Pelvic pain is both a common presentation in primary care and one of the most common reasons for referral to a gynaecologist. Pelvic pain may be either acute or chronic.
Acute pelvic pain
Acute pelvic pain is much more common in women than in men. Most women experience mild pelvic pain at some time due to periods, ovulation or sexual intercourse. In its severest form, it is the most common reason for urgent laparoscopic examination in the UK.
- Pregnancy-related: miscarriage, ectopic pregnancy, rupture of corpus luteum cyst; causes in later pregnancy include premature labour, placental abruption and (rarely) uterine rupture.
- Gynaecological: ovulation (mid-cycle, may be severe pain), dysmenorrhoea, PID, rupture or torsion of ovarian cyst, degenerative changes in a fibroid; the possibility of a pelvic tumour or pelvic vein thrombosis should also be considered.
- Other causes: these include appendicitis, irritable bowel syndrome (IBS), adhesions, prostatitis, strangulated hernia.
- Urinalysis, midstream specimen of urine (MSU).
- High vaginal swab (HVS) for bacteria and endocervical swab.
- Pregnancy test.
- Urgent ultrasound (if miscarriage or ectopic pregnancy is suspected).
- Management is based on identifying and treating the cause.
- Empirical use of antibiotics and analgesia without a clear diagnosis should be avoided.
- Referral is required if the diagnosis cannot be established if there is no response to treatment in primary care.
- Urgent admission is necessary if there is a possibility of urgent treatment being required - eg, ectopic pregnancy, appendicitis or if the patient is haemodynamically unstable.
Chronic pelvic pain
Chronic pelvic pain is much more common in women than in men. It may occur in as many as 1 in 6 adult women.
- Chronic pelvic pain is defined as:
- Intermittent or constant pain in the lower abdomen or pelvis in women.
- Lasting for at least six months.
- Not occurring exclusively with menstruation or sexual intercourse.
- Not being associated with pregnancy.
- Chronic pelvic pain is a symptom, not a diagnosis.
- The prevalence of chronic pelvic pain in general practice has been estimated to range between 5.7% and 26.6%.
- The aetiology of chronic pelvic pain is still not well understood.
- There is often more than one cause of the pain.
- The pain may persist long after the original tissue injury has healed.
- Psychological, social and physical factors are all important in the aetiology.
- Persistence of pain may lead to changes within the central nervous system, which magnify the original signal.
- Sensation and perception of pain can be influenced by previous experiences.
- Nerve damage following surgery, trauma, inflammation, fibrosis or infection may play a part in pain perception.
Possible causes of chronic pelvic pain include:
- Pain usually varies during menstrual cycle.
- Can be associated with dysmenorrhoea and dyspareunia.
- May be caused by previous surgery, endometriosis, previous infection.
- Some adhesions are asymptomatic.
- Interstitial cystitis.
- Musculoskeletal problems.
- Pelvic organ prolapse.
- Nerve entrapment:
- This can occur in scar tissue or fascia.
- Psychological and social issues:
- Depression and sleep disorders are common.
- Women with chronic pelvic pain are more likely to have experienced physical or sexual abuse as children.
- Other causes in men include epididymo-orchitis and testicular tumours.
- Chronic pain in the region of the prostate was previously called chronic prostatitis; however, there is a proven bacterial infection in only 10% of these cases. The remaining 90% should now be classified as prostate pain syndrome (PPS), based on the fact that there is no proven infection or other obvious pathology.
- Initial history should include questions about the pattern of the pain and its association with other problems. These may include bladder and bowel symptoms and the effect of movement and posture on the pain.
- Questions should be addressed regarding psychological and social issues.
- Although many symptom complexes (eg, IBS) and pain perception itself may vary a little with the menstrual cycle (50% of women experience a worsening of their symptoms in association with their period), strikingly cyclical pain is usually gynaecological in nature - eg, endometriosis.
- Suggested red flag symptoms and signs:
- Bleeding per rectum.
- New bowel symptoms in patients over 50 years old (see 'Investigations', below).
- New pain after the menopause.
- Pelvic mass.
- Suicidal ideation.
- Excessive weight loss.
- Irregular vaginal bleeding in patients over 40 years old.
- Postcoital bleeding.
NB: women with chronic pelvic pain often present without obvious cause on history, investigations or physical examination.
- Samples to screen for infection (particularly chlamydia and gonorrhoea) should be considered in all those who are sexually active.
- If there is any suspicion of PID. Ideally, all sexually active women below the age of 25 years who are being examined should be offered opportunistic screening for chlamydia.
- Blood tests such as FBC and CRP may be useful for some women.
- Ca125 measurement is appropriate if symptoms suggesting ovarian cancer are experienced. A new diagnosis of IBS in a woman aged over 50 years is suspicious.
- Urinalysis and send MSU.
- Transvaginal scanning (TVS) using ultrasound is an appropriate investigation to screen for and assess adnexal masses.
- TVS and magnetic resonance imaging (MRI) are useful tests to diagnose adenomyosis. The role of MRI in diagnosing small deposits of endometriosis is uncertain.
- Diagnostic laparoscopy has been regarded in the past as the gold standard in the diagnosis of chronic pelvic pain. It may be better seen as a second line of investigation if other therapeutic interventions fail.
- Further urological investigations (eg, cystourethroscopy) and/or bowel investigations (eg, barium enema) may be required.
Management is focused on identifying and treating the cause but the psychosocial causes and effects of chronic pelvic pain should also be considered. The management of chronic pelvic pain is challenging, as despite interventions involving surgery, many women remain in pain without a firm gynaecological diagnosis.
- The aim of treatment should be to develop a partnership between clinician and patient to plan a management programme.
- A multidisciplinary approach to assessment and treatment with a focus on improving emotional, physical and social functioning instead of focusing strictly on pain reduction should be undertaken.
- The woman should be given adequate time to tell her story. A symptom diary may be useful.
- Appropriate management of any specific underlying disorder.
- Many women with chronic pelvic pain can be managed in primary care. Referral should be considered when the pain has not been explained to the woman's satisfaction or when pain is inadequately controlled.
- If the history suggests a non-gynaecological component to the pain, referral to a gastroenterologist, urologist, genitourinary specialist, physiotherapist, psychologist or psychosexual counsellor should be considered.
- Women with cyclical pain should be offered a therapeutic trial using the combined oral contraceptive pill or a gonadotrophin-releasing hormone (GnRH) agonist for a period of three to six months before having a diagnostic laparoscopy. The levonorgestrel-releasing intrauterine system (Mirena® coil) could be considered.
- Division of fine adhesions has not been proven to be beneficial.
- Appropriate analgesia to control pain, even if no other therapeutic manoeuvres are yet to be initiated. If pain is not adequately controlled, there may be a need to refer the patient to a pain management team or a specialist pelvic pain clinic.
- For men with PPS, the following are recommended:
- Alpha-blockers in those with symptoms for less than one year.
- Antibiotics (quinolones or tetracyclines) for at least six weeks for those with symptoms for less than one year.
- Non-steroidal anti-inflammatory drugs (NSAIDs) may be effective.
- Electro-acupuncture or perineal extracorpreal shock wave therapy may be considered for some men.
Further reading and references
UK National Guideline for the Management of Pelvic Inflammatory Disease; British Association for Sexual Health and HIV (2011)
The initial management of chronic pelvic pain; Royal College of Obstetricians and Gynaecologists (May 2012)
Ahangari A; Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014 Mar-Apr17(2):E141-7.
Guidelines on Chronic Pelvic Pain; European Association of Urology (2015)
Hoffman D; Central and Peripheral Pain Generators in Women with Chronic Pelvic Pain: Patient Centered Assessment and Treatment. Curr Rheumatol Rev. 2015 Jun 18.
Ovarian cancer - the recognition and initial management of ovarian cancer; NICE Clinical Guideline (April 2011)
Cheong YC, Smotra G, Williams AC; Non-surgical interventions for the management of chronic pelvic pain. Cochrane Database Syst Rev. 2014 Mar 53:CD008797. doi: 10.1002/14651858.CD008797.pub2.
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