| Suspected cause | Pain history | Associated symptoms | Supporting history | Physical examination | Useful tests | Atypical or additional aspects |
| Gynecologic |
| Mittelschmerz | - Cyclic unilateral lower quadrant pain, usually mild pain
| - Midway between menstrual periods and lasts for a few hours to a couple of days
| - Recurrent midcycle pain in females with regular ovulatory cycles
| | | - May be associated with significant hemoperitoneum
|
| Leiomyoma (degenerating) | | - Low-grade fever, elevated white blood cell count, or peritoneal signs
| - Known history of fibroids, especially larger ones
| - Focal uterine tenderness with palpation
| | - Discomfort usually self-limited, lasting from days to a few weeks, and usually responds to NSAIDs
- Can occur with uterine growth during pregnancy
|
| Adenomyosis | | | - May have chronic pelvic pain but not dyspareunia
| - Mobile, diffusely enlarged (often referred to as "globular" enlargement) and soft (often referred to as "boggy") uterus
| | - Endometriosis commonly coexists
- Possible increased risk of preterm birth in women with adenomyosis, diagnosed by either US or MRI
|
| Imperforate hymen | - Cyclic abdominal or pelvic pain
| - Primary amenorrhea (sometimes referred to as crypto-menarche)
| - Adolescent without prior menses
| - Hematocolpos bulging obstruction of the vagina, may give the hymenal membrane a bluish discoloration
| | - Mucocolpos, or pyohematocolpos if the hymen has any perforations
- Marked vaginal distension may result in back pain, pain with defecation, or difficulties with urination
|
| Pelvic organ prolapse | - Sensation of pelvic pressure/heaviness
| - Protrusion of tissue from the vagina
- Other pelvic floor disorders, including urinary, bowel, and sexual complaints
| - Increasing parity, advancing age, obesity, prior hysterectomy, chronic constipation
- Have job that involves heavy lifting
| - Cystocele, rectocele, enterocele, uterine prolapse, vaginal vault prolapse
| - Physical examination only
| - Obstructed urination or defecation or hydronephrosis from chronic ureteral kinking are indications for treatment, regardless of degree of prolapse
|
| Gastrointestinal |
| Inflammatory bowel disease | - RLQ pain with Crohn disease
- Rectal tenesmus with ulcerative colitis
| - Loose stools or bloody diarrhea, abdominal pain, or tenesmus
| - Chronic watery diarrhea
- Chronic abdominal pain
- Fever and fatigue are common at presentation and during disease flares
- Perianal abscesses, fistulae, and fissures, oral ulcers, or arthritis
| - Abdominal examination for focal tenderness
- Rectal examination for tenesmus and perianal abscesses/fissures
| - CBC with differential
- ESR
- CRP
- Albumin
- Stool tests for gross or occult blood
- Fecal calprotectin
| - Perianal disease (fistulae, anal skin tags, or fissures), or occult blood in stool
- Fulminant disease presents with severe abdominal pain, frankly bloody diarrhea, tenesmus, fever, leukocytosis, and hypoalbuminemia
- Subacute illness characterized by diarrhea that usually contains blood, fatigue, anemia, and sometimes weight loss
|
| Rectal obstruction | | - Focal abdominal pain may indicate peritoneal irritation due to ischemia or colonic necrosis
- A sudden relief of pain followed by a progressive worsening of pain may occur with intestinal perforation
- Progressive change in bowel habits associated with unintentional weight loss over months suggests malignancy
| - No passage or stool; change in bowel habits or stool caliber
- Abdominal distention or increased abdominal girth
| - Abdominal examination for distension
- Rectal tenesmus
| - CBC with differential, electrolytes including BUN and creatinine
- Imaging with plain radiographs or CT
| - Evaluate for systemic signs of dehydration, shock, or abdominal compartment syndrome from severe colonic distention
- Laboratories assess presence and severity of hypovolemia or other metabolic abnormalities, and for leukocytosis with a leftward shift
- Progressive change in bowel habits associated with unintentional weight loss over months suggestive of malignancy
- If malignancy of the colon is suspected, obtain CEA level
|
| Inguinal or femoral hernia | - Heaviness or dull discomfort in the groin
- Moderate to severe pain is unusual and suggests strangulation of bowel
| - Presentations range from a bulge in the groin region with or without pain to emergent, life-threatening due to bowel strangulation
- Groin discomfort most pronounced with increased intra-abdominal pressure as with heavy lifting, straining, or prolonged standing
- Strangulated hernias may manifest with symptoms of bowel obstruction and possibly systemic symptoms if bowel necrosis occurred
| - Congenital or acquired
- Older age, chronic cough, chronic constipation, smoking
- If acquired, associated with connective tissue abnormalities, chronic abdominal wall injury, or possibly drug effects
| - Bulge in the groin while standing and patient coughs or does Valsalva maneuver
| - Groin US or herniography (peritoneography)
- CT or MRI
| - Inguinal more common than femoral
- Risk of incarceration/strangulation low
- If incarcerated/strangulated hernia, imaging generally not necessary prior to surgical repair
- Women more likely to present emergently due to a higher incidence of femoral hernias, which are more likely to strangulate
|
| Urinary tract |
| Bladder pain syndrome/interstitial cystitis | - Discomfort with bladder filling and a relief with voiding
- Pain location is suprapubic or urethral, although can be unilateral lower abdominal pain or low back pain
| - Urinary frequency, urgency, and nocturia often accompany the discomfort or pain
| - Bothersome sensations are worsened by bladder filling and/or relieved by emptying
| - Variable tenderness of the abdominal wall, hip girdle, pelvic floor, bladder base, and urethra
- Allodynia (as with other patients with chronic pain)
- Tenderness or tightness of the pelvic floor muscles
| - Urinalysis with microscopy to exclude infection and hematuria
- Chlamydia testing
| - Other chronic pain symptoms (eg, irritable bowel syndrome, vulvodynia, endometriosis, dysmenorrhea, fibromyalgia) present in many patients
- Exacerbation of IC/BPS symptoms may occur after intake of certain foods or drinks, during stress, after certain activities (eg, exercise, sexual intercourse, prolonged sitting), or during the luteal phase of the menstrual cycle
|
| Urinary retention | - Lower abdominal and/or suprapubic discomfort
| | - Previous history of retention or lower urinary tract symptoms, pelvic surgery, radiation, or pelvic trauma
| - Pelvic examination for uterus size and location
- Rectal examination to evaluate for masses, fecal impaction, perineal sensation, and rectal sphincter tone
| - Urine sample for urinalysis and urine culture
- Bladder US or catheterization for diagnosis
| - Presence of hematuria, dysuria, overflow incontinence, fever, low back pain, neurologic symptoms, or rash
- Obtain a complete list of medications (including over-the-counter medications)
- Urethral catheterization contraindicated in patients who had recent urologic surgery (eg, reconstruction)
- With catheterization, if greater than 200 mL of urine, record volume drained in the first 10 to 15 minutes
- If this volume exceeds 400 mL, catheter typically left in place
|
| Urethral diverticulum | | | - Chronic or recurrent UTIs
- Urinary frequency and/or urgency
- Hematuria
- Bloody urethral discharge
- Urinary incontinence
- Urinary retention
- Pelvic or urethral pain
- Vaginal mass
| - Anterior vaginal wall mass, particularly a tender mass
| - Urinalysis if dysuria, frequency, hematuria
- MRI preferable, US if MRI unavailable
| - Classic triad of dysuria, dyspareunia and postvoid dribbling often not present
- Anterior vaginal wall visualized for mass by using a half speculum to retract the posterior vaginal wall
- The anterior vaginal wall is inspected for mass while the patient rests and then does a Valsalva maneuver
|
| Musculoskeletal |
| Aseptic necrosis of femoral head | - Groin pain is most common in patients with femoral head disease, followed by thigh and buttock pain
| - Weightbearing or motion-induced pain is found in most cases
- Rest pain occurs in approximately two-thirds of patients, and night pain occurs in one-third
| - Use of glucocorticoids and excessive alcohol intake
| - Hip range of motion, particularly with forced internal rotation and abduction
| - Plain film radiographs, radionuclide scans, and MRI
| - Although rare, pain in multiple joints suggests a multifocal process
- Early diagnosis of osteonecrosis may provide the opportunity to prevent collapse and, ultimately, the need for joint replacement
- A limp may be present late in the course of lower extremity disease
|
| Ehlers-Danlos syndrome (joint hypermobility syndromes) | - Vulvodynia
- Generalized pelvic pain
| - Joint hypermobility
- Skin hyperextensibility
- Mitral valve prolapse
| - Chronic widespread pain
- Fatigue
- Mood disorders (anxiety and depression)
- Palpitations, chest pain, and near-syncope or syncope due to postural tachycardia
- Orthostatic symptoms, including (near) blackouts due to postural hypotension
- Varicose veins
- Eye abnormalities
| - Pelvic floor dysfunction
- Beighton hypermobility score
| | - Pain management using a multidisciplinary approach of the type advocated for patients with fibromyalgia or chronic centralized pain
|
| Hip osteoarthritis or inflammatory arthritis | - Pain is usually felt deep in the anterior groin but may involve the anteromedial or upper lateral thigh and occasionally the buttocks
| - Pain, aching, stiffness, and restricted movement
| - Generalized or restricted to a few joints
| - Joint examination for mobility, warmth, swelling
| - US
- MRI
- Radiography
- Synovial fluid assessment
| - Differential diagnosis for osteoarthritis depends largely on the location of the affected site as well as the presence or absence of additional systemic symptoms
|
| Fibromyalgia | - Widespread musculoskeletal pain
| - Symptoms suggestive of IBS
- Pelvic pain and bladder symptoms of frequency and urgency suggestive of the interstitial cystitis/painful bladder syndrome (formerly female urethral syndrome)
| - Pain is often chronic and associated with numbness, tingling, and other abnormal sensations
- Fatigue and poor sleep
- Cognitive and psychiatric symptoms
- Headache
| - Tenderness in soft-tissue anatomic locations
| - None or to exclude other conditions (eg, CBC, ESR, CRP antinuclear antibody and rheumatoid factor)
| - Multiple nonspecific symptoms of fibromyalgia can mimic many other conditions, and consideration of the differential diagnosis is important coexisting with other common functional somatic syndromes, including chronic fatigue syndrome, irritable bowel syndrome, endometriosis migraine, and temporomandibular disorder, as well as chronic bladder and pelvic pain syndromes
|
| Vascular |
| Ovarian vein thrombophlebitis | - Pain localizes to the side of the affected vein (usually the right) but can be felt in the flank or back
| - Acutely ill, with fever and abdominal pain within 1 week after delivery or pelvic surgery
| - Nausea, ileus, and other gastrointestinal symptoms may occur but are usually mild
| - Pelvis is tender to palpation, and some patients may have a tender rope-like mass on examination that extends centrally from the uterus to the upper lateral abdomen
| - CBC for leukocytosis
- CT with contrast
- Dedicated venous imaging
| - Leukocytosis of >12,000/microL occurs in 70 to 100% of patients with SPT
- OVT is most often right-sided, as that vein is longer and more likely to be compressed by the uterus
|
| Septic pelvic thrombophlebitis | - Intermittent or mild abdominopelvic pain
| - With fever in the early postpartum or postoperative period (usually within 3 to 5 days, but onset may be delayed to up to 3 weeks following delivery)
| - Recent vaginal or cesarean delivery or pelvic surgery
- Patients may present following vaginal or cesarean delivery or pelvic surgery with persistent fever despite antibiotic therapy for presumed endometritis and no other apparent cause
| - Tenderness to palpation is typically absent
| - Optimal imaging modality is uncertain
- CT with contrast
- Dedicated venous imaging MRI with gadolinium-enhanced magnetic resonance venography to highlight any pelvic vein-filling defect
| - Leukocytosis of >12,000/microL occurs in 70 to 100% of patients with SPT
- If the patient presents with persistent fever after vaginal or cesarean delivery or pelvic surgery despite adequate antibiotic therapy and no other apparent cause is identified, treat for possible SPT with addition of anticoagulation, even if no thrombosis identified on imaging
- Imaging findings suggestive of pelvic venous thrombosis can be seen in absence of suspected SPT, making clinical correlation essential; many patients with SPT have unrecognized involvement of other pelvic veins
|
| Vulvar varicosities | - Vulvar discomfort, swelling, and pressure that are exacerbated by prolonged standing, exercise, and coitus
| | - Chronic pelvic discomfort exacerbated by prolonged standing and coitus in women who have periovarian varicosities on imaging studies
| | | - Vulvar varices are often asymptomatic
|
