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 the menstrual cycle). In others, pain is a 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

• Ovarian 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 degenerate.

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

• Gastrointestinal (eg, tumors, constipation, inflammatory bowel disease, high perirectal abscess)

• Urinary (eg, cystitis, interstitial cystitis, calculi)

• Musculoskeletal (eg, myofascial pain, abdominal muscle strains)

• Vascular (rapid expansion or rupture of aortic aneurysm)

History of present illness should include onset, duration, location, severity, and character of pain. 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 include the following:

• Amenorrhea, morning sickness, or breast swelling or tenderness: Pregnancy

• Fever, chills, or vaginal discharge: Infection

• Abdominal pain, 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. Rectal examination is done to check for tenderness, masses, and occult blood. Location of pain and any associated findings may provide clues to the cause (see table Some Clues to Diagnosis of Pelvic Pain).

Pelvic examination includes inspection of external genitals, speculum examination, and bimanual examination. The cervix is inspected for discharge or lesions. Bimanual examination should assess cervical motion tenderness, adnexal masses or tenderness, and uterine enlargement or tenderness. If ectopic pregnancy is suspected, pressure should not be applied to an adnexal mass because pressure may cause rupture.

The following findings are of particular concern:

• Syncope or hemorrhagic shock (eg, tachycardia, hypotension)

• Peritoneal signs (rebound, rigidity, guarding)

• Postmenopausal vaginal bleeding

• Fever or chills

• Sudden severe pain with nausea, vomiting, or diaphoresis

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). Quality 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.

All patients with pelvic pain should have

• Pregnancy test

• Urinalysis

If a patient is pregnant and has pain or bleeding, ectopic pregnancy is assumed until excluded by ultrasonography or, if ultrasonography is unclear, by other tests. If a suspected pregnancy may be < 5 weeks, a serum pregnancy test should be done; a urine pregnancy test may not be sensitive enough to rule out pregnancy that early in gestation. If urinary symptoms are present, urinalysis is a fast, simple test done to rule out many common causes of pelvic pain (eg, cystitis, urinary calculi).

Other testing depends on which disorders are clinically suspected. If a patient cannot be adequately examined (eg, because of pain) or if a mass is suspected, pelvic ultrasonography is done. If the cause of severe or persistent pain remains unidentified and a serious cause (eg, ruptured ectopic pregnancy, peritonitis) is suspected, laparoscopy or laparotomy may be done.

Transvaginal pelvic ultrasonography can be a useful adjunct to pelvic examination; it can better define a mass or help diagnose a pregnancy after 5 weeks gestation (ie, 1 week after a missed menstrual period). For example, a positive pregnancy test plus no evidence of an intrauterine pregnancy support a diagnosis of ectopic pregnancy.