Pelvic Pain - Female
Pelvic pain is a common primary care complaint that should be distinguished as acute (<6 months) versus chronic (>6 months), and cyclic, noncyclic, or pregnancy-related. Gynecologic, urologic, and intestinal etiologies are common, but psychological, oncologic, and other causes must also be carefully considered.
Differential Diagnosis
Acute pain (<6 months)
-
Pregnancy-related
–Ectopic pregnancy
–Threatened abortion
–Incomplete abortion
–Septic abortion
–Ruptured corpus luteal cyst
-
Gynecologic (noncyclic)
–Ovarian cyst
–Pelvic inflammatory disease
–Tubo-ovarian abscess
–Vaginitis/cervicitis
–Ovarian torsion
–Uterine fibroids
–Pelvic (ovarian, uterine, urinary) neoplasm
–Pelvic floor prolapse (cystocele/rectocele)
-
Gynecologic (cyclic pain)
–Primary dysmenorrhea
–Endometriosis
–IUD
–Mittelschmerz (midcycle ovulation) -
Nongynecologic
–Irritable bowel syndrome
–UTI/pyelonephritis
–Nephrolithiasis
–Appendicitis
–Diverticulitis
–Sexual abuse/trauma
–Abdominal aortic aneurysm
–Mesenteric ischemia/infarction
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Chronic pain (>6 months) -
Very difficult to diagnose; differential includes gynecologic and nongynecologic etiologies (above), as well as the following
–Pelvic adhesions
–Interstitial cystitis
–Inflammatory bowel disease
–Adenomyosis
–Leiomyoma (fibroids)
–Hernia (femoral or inguinal)
–Depression
–Irritable bowel syndrome
–Diverticulosis or diverticular abscess
–Lymphoma
-
Less common etiologies (“zebras”) include pelvic congestion syndrome, mesenteric adenitis, surgical adhesions, Asherman's syndrome, foreign body (e.g., tampon), abdominal wall nerve entrapment, and porphyria
Workup and Diagnosis
- History and physical examination
–Note the nature, severity, onset, radiation, duration of pain; relation to menstrual cycle, intercourse, or other activities; chronic versus acute; chance of pregnancy
–Note associated symptoms: Fever, nausea, vomiting, dysuria, frequency, vaginal bleeding/discharge, abdominal or back pain
–Screen for domestic violence and sexual abuse
–Full abdominal and pelvic exams, including speculum, bimanual, and rectal exam
-
Laboratory studies may include urine pregnancy test, urinalysis, urine Gram stain and culture, cervical cultures for Chlamydia and gonorrhea, and wet mount of vaginal smear
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Consider ultrasound if ovarian cyst, torsion, or mass is suspected, or to evaluate for intrauterine versus ectopic pregnancy
-
Diagnostic laparoscopy for acute abdomen or endometriosis
Treatment
-
Primary dysmenorrhea: NSAIDs; consider oral contraceptives to suppress ovulation in severe disease
-
Positive pregnancy test: Determine last menstrual period; obtain quantitative β-hCG; confirm intrauterine pregnancy
-
In patients at high risk for STDs, treat empirically for PID (to cover gonorrhea and Chlamydia)
–Ofloxacin 400 mg PO BID for 14 days plus metronidazole 500 mg PO BID for 14 days, or
–Ceftriaxone 250 mg IM single dose plus doxycycline 100 mg PO BID for 14 days
-
Endometriosis: Treat with hormonal medications or surgical
laparoscopy
–Oral contraceptives for 3–4 months, or
–Provera 39 mg QD for 2 months, or
–Danazol 200–800 mg QD for 6 months, or
–GnRH agonist (e.g., leuprolide)
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Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
Other Book Chapters Related to Pain
Read excerpts from these other book chapters related to Pain:
Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Pain
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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