Pelvic pain (females)
Pelvic pain in females is a common presentation to the ED. Causes can be divided into Pregnancy related; Gynaecological and Non-gynaecological.
Pelvic pain in females is a common presentation to the ED.
Causes are legion, but can be thought of as:
- Pregnancy related
- Gynaecological
- Non-gynaecological.
The most important consideration in women of child bearing age will be to rule out pregnancy and specifically ectopic pregnancy.
Imaging involves ultrasound and CT scan with contrast if ultrasound is inconclusive
Ultimately laparoscopy may be required.
Definitive diagnosis is frequently not possible in the ED and assessment necessarily involves ruling out immediately serious / life-threatening conditions, managing pain and formulating an appropriate disposition plan.
See also separate documents on:
- Ovarian Torsion (in O&G folder)
- Ectopic Pregnancy (in O&G folder)
- PID (in O&G folder)
- Dysmenorrhea (in O&G folder)
Aetiology
Pelvic pain in women can be thought of in 3 categories:
- Pregnancy related
- Gynaecological related.
- Non-gynaecological related.
Pain may additionally be:
- Acute
- Chronic:
- Usually defined as pain pelvic pain persisting for 6 months.
- Acute on chronic
- Cyclic
Pregnancy related:
Early < 20 weeks:
- Ectopic
- Abortion
Late > 20 weeks:
- Abruption (or accidental) haemorrhage
- Premature Labour
- Round ligament pain
Gynaecological related:
- PID
- Mittelschmerz i.e. mid-cycle or ovulation pain
- Endometriosis / adenomyosis:
- Endometriosis is a common, chronic gynaecological condition defined as the presence of functional endometrial glands and stroma-like lesions outside the uterus.
It manifests in 3 ways:- Superficial (peritoneal) disease
- Ovarian disease (endometriomas)
- Deep infiltrating endometriosis.
- Adenomyosis is ectopic endometrial tissue within the myometrium, and is considered a subset of endometriosis.
- Endometriosis is a common, chronic gynaecological condition defined as the presence of functional endometrial glands and stroma-like lesions outside the uterus.
- Fibroids, (leiomyoma):
- Fibroids are responsive to hormones (e.g. stimulated by oestrogens).
- They are rare in prepubertal females
- They commonly accelerate in growth during pregnancy
- They tend to involute with menopause.
- They can degenerate, resulting in pain.
- Most commonly this will be due to hyaline degeneration. This happens when fibroids outgrow their blood supply.
- Hyaline degeneration involves the presence of homogeneous eosinophilic bands or plaques in the extracellular space, which represent the accumulation of proteinaceous tissue.
- Pedunculated serosal fibroids can also cause pain if they undergo torsion.
- Pelvic vascular:
- Pelvic venous thrombosis
- Pelvic congestion syndrome:
- This is a condition that results from retrograde flow through incompetent valves in ovarian veins.
- It is a commonly missed and potentially-treatable cause of chronic abdominopelvic pain.
- It can be a cause of chronic pelvic pain, predominantly in multiparous, premenopausal women.
- Ovarian cyst pathology:
- Torsion (May be intermittent, unilateral, lead to necrosis)
- Haemorrhage (Usually unilateral signs)
- Infection (Tubo-ovarian abscess)
- Necrosis (Usually unilateral signs)
- Rupture (Often bilateral signs)
- Incarceration
- Malignancy
Non-gynaecological related:
- Adhesions from previous surgery.
- GIT
- Appendicitis.
- Irritable bowel syndrome.
- Diverticulitis
- Inflammatory bowel disorders.
- Inguinal / femoral hernias
- Urinary Tract
- UTI
- Renal colic with stones at or near the VUJ.
- Urinary retention.
- Musculoskeletal
- Psychogenic:
- Psychosomatic:
- There is an association between chronic pelvic pain and somatization disorders.
- Additionally, many women with chronic pelvic pain have suffered physical, sexual and emotional abuse or have other concomitant psychiatric illnesses.
- Psychosomatic:
- Munchausen’s syndrome
Clinical Assessment
Important points of history:
1. Is the patient pregnant?
The most important consideration in women of child bearing age will be to rule out pregnancy and specifically ectopic pregnancy.
2. Nature of the pain:
Acuteness of onset:
- Gynecologically acute onset may suggest:
- Ovarian cyst rupture
- Ovarian cyst bleed
- Torsion of an ovary
- Rupture of an ectopic pregnancy
- For non-gynaecological causes consider:
- Ruptured appendix.
Severe /unrelenting pain:
- The pain is severe, unrelenting and / or difficult to control even with adequate analgesia.
- From the gynecological perspective this can often be a sign of:
- Ruptured ectopic pregnancy.
- Ovarian torsion
- Tubo-ovarian abscess
- A bleed into an ovarian cyst.
Is the pain subacute, chronic?
- Endometriosis / adenomyosis.
- Adhesions:
- These are associated with previous abdominal/pelvic surgery/ PID/ IBD/ perforated appendix endometriosis.
- PID (chronic)
- Pelvic congestion syndrome.
- Psychogenic
Is the pain cyclical?
- Dysmenorrhoea
- Mittelschmerz
- Endometriosis (in women of reproductive age).
- Adenomyosis
- IUDs
- Fibroids.
3. Does the patient have risk factors for PID?
- Sexual history
- Recent pelvic instrumentation
4. Dyspareunia:
- PID
- Endometriosis
5. Past history
6. Are there any psycho-social stresses?
Important points on examination:
Indicators for a potentially serious / urgent problem on examination include:
- Abnormal vital signs:
- Tachycardia, hypotension, fever, tachypnea or looks unwell in general.
- Signs of abdominal or pelvic “peritonism”.
- Guarding
- Rigidity
- PV examination:
- “Cervical excitation” on PV bimanual palpation of cervix, indicates inflammation
- A bulky uterus may indicate fibroids.
- Exclude inguinal/ femoral hernias
- Rectal examination: If considered necessary, this should only be performed once, and preferably by the doctor with ongoing clinical care. 1
Investigations
These will be guided by the degree of clinical suspicion for any given condition
The following should be considered:
Blood Tests
- FBE
- CRP: if an inflammatory / infective process is being considered.
- Beta HCG:
- Should be done in any female of child bearing age with pelvic pain.
Urine
- FWT: especially for nitrites and white cells if UTI is suspected.
- MSU: for M&C if UTI is suspected.
Vaginal and Cervical Swabs
Swabs for N. gonorrhoeae or C. trachomatis will need to be done if PID is suspected.
Viral swabs re taken for suspected herpes infections.
Ultrasound
Ultrasound is virtually a non-invasive extension of the physical examination, in the female patient with pelvic pain. 1
Ultrasound is first line investigation for:
- Pregnancy related causes, (in particular ectopic pregnancy).
- Gynaecological related causes, in particular:
- Ovarian torsion
- Tubo-ovarian abscess
- Bleed into an ovarian cyst
- Rupture of an ovarian cyst
Ultrasound may also be useful in cases of suspected appendicitis.
CT scan pelvis and abdomen
This may be required to help rule out other non-gynecological related problems or complicated or complex gynaecological related problems.
CT with contrast is a more sensitive imaging modality than ultrasound for ovarian torsion, however, the risk of radiation to a young female however must always be weighed against the possible benefits of the examination.
MRI
MRI has the advantage over CT of avoiding radiation and contrast exposure.
Pelvic MRI is the modality of choice to diagnose and characterise endometriosis and adenomyosis.
Laparoscopy
Ultimately laparoscopy may be necessary to determine the cause of pelvic pain in both the acute and chronic settings.
Management
Management will depend on the cause of the pelvic pain.
It will also be guided by the degree of clinical suspicion for any given condition, when the diagnosis is uncertain.
The important issues will include:
- Initial resuscitation
- Analgesia
- Ruling out pregnancy
- The extent of investigation required in the ED
- An adequate period of observation in the ED, when the diagnosis is unclear
- A decision on whether admission is necessary.
- A decision on disposition, when discharge from the ED is appropriate
Disposition
Indications for admission:
These include:
- Patients requiring resuscitation.
- Confirmed or suspicion of serious pathology, (such as ruptured ectopic pregnancy).
- Intractable pain
- Uncertain diagnosis, where ongoing observation is warranted, especially in the presence of abnormal vital signs, or abnormal but non-diagnostic investigation results.
- Threshold should be low for patients in late pregnancy
Discharge: Patients who are well, and have had other serious pathology ruled out may be discharged with analgesics and have an US as an outpatient with GP or Gynecology outpatients review as appropriate.
References
FOAMed
Publications
Fellowship Notes
Doctor at King Edward Memorial Hospital in Western Australia. Graduated from Curtin University in 2023 with a Bachelor of Medicine, Bachelor of Surgery. I am passionate about Obstetrics and Gynaecology, with a special interest in rural health care.
Physician in training. German translator and lover of medical history.