 hours but sometimes persisting for 2–3 days after onset of menses |
Clinical evaluation |
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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 Laparoscopy |
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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 |
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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) |
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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 |
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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 beta-hCG measurement Pelvic ultrasonography Sometimes laparoscopy or laparotomy |
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Acute degeneration of uterine fibroid |
Sudden onset of pain, vaginal bleeding Most common during the first 12 weeks of pregnancy or after delivery or termination of a pregnancy |
Pelvic ultrasonography |
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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 |
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Gradual onset of pain, clear or white watery or bloody vaginal discharge (which may precede bleeding), abnormal vaginal bleeding (eg, postmenopausal bleeding, premenopausal recurrent metrorrhagia) Rarely, a palpable pelvic mass |
Pelvic ultrasonography Biopsy Sometimes additional tests such as hysteroscopy or saline-infusion sonohysterography to help identify abnormalities in the endometrium |
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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) |
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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 |
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* Pelvic examination, urinalysis, and a urine or serum pregnancy test should be done. Most patients with acute or significant recurrent symptoms require pelvic ultrasonography. |
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Beta-hCG = beta subunit of human chorionic gonadotropin. |
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Nongynecologic disorders
Nongynecologic disorders that can cause pelvic pain may be
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Gastrointestinal (GI; eg, tumors, constipation, high perirectal abscess)
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Urinary (eg, cystitis, interstitial cystitis, calculi)
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Musculoskeletal (eg, diastasis of the pubic symphysis due to previous vaginal deliveries, abdominal muscle strains)
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Psychogenic (eg, somatization; effects of previous physical, psychologic, or sexual abuse)
The most common is difficult to specify.
Evaluation
Evaluation of pelvic pain must be expeditious because some causes of pelvic pain (eg, ectopic pregnancy, adnexal torsion) require immediate treatment.
Pregnancy should be excluded in women of reproductive age regardless of stated history.
History
History of present illness should include gynecologic history (gravidity, parity, menstrual history, history of sexually transmitted disease) and onset, duration, location, and character of pain. Quality, acuity, severity, and location of pain and its relationship to the menstrual cycle are noted and can suggest the most likely causes. 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 the following:
Past medical history should note history of infertility, ectopic pregnancy, pelvic inflammatory disease, urinary calculi, diverticulitis, and any GI or genitourinary cancers. Any previous abdominal or pelvic surgery should be noted.
Physical examination
The physical examination begins with review of vital signs for abnormalities or 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 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
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). Quality and location of pain and associated findings also provide clues (see table Some Clues to Diagnosis of Pelvic Pain). However, findings can be nonspecific. For example, endometriosis can result in a wide variety of findings.
Some Clues to Diagnosis of Pelvic Pain
Finding |
Possible Diagnosis |
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Syncope or hemorrhagic shock |
Ruptured ectopic pregnancy Possibly a ruptured ovarian cyst |
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Vaginal discharge, fever, bilateral pain and tenderness |
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Severe, intermittent colicky pain (sometimes with nausea), which may develop and reach peak intensity within seconds or minutes |
Ectopic pregnancy |
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Epigastric or periumbilical pain, followed by brief nausea and anorexia, then by fever and right lower quadrant pain |
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Constipation, diarrhea, relief or worsening of pain during defecation |
Gastrointestinal (GI) disorder |
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Left lower quadrant pain in women > 40 |
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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) |
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Tenderness in the anterior vaginal wall |
Lower urinary tract disorder (eg, interstitial cystitis), causing bladder or urethral pain |
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Uterine fixation detected by bimanual examination |
Adhesions Late-stage cancer |
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Tender adnexal mass or tenderness with cervical motion |
Ectopic pregnancy Pelvic inflammatory disease Ovarian cyst or tumor Adnexal torsion |
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Tenderness of the pubic bone in parous women, particularly if pain occurs during ambulation |
Diastasis of the pubic symphysis |
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Acute, painful defecation plus localized, tender, fluctuant mass felt during internal or external rectal examination; with or without fever |
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Gross or microscopic rectal blood |
GI disorder |
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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 with pelvic pain should have
Urinalysis is a fast, simple test done to rule out many common causes of pelvic pain (eg, cystitis, urinary calculi). The urine sample can also be used for a urinary pregnancy test. If a patient is pregnant, ectopic pregnancy is assumed until excluded by ultrasonography or, if ultrasonography is unclear, by other tests. 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.
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 weeks gestation (ie, 1 week after a missed menstrual period). 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.
Pelvic pain is initially treated with oral nonsteroidal anti-inflammatory drugs (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.
If patients have intractable pain, hysterectomy can be done, but it may be ineffective.
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 become more common as women age, particularly after menopause. These disorders include
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Many cancers of the reproductive tract, including cancers of the endometrium, fallopian tubes, ovaries, and vagina
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 older 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
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Pelvic pain is common and may have a gynecologic or nongynecologic cause.
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Pregnancy should be ruled out in women of reproductive age.
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Quality, acuity, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes.
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Dysmenorrhea is a common cause of pelvic pain but is a diagnosis of exclusion.
Drugs Mentioned In This Article
| Drug Name | Select Trade |
|---|---|
bupivacaine |
MARCAINE |
lidocaine |
XYLOCAINE |
