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Pelvic pain is extremely common and may have many causes. It may originate in gynecologic organs (cervix, uterus, or uterine adnexa) or nongynecologic organs. Sometimes the cause is unknown.
Some gynecologic disorders (eg, premenstrual syndrome, dysmenorrhea—see Menstrual Abnormalities) cause cyclic pain, which tends to recur at the same phase of the menstrual cycle. Dysmenorrhea (cramping or sharp pain during menses) can be a primary disorder or a symptom of another disorder. Mittelschmerz (severe but self-limited midcycle pain that occurs during ovulation) probably results from mild, brief peritoneal irritation due to a ruptured follicular cyst. Endometriosis typically causes pain before menses and during early menses but may eventually cause pain unrelated to menstrual cycles.
Some gynecologic disorders cause pain that is usually unrelated to menstrual cycles. Sudden, often severe pain can result from rupture of an ectopic pregnancy (see Abnormalities of Pregnancy: Ectopic Pregnancy), acute degeneration of a uterine fibroid (see Uterine Fibroids), adnexal torsion, or rupture or bleeding of ovarian cysts or masses (see Benign Gynecologic Lesions: Benign Ovarian Masses). Adnexal torsion usually indicates a preexisting ovarian abnormality such as enlargement (eg, due to follicular cysts or hyperstimulation with fertility drugs) or destabilization (eg, due to previous surgery). More gradual pain can result from pelvic inflammatory disease (PID—see Vaginitis and Pelvic Inflammatory Disease (PID): Pelvic Inflammatory Disease (PID)), pelvic tumors, or pelvic adhesions due to previous infection or surgery.
Nongynecologic disorders that can cause pelvic pain may be GI (eg, gastroenteritis, inflammatory bowel disease, appendicitis, diverticulitis, tumors, constipation, intestinal obstruction, perirectal abscess, irritable bowel syndrome), urinary (eg, cystitis, interstitial cystitis, pyelonephritis, calculi), musculoskeletal (eg, diastasis of the pubic symphysis due to previous vaginal deliveries, abdominal muscle strains), or psychogenic (eg, somatization; effects of previous physical, psychologic, or sexual abuse).
Evaluation
Diagnosis must be made expeditiously because some causes of pelvic pain (eg, ectopic pregnancy, adnexal torsion) require immediate treatment.
History and examination:
A complete gynecologic history and physical examination are necessary. Acuity and severity of pain and its relationship to menstrual cycles can suggest the most likely possibilities. Quality and location of pain and associated findings also provide clues (see
Table 1: Approach to the Gynecologic Patient: Clues to Diagnosis of Pelvic Pain ).
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Table 1
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Clues to Diagnosis of Pelvic
Pain
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Finding
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Possible Diagnosis
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Syncope or hemorrhagic shock
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Ruptured ectopic pregnancy, possibly ovarian cyst
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Vaginal discharge, fever, and bilateral pain and tenderness
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PID
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Severe, intermittent colicky pain, sometimes with nausea, which may develop and reach peak intensity within seconds or minutes
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Adnexal torsion
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Nausea followed by anorexia, fever, and right-sided pain
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Appendicitis
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Constipation, diarrhea, and relief or worsening of pain with defecation
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GI disorder
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Left lower quadrant pain in women > 40
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Diverticulitis
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Generalized abdominal tenderness or peritoneal signs
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Peritonitis (eg, due to appendicitis, diverticulitis, another GI disorder, PID, adnexal torsion, or rupture of an ovarian cyst or ectopic pregnancy)
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Tenderness in the anterior vaginal wall
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Bladder or urethral pain due to a lower urinary tract disorder
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Uterine fixation detected by bimanual examination
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Adhesions, endometriosis, or late-stage cancer
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Tender adnexal mass or tenderness with cervical motion
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Ectopic pregnancy, PID, ovarian cyst or tumor, or adnexal torsion
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Tenderness of the pubic bone in parous women, particularly if pain occurs during ambulation
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Diastasis of the pubic symphysis
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Painful defecation plus localized tender mass felt during internal or external examination of rectum, with or without fever
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Perirectal abscess
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Gross or microscopic rectal blood
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GI disorder
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PID = pelvic inflammatory disease.
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Testing:
A pregnancy test is done; if it is positive, ectopic pregnancy is assumed until excluded by ultrasonography or, if ultrasonography is indeterminate, by other tests (see Abnormalities of Pregnancy: Diagnosis). Other tests are determined by 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. Pelvic masses are evaluated (see Approach to the Gynecologic Patient: Evaluation). If the cause of severe or persistent pain remains unidentified, laparoscopy is done.
Treatment
The underlying disorder is treated when possible. Pain is initially treated with oral 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 trigger point injection. For patients with intractable pain due to dysmenorrhea or some other disorders, uterosacral nerve ablation or presacral neurectomy can be tried. If all measures are ineffective, hysterectomy can be done, but it may be ineffective or even worsen the pain.
Last full review/revision November 2005
Content last modified January 2007
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