Gynecology Topic 37. Pelvic pain

I. Pelvic Pain

Definition

• Pelvic pain: Pain or discomfort in the lower abdomen/pelvis, originating from gynecologic, urinary, gastrointestinal, musculoskeletal, vascular, neurologic or psychosocial causes.
• Acute pelvic pain: Sudden or recent pelvic pain, usually < 3 months.
• Chronic pelvic pain (CPP): Non-cyclic pelvic pain lasting ≥ 6 months and affecting function/quality of life.

Red Flags

• Syncope, tachycardia, hypotension or hemorrhagic shock.
• Peritoneal signs: Guarding, rebound tenderness, rigid abdomen, absent bowel sounds.
• Positive pregnancy test or possible pregnancy.
• Postmenopausal vaginal bleeding.
• Fever, chills or sepsis signs.
• Sudden severe pain with nausea, vomiting, diaphoresis or agitation.
• Palpable pelvic/adnexal mass, ascites or suspected malignancy.

II. Acute Pelvic Pain

Gynecological Causes

• PID / endometritis / salpingitis → Bilateral pain, fever, purulent discharge, cervical motion tenderness.
• Ovarian cyst rupture/bleeding → Sudden pain, possible hemoperitoneum.
• Ovarian/adnexal torsion → Sudden severe unilateral pain, nausea/vomiting; gynecologic emergency.
• Ectopic pregnancy → Delayed menses, vaginal bleeding, unilateral pain; rupture causes shock.
• Abortion → Crampy lower abdominal pain + vaginal bleeding in pregnancy.
• Degenerating leiomyoma → Acute pain, AUB, fever/leukocytosis may occur.

Non-Gynecological Causes

• GI: Appendicitis, diverticulitis, mechanical ileus/bowel obstruction, bowel ischemia, IBD flare, IBS.
• Urinary: Acute cystitis, pyelonephritis, kidney stone/urolithiasis.
• Vascular/CV: Aortic aneurysm/dissection, pelvic vessel thrombosis.
• Musculoskeletal: Abdominal wall strain, hernia, pelvic floor pain.
• Psychogenic: Somatization/anxiety only after organic emergencies are excluded.

Initial Work-Up

1. Assess stability: Vitals, shock signs, peritoneal signs → Resuscitate and call surgery/gynecology if unstable.
2. History: LMP, pregnancy possibility, contraception/IUD, bleeding, discharge, fever, urinary/GI symptoms, sexual history, previous PID/surgery/endometriosis.
3. Physical examination: Abdomen, speculum examination, bimanual examination, cervical motion/adnexal/uterine tenderness.
4. Pregnancy test: Urine or serum beta-hCG in all reproductive-age women.
5. Laboratory tests: CBC, CRP, urinalysis/urine culture, blood group/crossmatch if bleeding, STI NAAT if indicated.
6. Imaging: Transvaginal + abdominal pelvic US first-line.
7. Further imaging: CT/MRI if US is inconclusive or GI/urinary/vascular cause is suspected.
8. Laparoscopy: Diagnostic and therapeutic if torsion, ectopic pregnancy, ruptured cyst, severe PID/abscess or unclear surgical abdomen is suspected.

III. Chronic Pelvic Pain

Gynecological Causes

• Endometriosis: Chronic/cyclic pain, dysmenorrhea, dyspareunia, dyschezia, infertility.
• Adenomyosis: Dysmenorrhea, menorrhagia, enlarged globular uterus.
• Chronic PID / pelvic adhesions: Chronic pain, dyspareunia, infertility, ectopic pregnancy risk.
• Ovarian cysts / endometrioma: Adnexal mass, pressure, intermittent pain.
• Leiomyoma: Heavy bleeding, bulk symptoms, pelvic pressure/pain.
• Pelvic organ prolapse: Vaginal fullness, pressure, urinary/rectal symptoms.

Non-Gynecological Causes

• GI: Diverticulitis, IBD, IBS, celiac disease, colorectal cancer, chronic constipation.
• Urinary: Interstitial cystitis/bladder pain syndrome, bladder cancer, recurrent cystitis/urolithiasis.
• MSK: Pelvic floor myalgia, abdominal/inguinal hernia, abdominal wall pain.
• Neurological: Pudendal neuralgia, nerve entrapment.
• Psychosocial: Depression, anxiety, somatization, history of abuse/trauma.

Work-Up

1. Detailed history: Pain onset, duration, cyclicity, relation to menses/sex/urination/defecation, prior treatments and surgeries.
2. Map gynecologic, urinary, GI, musculoskeletal, neurologic and psychosocial symptoms.
3. Physical examination: Abdomen, pelvic examination, pelvic floor tenderness, back/hip/hernia examination.
4. Basic tests according to suspicion: Pregnancy test, CBC/CRP, urinalysis/culture, vaginal/cervical microbiology.
5. Imaging: Transvaginal US first-line; MRI for adenomyosis/deep endometriosis/complex masses; CT if GI/urinary cause is suspected.
6. Laparoscopy: When non-invasive evaluation is inconclusive or endometriosis/adhesions need diagnosis/treatment.
7. Refer according to dominant symptoms: Gynecology, urology, gastroenterology, pain specialist, physiotherapy, psychology/psychiatry.

IV. General Management

Principles

• Treat the underlying cause: antibiotics, hormonal suppression, surgery, GI/urinary/MSK treatment as indicated.
• Unstable patient or surgical abdomen → ABC, IV access, fluids/blood, analgesia, urgent gynecologic/surgical management.
• Stable patient → analgesia ± antiemetics, then targeted treatment according to diagnosis.
• NSAIDs are useful for many gynecologic causes if not contraindicated.
• Do not delay empiric PID treatment when clinical suspicion is high.
• Cyclic gynecologic pain/endometriosis suspicion → combined OCP, progestin or LNG-IUD; surgery if indicated.
• Chronic/multifactorial pain → multidisciplinary care, pelvic floor physiotherapy, psychology/pain support when needed.
• Emergency signs or malignancy signs → investigate urgently, not as functional pain.