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 of Pelvic Pain
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 Some Gynecologic Causes of 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... read more ) 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
Ovulation (mittelschmerz)
Uterine fibroids Uterine Fibroids Uterine fibroids are benign uterine tumors of smooth muscle origin. Fibroids frequently cause abnormal uterine bleeding, pelvic pain and pressure, urinary and intestinal symptoms, and pregnancy... read more 
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.
Nongynecologic disorders
Nongynecologic disorders that can cause pelvic pain may be
Gastrointestinal (GI; 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 , 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, diastasis of the pubic symphysis due to previous vaginal deliveries, abdominal muscle strains)
Psychogenic (eg, somatization Overview of Somatization Somatization is the expression of mental phenomena as physical (somatic) symptoms. Disorders characterized by somatization extend in a continuum from those in which symptoms develop unconsciously... read more ; effects of previous physical, psychologic, or sexual abuse)
The most common is difficult to specify.
Evaluation of Pelvic Pain
Evaluation of pelvic pain must be expeditious because some causes of pelvic pain (eg, ectopic pregnancy Ectopic Pregnancy In ectopic pregnancy, implantation occurs in a site other than the endometrial lining of the uterine cavity—ie, in the fallopian tube, uterine cornua, cervix, ovary, or abdominal or pelvic cavity... 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. Adnexal torsion is uncommon, occurring most often during reproductive... read more ) 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 Vaginal Bleeding Abnormal vaginal bleeding includes Menses that are excessive (menorrhagia or hypermenorrhea) or too frequent (polymenorrhea) Bleeding that is unrelated to menses, occurring irregularly between... 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 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:
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
Urinary frequency, urgency, or dysuria: Urinary disorders
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 Some Clues to Diagnosis of 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... read more ).
Pelvic examination includes inspection of external genitals, speculum examination, and bimanual examination. The cervix is inspected for discharge, uterine prolapse Uterine and Apical Prolapse Uterine prolapse is descent of the uterus toward or past the introitus. Apical prolapse is descent of the vaginal vault or vaginal cuff after hysterectomy. Symptoms include vaginal pressure... read more 
, and cervical stenosis Cervical Stenosis Cervical stenosis is stricture of the internal cervical os. Cervical stenosis may be congenital or acquired. The most common acquired causes of cervical stenosis are Menopause Cervical surgery... read more 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 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 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... read more ). 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 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... read more ). However, findings can be nonspecific. For example, endometriosis Some Clues to Diagnosis of 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... read more can result in a wide variety of findings.
Testing
All patients with pelvic pain should have
Urinalysis
Urine pregnancy test
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 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.
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 of Pelvic Pain
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
Many cancers of the reproductive tract Introduction to Gynecologic Tumors Gynecologic cancers often involve the uterus, ovaries, cervix, vulva, vagina, fallopian tubes, or the peritoneum. The most common gynecologic cancer in the US is endometrial cancer, followed... read more , 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
Pelvic pain is common and may have a gynecologic or nongynecologic cause.
Pregnancy should be ruled out in women of reproductive 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.
