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Pelvic pain is a common presentation in women and can be acute or chronic. Acute pelvic pain is typically described as less than three months in duration, whereas chronic pelvic pain is usually described as lasting over six months.

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It is essential to explore the pain fully, delineating the location, onset and character of the pain. Radiation of the pain can give clues as to the organ of origin, and exacerbating and relieving factors can help the clinician narrow down a diagnosis.

Clinical examination of pelvic pain

Clinical examination in pelvic pain will involve abdominal palpation, pinpointing the site of pain, any abdominal guarding and any palpable masses. A bimanual examination may be required, checking for cervical excitation, a sign of acute inflammation, and any adnexal masses. A speculum examination is also indicated where there are symptoms or signs of vaginal infection or cervical pathology.

It is imperative to perform a pregnancy test in all women of childbearing age who present with acute pelvic pain, as a number of pregnancy-related conditions, including emergency conditions such as ectopic pregnancy, can present with acute pelvic pain. Ectopic pregnancy typically presents as one-sided pain, associated with a positive pregnancy test. These cases require urgent referral to secondary care. Other emergency scenarios include ovarian torsion and non-gynaecological causes such as appendicitis.

Causes of pelvic pain

One of the most common causes of acute pelvic pain in women under 25 is pelvic inflammatory disease (PID). This is an ascending inflammation of the reproductive tract, typically caused by vaginal infections such as chlamydia and gonorrhoea. There may be a vaginal discharge, and the patient may complain of intermenstrual or post-coital bleeding. There will usually be a history of recent unprotected intercourse.

PID can be diagnosed clinically in the presence of a typical history and examination findings such as cervical excitation. Where PID is suspected, appropriate vaginal swabs should be obtained, but this should not delay treatment with empirical antibiotics.

Urinary causes of acute pelvic pain include urinary tract infection, cystitis and pyelonephritis. The presence of urinary symptoms such as dysuria, urinary frequency or flank pain should prompt urinalysis, and if positive, urine culture. Again, urinary tract infection is a clinical diagnosis, and treatment should not be delayed pending culture results.

Pelvic pain and endometriosis

Chronic pelvic pain is often associated with the menstrual cycle, so it is important to query if the pain is cyclical. Cyclical pain is often due to endometriosis. This is due to ectopic endometrial tissue out with the uterus, which bleeds with every period. The presence of blood in the pelvis triggers an inflammatory reaction and causes pain. Endometriosis may also cause bladder and bowel symptoms.

Endometriosis can only be definitively diagnosed via diagnostic laparoscopy; however, a trial of therapy should be considered before referral to surgery. Management of endometriosis is typically with contraceptives that aim to reduce menstruation.

Other considerations

Chronic pelvic pain often has a significant psychological element, particularly where a specific diagnosis cannot be established. Women with chronic pelvic pain may respond to non-medical therapies such as physiotherapy, exercise therapy, dietary changes, and in some cases, psychological counselling.

Pelvic pain is a common presentation in women in primary care, therefore it is important to be able to form a differential diagnosis and, in some cases, commence treatment right away.

Dr Samantha Miller, MBChB

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References

1. Royal College of Obstetricians and Gynaecologists (2012). The Initial Management of Chronic Pelvic Pain. Green Top Guideline No. 41. Available at: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_41.pdf
2. Australian Family Physician (2015). Management of persistent pelvic pain in girls and women. Available at: https://www.racgp.org.au/afp/2015/july/management-of-persistent-pelvic-pain-in-girls-and-women/
3. American Family Physician (2010). Evaluation of Acute Pelvic Pain in Women. Available at: https://www.aafp.org/afp/2010/0715/p141.html
4. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Australian STI Management Guidelines for use in primary care. Pelvic Inflammatory Disease (PID). Available at: https://sti.guidelines.org.au/syndromes/pelvic-inflammatory-diseases-pid/
5. National Institute of Clinical Excellence (NICE) (2021). Ectopic pregnancy and miscarriage: diagnosis and initial management. Available at: https://www.nice.org.uk/guidance/ng126
6. National Institute of Clinical Excellence (NICE) (2017). Endometriosis: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng73