Pelvic pain is discomfort that occurs in the lowest part of the abdomen. Pain that occurs externally in the genital area (vulva, or labia) is called vulvar pain. Many women have pelvic pain. Pain is considered chronic if it continues to occur for more than 3 to 6 months.
Pelvic pain can be a gynecologic symptom. That is, it can result from a problem affecting the female reproductive system. Or it may be caused by problems in the urinary, digestive, or musculoskeletal system.
The pain may start suddenly or gradually. The pain may gradually increase in intensity, sometimes occurring in waves. It may be constant or come and go. It may be sharp or dull or crampy (like menstrual cramps), or some combination.
The pelvic area may feel tender if touched. Depending on the cause, women may have bleeding or a discharge from the vagina. The pain may also be accompanied by fever, nausea, vomiting, and/or light-headedness.
Causes of Pelvic Pain
Pelvic pain is often related to the menstrual cycle or common gynecologic issues. However, several disorders that cause pelvic pain can lead to peritonitis (inflammation and usually infection of the abdominal cavity), which is a serious disorder.
Disorders that can cause pelvic pain include
Gynecologic disorders—those that affect the reproductive organs (vagina, cervix, uterus, fallopian tubes, and ovaries)
Disorders that affect other organs in the pelvis, such as the bladder, lower part of the ureters, urethra, rectum, appendix, or pelvic floor (the muscles, ligaments, and tissues that support the organs of the pelvis)
Disorders that affect structures near but outside the pelvis, such as the abdominal wall, intestine, kidneys, or upper part of the ureters
Often, it is difficult for doctors to identify what is causing pelvic pain.
Gynecologic disorders
Gynecologic disorders may be related to the menstrual cycle or not.
Overall, the most common gynecologic causes of pelvic pain include
Menstrual cramps (dysmenorrhea)
Endometriosis (abnormally located patches of tissue that is normally located only in the lining of the uterus)
Ovarian cysts
Fibroids in the uterus are noncancerous tumors composed of muscle and fibrous tissue. They can cause pelvic pain if they put pressure on other organs, are degenerating, or cause excessive bleeding or cramping. Most uterine fibroids do not cause pain.
Many other gynecologic disorders can cause pelvic pain (see table Some Gynecologic Causes of Pelvic Pain).
Other disorders
Other causes of pelvic pain include
Digestive tract disorders: Gastroenteritis, constipation, diverticulitis, irritable bowel syndrome, inflammatory bowel disease, collections of pus (abscesses), and tumors (cancerous or not), such as colon cancer
Urinary disorders: Urinary tract infections, kidney stones that have passed into the lower urinary tract, and inflammation of the bladder without infection (such as interstitial cystitis)
Musculoskeletal disorders: Fibromyalgia or chronic myofascial pain (pain that is caused by tension and tenderness in areas of muscle called trigger points)
Psychologic factors, especially stress and depression, may contribute to any kind of pain, including pelvic pain, but, by themselves, rarely cause pelvic pain. Women or girls that have had sexual trauma may develop chronic pelvic pain.
Evaluation of Pelvic Pain
Usually, pelvic pain is not an emergency, but when a woman has new, sudden, very severe pain in the lower abdomen or pelvis, medical attention should be sought as soon as possible. Sometimes, emergency surgery is required. Disorders that usually require emergency surgery include
A ruptured ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus)
Twisting of an ovary (adnexal torsion)
A ruptured abscess in the pelvis
A tear in the intestine
Doctors check for pregnancy in all girls and women of childbearing age.
Warning signs
In women with pelvic pain, certain symptoms are cause for concern:
Light-headedness or sudden loss of consciousness (fainting, or syncope), however brief
Dangerously low blood pressure (shock)
Sudden, severe pain, especially when accompanied by nausea, vomiting, excessive sweating, or agitation
Fever or chills
Vaginal bleeding after menopause
When to see a doctor
Women with most warning signs should see a doctor immediately.
Women may need to be seen the same day or within a few days if they have
Vaginal bleeding after menopause
Pain that is constant or steadily worsening
If women have new pain that is not constant and is not worsening or if they have pain that is recurring or chronic, they should schedule a visit when practical, but a delay of several days is usually not harmful.
Mild menstrual cramps are normal. Menstrual cramps do not require evaluation unless they are very painful.
What the doctor does
The doctor does a quick evaluation to see if emergency treatment is needed. Doctors ask the woman questions about her symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see table Some Gynecologic Causes of Pelvic Pain).
Doctors ask about the pain:
Whether it begins suddenly or gradually
Whether it is sharp or dull
How severe it is
When it occurs in relation to the menstrual cycle, eating, sleeping, sexual intercourse, physical activity, urination, and bowel movements
Whether any other factors worsen or ease the pain
The woman is asked about other symptoms, such as vaginal bleeding, a discharge, and light-headedness.
The woman is asked to describe past pregnancies and menstrual periods. Doctors also ask whether she has had any disorders that can cause pelvic pain and whether she has had abdominal or pelvic surgery.
Doctors may ask about stress, depression, and other psychologic factors to determine whether these factors may be contributing to the pain, especially if the pain is chronic.
Certain groups of symptoms that accompany pelvic pain suggest a type of medical condition. For example,
Fever and chills suggest an infection.
A vaginal discharge suggests an infection, such as pelvic inflammatory disease.
Abdominal pain, a change in bowel movements, or rectal bleeding suggests a digestive tract disorder.
Vaginal bleeding during pregnancy suggests an ectopic pregnancy or a possible miscarriage.
The physical examination starts with checking vital signs, such as temperature, blood pressure, and pulse. Then doctors focus on the abdomen and pelvis. Doctors gently feel the abdomen and do a pelvic examination. During an examination, the abdomen or other areas may feel tender if touched. This evaluation helps doctors determine which organs are affected and whether an infection is present. Often, doctors also check the rectum for abnormalities.
Testing
The following tests are routinely done:
Urine tests
A pregnancy test if women are of childbearing age
Urinalysis is a simple, fast urine test that is a first step to check for many common causes of pelvic disorders such as a bladder infection or most kidney stones. A urine culture is done if a urinary tract infection is suspected.
A pregnancy test is done if a woman is in her reproductive years. A urine pregnancy test is usually done first. If a very early pregnancy is possible and the urine test is negative, a blood test for pregnancy is done. The blood test is more accurate than the urine test when a pregnancy is less than 5 weeks.
If a woman is pregnant and has pain or vaginal bleeding, ultrasonography is done to rule out an ectopic pregnancy. For ultrasonography, doctors use a handheld ultrasound device that is placed on the abdomen or inside the vagina. Ultrasonography of the pelvis is done for many reasons. It is done whenever doctors think a gynecologic disorder may be the cause of the symptoms and the symptoms have begun suddenly, recur, or are severe.
If results of ultrasonography are unclear, other tests, such as a series of blood tests or laparoscopy, are done to rule out ectopic pregnancy. For the blood tests, doctors measure levels of a hormone produced by the placenta called human chorionic gonadotropin (hCG). If hCG levels are low, the pregnancy may be too early for ultrasonography to detect. If levels are high and ultrasonography does not detect a pregnancy, ectopic pregnancy is possible. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to directly look for an ectopic pregnancy or other causes of pelvic pain.
Tests depend on which disorders are suspected. Tests may include
Urine tests or testing of samples from the vagina or cervix to check for infections that can cause pelvic pain
Ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI) of the abdomen and pelvis to check for masses and tumors
If other tests do not identify the cause of severe or persistent pain and a serious cause (such as a ruptured ectopic pregnancy) is suspected, sometimes laparoscopy or laparotomy
Treatment of Pelvic Pain
If the cause of the pelvic pain is identified, it is treated if possible. Pain related to the menstrual cycle (such as cramps or endometriosis) may be treated with hormonal contraceptives.
If the pain involves muscles, rest, heat, or physical therapy may help.
Rarely, when women have severe pain that persists despite treatment, surgery, such as laparoscopy to treat endometriosis or an ovarian cyst or hysterectomy (surgery to remove the uterus), can be done.
Essentials for Older Women: Pelvic Pain
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. Obviously, disorders related to menstrual periods are no longer possible causes.
Common disorders in older women include
Bladder problems, including infections (urinary tract infection)
Cancers of the reproductive tract, including cancers of the lining of the uterus (endometrial cancer), ovaries, and vulva (labia)
After menopause, estrogen levels decrease, weakening many tissues, including bone, muscles (such as those supporting the bladder), and tissues around the vagina and urethra. As a result, pelvic fractures and bladder infections become more common.
Also, this weakening may contribute to pelvic organ prolapse, which may cause symptoms as women become older. In these disorders, weakened or damaged tissues in the pelvis can no longer hold the uterus, vagina, or other organs in the pelvis in place. As a result, one or more of these organs may drop down (prolapse) and women may feel pressure in the vagina or have urinary incontinence or difficulty having a bowel movement.
Symptoms that affect the vagina and urinary tract after menopause are called the genitourinary syndrome of menopause (formerly called vaginal atrophy or atrophic vaginitis). These symptoms include vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections. This condition may make sexual intercourse painful, and women may describe or experience this pain as pelvic pain.
Evaluation
Evaluation is similar to that for younger women, except doctors pay particular attention to symptoms of urinary and digestive tract disorders that are common in older women. Older women should see a doctor promptly if they
Suddenly lose weight or their appetite
Suddenly start having indigestion
Feel bloated
Have a sudden change in bowel movements
The doctor then does an examination to make sure that the cause is not ovarian or endometrial cancer.
If the vaginal lining is thin in a woman with pelvic pain, doctors ask her questions to determine whether she is sexually active. If so, doctors may recommend a break from sexual intercourse until symptoms subside, or they may prescribe an estrogen cream.
Key Points
Many women have pelvic pain.
Many disorders (related to reproductive organs or other nearby organs) can cause pelvic pain.
Doctors can determine likely causes based on a description of the pain, its relationship to the menstrual cycle, and results of a physical examination.
If women are of childbearing age, a pregnancy test is always done.
Urine tests and usually other tests, such as blood tests and ultrasonography of the pelvis, are done to confirm the suspected diagnosis.
