Female Pelvic Pain

Some gynecologic disorders (see table Some Gynecologic Causes of Pelvic Pain) cause cyclic pelvic pain (ie, pain recurring during the same phase of each menstrual cycle). In others, pain is constant or intermittent but 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

• Primary dysmenorrhea

• Endometriosis

• Adnexal mass, sometimes with rupture or torsion

• Pelvic inflammatory disease

Uterine fibroids do not usually cause pain, but pain is possible if they put pressure on surrounding structures, contribute to dysmenorrhea, or undergo degenerative changes.

Other causes of female pelvic pain include pelvic adhesions, ovarian remnant syndrome, or gynecologic malignancy.

Nongynecologic disorders in any system located in the pelvis can cause pelvic pain:

• Gastrointestinal (eg, constipation, celiac disease, inflammatory bowel disease, irritable bowel syndrome, diverticular colitis, high perirectal abscess, or colorectal cancer)

• Urinary (eg, cystitis, interstitial cystitis [painful bladder syndrome], calculi, bladder cancer, urethral diverticulum)

• Musculoskeletal (eg, fibromyalgia, myofascial syndromes, anterior cutaneous nerve entrapment syndromes)

• Neurologic (eg, neuropathic pain, abdominal migraine, abdominal epilepsy)

• Vascular (eg, rapid expansion or rupture of aortic aneurysm)

• Related to psychiatric disorders (eg, depressive disorders, anxiety, somatic symptom disorder, substance use disorders)

History of present illness should include onset, duration, location, severity, pattern (intermittent or constant), and character of pain (sharp, dull, crampy). Relationship of pain to the menstrual cycle is noted. Important associated symptoms include vaginal bleeding or discharge, dyspareunia, fever, and symptoms of hemodynamic instability (eg, dizziness, light-headedness, syncope).

Review of systems should seek symptoms of possible causes, including the following:

• Amenorrhea, morning sickness, or breast swelling or tenderness: Pregnancy-related pain

• Fever, chills, or vaginal discharge: Pelvic infection

• Abdominal pain (particularly if triggered by meals), 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.

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. The patient can be tested for the Carnett sign (local abdominal tenderness when a supine patient contracts the rectus abdominis muscles by raising either the head or both legs). A positive test suggests anterior cutaneous nerve entrapment syndrome, which can be a musculoskeletal cause of chronic pelvic pain.

A complete pelvic examination is done. During the speculum examination, the vagina and cervix are inspected for discharge, lesions, or bleeding. Bimanual examination should assess cervical motion tenderness; uterine size, masses, tenderness, consistency (firm or soft), and mobility; and adnexal masses, tenderness, and mobility.

Rectovaginal examination is done to check for posterior pelvic masses or tenderness, rectovaginal septum tenderness or nodularity, and rectal masses or bleeding.

Location of pain and any associated findings may provide clues to the cause (see table Some Clues to Diagnosis of Pelvic Pain).

The following findings are of particular concern:

• Syncope or hemorrhagic shock (eg, tachycardia, hypotension): Abdominal bleeding due to ectopic pregnancy, ruptured ovarian cyst, or other gynecologic or nongynecologic etiology

• Peritoneal signs (rebound, rigidity, guarding): Perforation of bowel or other abdominal organs, or tubo-ovarian abscess

• Fever or chills: Possible tubo-ovarian abscess or other infection

• Sudden onset severe pain with nausea, vomiting, or diaphoresis: Adnexal torsion

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). Character and location of pain and associated findings also provide clues (see table Some Clues to Diagnosis of Pelvic Pain). However, findings may be nonspecific. For example, endometriosis can result in a wide variety of findings (eg, dyspareunia, dysmenorrhea, constant pelvic pain, dyschezia).

Testing in patients with pelvic pain depends on whether the pain is acute or chronic.

All female patients with acute pelvic pain should have

• Complete blood count (CBC)

• Urinalysis

• Pregnancy test

A CBC can diagnose anemia (suggesting acute or chronic bleeding) or leukocytosis (suggesting infection). If urinary symptoms are present, urinalysis is a fast, simple test to evaluate for common causes of pelvic pain (eg, cystitis, urinary calculi).

If a patient has a positive pregnancy test and has pain or bleeding, ectopic pregnancy is assumed until excluded by transvaginal ultrasound (finding no fetal pole or yolk sac) or, if ultrasound is unclear, by other tests.

Transvaginal ultrasound may also identify or suggest other etiologies of acute pain, including

• Ruptured ovarian cyst: Ovarian cyst with echogenic pelvic fluid

• Adnexal torsion: Ovarian or fallopian tube mass (particularly if mass is > 5 cm) with absence of Doppler flow

• Complex multilocular adnexal mass: Tubo-ovarian abscess (may also be a benign tumor or malignancy, but these are less likely to present with acute pelvic pain)

If appendicitis is suspected, a pelvic and abdominal CT scan should be done.

If the cause of severe or persistent pain remains unidentified and a patient is hemodynamically unstable and a potentially serious etiology (eg, ruptured ectopic pregnancy, peritonitis) is suspected, laparoscopy or laparotomy may be required.

For women with chronic pelvic pain, testing depends on which disorders are clinically suspected (see table Some Gynecologic Causes of Pelvic Pain). Patients should also be screened for depression or other mental health disorders and for domestic violence or sexual trauma.

1. 1. Chronic Pelvic Pain: American College of Obstetricians and Gynecologists  (ACOG) Practice Bulletin, Number 218. Obstet Gynecol. 2020;135(3):e98-e109. doi:10.1097/AOG.0000000000003716