Pelvic pain is a common symptom in women. It typically has a different etiology than vulvar or vaginal pain. The pelvic cavity contains intestines, the 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 > 6 months is considered chronic pain. Chronic pain is often associated with negative cognitive, behavioral, sexual, and emotional consequences, as well as symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynecologic dysfunction (1).
Reference
1. Chronic Pelvic Pain: American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin Summary, Number 218. Obstet Gynecol. 2020;135(3):744-746. doi:10.1097/AOG.0000000000003717
Etiology of Female 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 muscles or connective tissue, or peritoneum).
Gynecologic disorders
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
Adnexal mass, sometimes with rupture or torsion
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.
Some Gynecologic Causes of Pelvic Pain
Cause | Suggestive Findings | Diagnostic Approach* |
|---|---|---|
Cyclic pain, related to menses | ||
Crampy or dull pain a few days before or at onset of menses, sometimes 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 | History and physical examination Transvaginal ultrasound to exclude other causes | |
Dysmenorrhea or pelvic pain not related to menses; pain can be mild to severe Classic triad of dysmenorrhea, dyspareunia, and infertility; sometimes painful defecation In advanced disease, pelvic examination with cervical or uterine malposition, tender nodules in the posterior cul de sac, immobile uterus or adnexa, or fixed adnexal mass (endometrioma) | Pelvic examination Laparoscopic biopsy (gold standard) Transvaginal ultrasound or MRI prior to laparoscopy or if laparoscopy is not possible (due to lack of facility or surgeon) Infrequently, laparotomy, sigmoidoscopy, or cystoscopy | |
Dysmenorrhea or pelvic pain not related to menses; pain can be mild to severe | Transvaginal ultrasound MRI if ultrasound is inconclusive Pathology after hysterectomy | |
Mittelschmerz | Sudden onset of severe, sharp pain lasting 1–2 days in midcycle (during ovulation) Sometimes light spotty vaginal bleeding | History and physical examination Transvaginal ultrasound to exclude other causes |
Constant or intermittent pain, unrelated to menses | ||
Adnexal mass (benign or malignant tumor or other type of mass) | Dull, persistent unilateral pain Palpable pelvic mass | Transvaginal ultrasound Additional tests such as tumor markers or abdominal and pelvic CT or MRI, if needed |
Ruptured ovarian cyst | Acute onset of pelvic pain, most severe at onset and often decreasing over a few hours, may be associated with sexual intercourse Associated with vaginal bleeding, nausea, vomiting, or peritoneal signs | Transvaginal ultrasound CBC (if significant bleeding is suspected) |
Sudden onset of severe, unilateral pain, occasionally colicky (intermittent torsion) Often with nausea, vomiting, peritoneal signs, and cervical motion tenderness Usually an ovary enlarged > 5 cm due to a mass or ovarian stimulation | Transvaginal ultrasound with color Doppler flow studies Laparoscopy | |
Gradual onset of pelvic pain; sometimes dyspareunia Sometimes fever Cervical motion tenderness, uterine, and adnexal tenderness, and mucopurulent cervical discharge Rarely, adnexal mass (tubo-ovarian abscess) | Pelvic examination Testing for gonorrhea and chlamydia, CBC, and urinalysis or urine culture Transvaginal ultrasound | |
Acute degeneration of uterine fibroid | Sudden onset of moderate to severe pain Sometimes vaginal bleeding Most common during the first 12 weeks of pregnancy or after delivery or termination of a pregnancy | Transvaginal ultrasound If diagnosis is unclear, MRI |
Pelvic adhesions | Gradual onset of pelvic pain (often becoming chronic) or dyspareunia in patients with a history of abdominal surgery or pelvic infection Rarely nausea and vomiting (if intestinal obstruction occurs) | Laparoscopy, sometimes laparotomy |
Myofascial pelvic pain | Chronic or recurring pain in one or more genital tract (vulva, vagina) or other pelvic structures (bladder, rectum, buttocks, hips, abdomen) | Physical examination with evaluation of trigger points and Carnett sign |
Pregnancy-related | ||
Pelvic pain and vaginal bleeding during early pregnancy Adnexal mass with or without tenderness If rupture occurs, sudden onset of localized, severe, sharp pain, often with vaginal bleeding and acute abdomen, and with or without hemodynamic instability | Pregnancy test, serial quantitative beta-hCG Transvaginal ultrasound Sometimes laparoscopy or laparotomy | |
* Pregnancy should be excluded in all patients of reproductive age regardless of menstrual or sexual history. | ||
Beta-hCG = | ||
Nongynecologic disorders
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)
Evaluation of Female Pelvic Pain
Evaluation of acute pelvic pain must be expeditious because some causes (eg, ectopic pregnancy, adnexal torsion) 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, 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.
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. 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).
Red flags
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
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). 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).
Some Clues to Diagnosis of Pelvic Pain
Finding | Possible Diagnosis |
|---|---|
Syncope or hemorrhagic shock | Ruptured ectopic pregnancy Possibly a ruptured ovarian cyst |
Vaginal discharge, cervical motion tenderness, uterine and adnexal tenderness; sometimes fever | Pelvic inflammatory disease, with possible tubo-ovarian abscess |
Sudden onset of severe pain, sometimes localized to one side or with nausea | Ruptured ovarian cyst |
Epigastric or periumbilical pain, followed by brief nausea and anorexia, then by fever and right lower quadrant pain (sometimes with cervical motion tenderness) | |
Constipation, diarrhea, relief or worsening of pain during defecation; sometimes rectal bleeding | Other gastrointestinal disorders |
Left lower quadrant pain and tenderness in patients > 40 years, sometimes with fever | |
Tenderness in the suprapubic area or anterior vaginal wall with chronic or recurrent urinary symptoms (dysuria, urinary frequency or urgency) | Lower urinary tract disorder (eg, interstitial cystitis [painful bladder syndrome]), causing bladder or urethral pain |
Fixed, immobile uterus or adnexa | Gynecologic or other pelvic cancer |
Adnexal mass, sometimes with tenderness | Ovarian cyst or tumor Tubo-ovarian abscess |
Acute, painful defecation plus localized, tender, fluctuant mass felt during internal or external rectal examination; with or without fever |
Testing
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.
Treatment of Female Pelvic Pain
The underlying disorder causing pelvic pain is treated when possible.
Pain related to the menstrual cycle (eg, dysmenorrhea, endometriosis) may be treated with hormonal contraceptives.
Pelvic pain in nonpregnant patients is initially treated with oral nonsteroidal anti-inflammatory drugs (NSAIDs) (1
In addition, pelvic floor physical therapy, sex therapy, or cognitive-behavioral therapy is recommended for management of myofascial pelvic pain or pain associated with psychiatric comorbidities. Procedures such as trigger point or botulinum toxin injections can be used for refractory cases.
If patients have intractable pain unresponsive to any of the above measures, diagnostic or laparoscopic treatment of endometriosis or adhesiolysis, uterosacral nerve ablation, presacral neurectomy, or hysterectomy may be offered.
Treatment reference
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
Geriatrics Essentials: Female Pelvic Pain
Pelvic pain symptoms in older women may be nonspecific. 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, 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 in women and may have a gynecologic or nongynecologic cause.
Test reproductive-aged women who have pelvic pain with a pregnancy test, even when history does not suggest pregnancy.
Character, acuity, severity, and location of pain and its relationship to the menstrual cycle can suggest the most likely causes.
Evaluate acute pelvic pain with vital signs, physical examination, pregnancy test, complete blood count, urinalysis, and pelvic imaging.
Evaluate chronic pelvic pain with a detailed medical, surgical, obstetric, and gynecologic history and with a thorough physical examination.
