Pelvic Pain

Pelvic pain in women can be due to gynecological or obstetric reasons. A thorough history is obtained which addresses the location, onset and duration, character, and prior history of the pain. The presence of vaginal discharge or bleeding or recent history of dysmenorrhea can be due to a pelvic pathology. For example, purulent vaginal discharge can suggest a STI, while cramping and vaginal bleeding can be suggestive of ectopic pregnancy or threatened abortion. The gynecological history includes the date of the last menstrual period, menstrual pattern, current contraception use, history of STDs, sexual history, cervical cancer screening results, and outcomes of prior pregnancies. Along with a gynecological history, a past medical and surgical history can also be useful. For example, a woman with a history of pelvic organ surgery, pelvic inflammatory disease, or prior ectopic pregnancy can be risk factors for an ectopic pregnancy; a history of abdominal surgery can increase the risk of bowel obstruction. Lastly, social history may also be important, especially if there is a risk of substance abuse, history of domestic violence, and/or high-risk behavior.

After obtaining a history, a physical examination will be performed especially a pelvic examination for any women that presents with pelvic pain. A pelvic examination consists of an external genitalia inspection, speculum exam, and bimanual examination. In speculum examination, visual examination of vaginal walls and presence of discharge can be assessed. It can be determined if there is cervical motion tenderness by opening the blades of the speculum. Significant tenderness usually implies there is pelvic inflammation present most likely pelvic inflammatory disease, but can also be due to acute appendicitis and ectopic pregnancy. In bimanual examination, the size and symmetry of uterus and tenderness is determined. A symmetrical enlargement suggests pregnancy or adenomyosis but asymmetrical enlargement would suggest leiomyomas or adnexal masses adherent to the uterus. A fixed and painful adnexal mass could be suggestive of endometrioma or tubovarian abscess.

In pelvic pain, all women with a sexual history will be evaluated for pregnancy. Other tests that might be conducted are a complete blood count with differential, urinalysis with culture especially if urinalysis shows hematuria or pyuria, and nucleic acid amplification tests for chlamydia and gonococcus. Women with pelvic pain might also undergo an ultrasound examination. An abdominal/pelvic CT and/or MRI can also be used for further evaluation. In pregnant women, imagining modalities that do not use ionizing radiation, such as ultrasound and MRI are preferred. Laproscopy might be indicated in acute pelvic pain if diagnosis is unclear after less invasive tests.

Chronic pelvic pain is pain below the umbilicus that lasts for 6 months or longer. Causes of chronic pelvic pain can be due to but not limited to many gynecological and obstetric reasons. Endometriosis can be a cause where endometrial tissue can be present outside the uterus. Pelvic inflammatory disease is an acute infection most likely due to a sexually transmitted organism which can involve the uterus, ovaries, and fallopian tubes. Pelvic adhesive disease refers to abnormal tissue that can cause internal organs like ovaries and fallopian tubes to adhere to one another, adhesions can be due to abnormal reactions to surgery, infection, or inflammation. Painful bladder syndrome and interstitial cystitis is not caused by infection and symptoms include urgency, frequency and can present as abdominal and pelvic pain. Irritable bowel syndrome is a GI condition that can cause abdominal pain, which can be mistaken for pelvic pain. Diverticulitis is caused by inflammation of the diverticulum, which usually causes abdominal pain, nausea, vomiting, diarrhea, and urinary symptoms and most often causes acute abdominopelvic pain. Pelvic floor pain includes symptoms of pelvic pain, pain with urination, difficult urinating, constipation, pain with intercourse, or frequent/urgent urination; it can be diagnosed by feeling the pelvic floor muscles through the vagina and rectum and if they feel tight, tender, or band like it can indicate that pelvic floor dysfunction could be the cause of the pelvic pain.