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 = | ||