Pelvic pain is a common complaint. It may originate in pelvic or extrapelvic organs, or it may be secondary to a systemic disease. Sometimes no cause is found.

Pelvic pain may be due to a surgical emergency (eg, ovarian cyst torsion, ectopic pregnancy, ruptured tubo-ovarian abscess, appendicitis, bowel perforation). Chronic pelvic pain (lasting >= 6 mo) may require surgical intervention and can be debilitating.

Diagnosis

Categorizing pain as cyclic or noncyclic may help determine the cause. However, disorders causing cyclic pain occasionally cause noncyclic pain, and vice versa.

History: A thorough history--including the type, location, radiation, status (stable or increasing or decreasing in severity), and onset (circumstances and suddenness) of the pain--can help identify the cause (see Table 237-1). The patient should be asked if any factors exacerbate or alleviate the pain and if the pain is related to menses, movement, micturition, defecation, sexual activity, sleep, or eating.

The history should include past surgical procedures and episodes of pelvic inflammatory disease. The patient should be asked about past treatment of the pain and its effectiveness. A detailed menstrual history (including time of menarche, cycle regularity and length, duration of menses, and amount of blood loss) should be obtained. Whether the pain began with menarche or is relatively new should be determined.

Physical examination: General observation may be diagnostically helpful; eg, poor posture and ambulation difficulties suggest a musculoskeletal cause.

The abdomen is examined for tenderness or masses. If a painful area is found, the patient should be asked whether this pain is the same as the primary complaint.

Pelvic examination: Examination of the introitus includes culture of a specimen obtained with a cotton swab to identify agents (eg, Candida sp) responsible for vulvar pain syndromes, including vulvar vestibulitis, a cause of dyspareunia. A sequential one-finger vaginal examination of the bladder, urethra, cervix, fornices, rectum, and levator muscles can help differentiate pelvic pain from lower abdominal muscular pain. Bladder and urethral pain, associated with such disorders as interstitial cystitis, can be elicited when the anterior vaginal wall is palpated. Levator spasm is present if pain is felt when the levator muscles behind the posterior vaginal wall are palpated. Assessment of cervical motion tenderness, vaginal fornix pain, and adnexal tenderness can help differentiate pelvic inflammatory disease or endometriosis from adhesions.

During bimanual examination, uterine size, tenderness, and mobility are evaluated. A markedly enlarged, bulky uterus suggests fibroids; a mildly enlarged, boggy, symmetric uterus suggests adenomyosis. Fixation of the uterus may indicate adhesions or endometriosis. Uterosacral nodularity (confirmed by a rectal examination) suggests endometriosis. A rectal examination should always be performed, and the stool should be tested for occult blood.

Special procedures: Laboratory tests are of limited use in evaluating patients with pelvic pain. A serum or urine pregnancy test should be performed. For patients with bleeding, measuring Hb or Hct identifies anemia. Measuring ESR or C-reactive protein may help identify an inflammatory or infectious process.

Ultrasonography may help if a physical examination is difficult (eg, if the patient has pain) or if an adnexal mass is suspected. However, inconclusive ultrasound results may further confuse the diagnosis, resulting in additional tests and/or unnecessary surgery.

Diagnostic laparoscopy is appropriate if a patient has severe pain and the diagnosis is unclear, if pathology is suspected on the basis of the history and physical examination, or if a patient does not respond or responds poorly to medical therapy (eg, oral contraceptives, NSAIDs). Laparoscopy can confirm the diagnosis and provide histologic documentation. It can also confirm that there is no anatomic abnormality of the pelvic or abdominal organs.

Treatment

Because there are so many causes of pelvic pain and some are serious conditions, we recommend strongly that you Ask the Doctor about this conditions.