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Acute pelvic pain in nonpregnant adult females: Evaluation

Acute pelvic pain in nonpregnant adult females: Evaluation
Literature review current through: Jan 2024.
This topic last updated: May 19, 2023.

INTRODUCTION — Acute pelvic pain is generally defined as lower abdominal or pelvic pain that has lasted less than three months. Over one-third of reproductive-aged women will experience nonmenstrual pelvic pain at some point. While most acute pelvic pain is caused by reproductive, urinary, or gastrointestinal tract disorders, abnormalities of musculoskeletal, vascular, and neurologic processes can contribute as well. Excluding pregnancy is a critical step, as the causes and management of pelvic pain in pregnant women differ significantly; women diagnosed with pregnancy are referred for immediate evaluation. Pelvic pain frequently occurs with abdominal pain and can be a challenging complaint because of the need to consider a wide array of possible conditions.

This topic presents a framework for the evaluation of nonpregnant adult women with acute pelvic pain, with an emphasis on gynecologic conditions.

Related topics for adult women that are covered separately include:

(See "Evaluation of the adult with abdominal pain".)

(See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients".)

(See "Chronic pelvic pain in adult females: Evaluation".)

Related topics for pediatric and adolescent patients include:

(See "Causes of acute abdominal pain in children and adolescents".)

(See "Emergency evaluation of the child with acute abdominal pain".)

(See "Evaluation of acute pelvic pain in female children and adolescents".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DEFINITION — Acute pelvic pain is a nonspecific symptom that is generally defined as pain of the low abdomen or pelvis that has lasted less than three months. The pain may be diffuse or focal and, in some cases, includes musculoskeletal and low back pain. The pain can be sharp or dull, focal or diffuse, and sporadic or constant. Most commonly, the cause is some pelvic pathology, including disease of the gynecologic, gastrointestinal, and urologic systems. A patient can simultaneously have pain both in the pelvis and abdomen or have pain that starts in one location and radiates to another. Importantly, a patient with chronic pelvic pain, of known or unknown etiology, can present with an acute process arising de novo or a pain exacerbation that is related to the chronic condition. (See "Chronic pelvic pain in nonpregnant adult females: Causes".)

Pain that is exclusive to the mid or upper abdomen, low back, and external urogenital tissue (eg, vulva, rectum) is not considered pelvic pain. Information on these topics is presented separately:

(See "Evaluation of the adult with abdominal pain".)

(See "Causes of abdominal pain in adults".)

(See "Evaluation of low back pain in adults".)

(See "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

(See "Vulvar lesions: Diagnostic evaluation".)

(See "Evaluation and management of female lower genital tract trauma".)

(See "Female sexual pain: Differential diagnosis".)

(See "Hemorrhoids: Clinical manifestations and diagnosis".)

CAUSES

Life-threatening — Common processes that are potentially life-threatening must be quickly diagnosed and treated. These include (table 1):

Gynecologic – Common gynecologic conditions include ruptured ectopic pregnancy, ruptured ovarian cyst (any kind), ovarian torsion, pelvic inflammatory disease (PID), tubo-ovarian abscess (TOA), and ruptured uterus (rare in nonpregnant women) [1]. Ectopic pregnancy and ovarian cysts can result in uncontrolled intraperitoneal hemorrhage should rupture occur. Ovarian torsion needs to be diagnosed and corrected quickly to preserve ovarian function [2]. Both PID and its severe manifestation, TOA, can result in acute sepsis and long-term infertility [3]. Ruptured uterus can occur in the nonpregnant woman, but this is uncommon [4,5].

Detailed information on the evaluation of each of these processes is presented separately:

(See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

(See "Evaluation and management of ruptured ovarian cyst".)

(See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

(See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)

Gastrointestinal – Common diagnoses include appendicitis and diverticulitis. Both can cause intestinal perforation and result in sepsis.

(See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

(See "Clinical manifestations and diagnosis of acute colonic diverticulitis in adults".)

Urinary – Ureteral obstruction (eg, from kidney stone or surgery) and complicated urinary tract infections (UTIs) can result in renal damage (both) and sepsis (complicated UTI) if not diagnosed and treated.

(See "Clinical manifestations and diagnosis of urinary tract obstruction (UTO) and hydronephrosis".)

(See "Acute complicated urinary tract infection (including pyelonephritis) in adults and adolescents".)

Common — The female pelvis contains the uterus, ovaries and fallopian tubes, vagina, urinary bladder and ureters, sigmoid colon, and rectum, as well as supporting vascular, neurologic, and musculoskeletal structures (figure 1 and figure 2 and figure 3 and figure 4). While acute pelvic pain is a presenting symptom for many common gynecologic, gastrointestinal, and urinary tract disorders, common causes of acute pelvic pain also span the musculoskeletal, vascular, and neurologic systems.

Pain may result from infection and/or inflammation; organ ischemia or distention; or leakage of pus, blood, feces, or other material into the pelvis. Visceral pain afferents innervating the reproductive organs arise from spinal segments that share innervation with other pelvic viscera including the appendix, lower ileum, colon, bladder, and ureters. Similarly, neural cross-talk happens between the visceral (organs) and somatic (muscles/fascia) systems such that pain from myofascial structures is referred to viscera and vice versa. These physiologic factors make the accurate clinical diagnosis of adult women presenting with acute pelvic pain challenging. Because multiple organ systems contribute to and are contained within the pelvis, a broad differential is initially developed for these patients. (See "Causes of abdominal pain in adults", section on 'Pathophysiology of abdominal pain'.)

A range of potential causes of acute pelvic pain in adult women, by organ system, are presented in the table (table 2).

Both the age and reproductive status of the patient impacts the likelihood of various causes of acute pelvic pain (table 3).

Acute pelvic pain may present in combination with abdominal pain of various etiologies (table 4A-D).

Other — Less common and rare medical causes are pursued if the common etiologies have been excluded and the patient continues to have pain (table 5).

EXCLUDE LIFE-THREATENING DISORDERS

Rapid preliminary assessment — The goal of the preliminary assessment is to identify patients who need emergency or urgent treatment for their likely source(s) of pain (table 1). We simultaneously develop a general overall impression, identify any vital sign abnormalities, obtain a focused clinical history, and perform a limited physical examination (algorithm 1). Concerning physical examination findings include unstable vital signs, peritoneal signs, or suspected life-threatening pathology (eg, ectopic pregnancy, bowel perforation).

We take the following approach:

Obtain focused history – In addition to questions relating to the onset and nature of the patient's pain, we ask about the date of the last menstrual period, other medical conditions (including pregnancy or delivery), any recent surgery, medications, and allergies. (See "Evaluation of the adult with nontraumatic abdominal or flank pain in the emergency department", section on 'History'.)

Assess for pregnancy – We perform a pregnancy test on any patient who has the potential to be pregnant. As both the patient’s age and hormonal status can be difficult to assess in an emergency setting, we perform pregnancy testing on most patients except those who are clearly currently pregnant, prepubertal, or who are known to have no uterus. Determining pregnancy status is a critical first step in the management of women of reproductive age to enable expeditious diagnosis of conditions that warrant rapid assessment and triage. For example, among women with pelvic pain or vaginal bleeding (or both) visiting the emergency department in the first trimester of pregnancy, as many as 18 percent will have an ectopic pregnancy [6]. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Diagnosis'.)

Assess hemodynamic status – We obtain vital signs, including temperature and orthostatic vital signs, on all women. Women with hemodynamic instability are immediately resuscitated. (See "Initial management of moderate to severe hemorrhage in the adult trauma patient", section on 'Resuscitation and transfusion'.)

Perform abbreviated physical examination – We perform an abdominal examination to assess for peritoneal signs, location of pain, and palpable masses. Transabdominal palpation of the uterine fundus can identify advanced pregnancy, which can be especially useful in settings where pregnancy testing is not available (figure 5). Next, we perform a pelvic examination that includes visual inspection of external genitalia, speculum examination of the vagina and cervix, and bimanual examination of the uterus and adnexal structures. However, for women who could be pregnant and are hemodynamically stable, we defer intravaginal digital examination until pregnancy has been definitely excluded or ultrasound has provided information about the pregnancy such as the location of the placenta (eg, to exclude placenta and vasa previa). For women with hemodynamic instability or a suspected critical condition, such as intraperitoneal bleeding from any etiology, physical examination may be deferred in favor of immediate imaging, typically with rapid assessment ultrasound (see the bullet below).

Perform rapid assessment ultrasound – A Focused Assessment with Sonography for Trauma (FAST) ultrasound can quickly assess for intraperitoneal fluid and blood (even in non-trauma patients) [7,8]. Individuals trained in ultrasound technique may also evaluate for intrauterine pregnancy and adnexal mass. More detailed assessment of the uterus and adnexa often requires a transvaginal approach. While trace-free pelvic fluid can result from ovulation, larger volumes of fluid are generally not caused by ovulation and warrant consideration of type and source of fluid (eg, blood, urine, pus). (See "Emergency ultrasound in adults with abdominal and thoracic trauma", section on 'Abdominal examination' and "Indications for bedside ultrasonography in the critically ill adult patient".)

Obtain emergency blood work – We request an urgent complete blood count (CBC) and type and cross for patients with suspected hemorrhage or who will likely require surgical treatment. For patients who have profound bleeding or are hemodynamically unstable from any cause (eg, sepsis, trauma), we order a fibrinogen level and bleeding panels to assess for disseminated intravascular coagulation (DIC). For patients with suspected sepsis who have signs of hemodynamic instability and infection, we request CBC with differential, chemistries, liver function tests, coagulation studies including D-dimer level, and peripheral blood cultures.

(See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis".)

(See "Evaluation and management of suspected sepsis and septic shock in adults".)

Management — Women diagnosed with, or suspected of having, a life-threatening condition (table 1) are stabilized and referred expeditiously to a facility with the staff and resources to appropriately treat the patient. Women with frank trauma are evaluated and treated for such. Women with hemodynamic instability and/or peritoneal findings suggesting a surgical emergency (eg, appendicitis, bowel perforation, intraperitoneal hemorrhage, and/or ovarian torsion) are referred immediately for surgical evaluation. Pregnancy-related life-threatening emergencies, such as placental abruption or uterine rupture, also necessitate immediate referral.

Fortunately, in most circumstances, the patient will not have a dangerous or life-threatening problem. The rapid preliminary history and physical examination may not conclusively lead to a diagnosis. In this scenario, the patient then proceeds through the complete initial evaluation for common conditions. (See 'Initial evaluation for common conditions' below.)

INITIAL EVALUATION FOR COMMON CONDITIONS

Challenges — The goal of the routine evaluation is to determine the most likely source(s) of the symptom. This process is often challenging since there are many organ systems that can cause pelvic pain, the differential diagnosis is impacted by the patient's age and reproductive status, common diseases may manifest in uncommon ways, more than one disease may be present, or a particular finding may not entirely explain the patient's presentation. As examples, pyuria may occur in appendicitis and not all ovarian cysts are symptomatic [9]. In some diseases, like endometriosis, the patient's history, including prior and current treatment, may be important to guiding diagnosis and approaches to treatment.

Initially, we evaluate for both gynecologic and intraabdominal causes of pain in parallel, especially if the initial history and physical examination do not provide clear guidance (algorithm 1). Findings and test results are considered and interpreted in the context of each patient's presentation. A synthesis of the history, physical examination, and diagnostic tests guides the clinician to the diagnosis of the etiology of pelvic pain.

History — We inquire about the pain location, characteristics, associated symptoms such as fever and vaginal bleeding, and general medical issues in an attempt to identify the likely cause(s) of the patient's symptoms.

Pain location – We ask the patient to describe the location of the pain and how that location may have changed over time.

Lateral pelvic pain may be related to a process in the ovary or fallopian tube. Lateral pain is also observed with a ureteral stone, especially if it is at the ureterovesical junction. Right-sided pain is generally associated with appendicitis while left-sided pain is common with diverticulitis and colitis, especially in patients over 40 years.

Pain radiating to the rectum may occur when fluid or blood pools in the cul-de-sac or with rectovaginal endometriosis.

Central pelvic pain is observed with disorders of the uterus, both adnexa, or the bladder.

Diffuse pain may occur with peritonitis from intraabdominal hemorrhage or infection or with a bilateral or central process like pelvic inflammatory disease (PID).

Timing of pain onset

Sudden onset – Pain with an abrupt onset suggests an acute process such as intrapelvic hemorrhage, ovarian torsion, urolithiasis, or ovarian cyst rupture.

Gradual onset – Gradual-onset pain is more common with inflammatory or infectious processes such as PID or appendicitis.

Pain characteristics – We also ask the patient what makes the pain better or worse (ie, provocative and palliative factors), if the pain radiates to another location, if the pain has occurred in the past, the timing relative to menses, and if the pain is cyclic in nature. As examples, pain that improves with voiding suggests bladder pain syndrome, while pain that worsens with voiding is suggestive of infectious cystitis. Appendicitis classically begins with periumbilical pain and moves to the right lower quadrant. Pain that is related to inflammatory bowel disease, painful bladder syndrome, or endometriosis usually presents with similar characteristics when it recurs. Pain that worsens in relation to changes in the menstrual cycle can be Mittelschmerz (pain related to ovulation), dysmenorrhea (pain related to menstruation), or endometriosis.

Associated symptoms – As part of the history, we also try to elicit other symptoms or processes that may be associated with the patient's pain. We generally inquire about the following conditions and then ask follow-up questions as directed by the initial answers.

Fever and chills are more common with an infectious or inflammatory process, such as PID, cystitis with or without pyelonephritis, or diverticulitis.

Nausea and vomiting frequently accompany a gastrointestinal process but may also occur in any severe pain or any pain of visceral origin such as ureteral colic or ovarian torsion.

Dysuria can occur with urinary tract infections (UTIs), but if pain occurs when the urine touches the vulva, it may indicate vulvar and vaginal diseases such as herpes simplex infection, vulvovaginal candidiasis, or bacterial vaginosis. Urinary frequency can occur with UTI, urethral diverticulum, and bladder pain syndrome, all of which can also cause pelvic pain.

Common processes that can cause vaginal bleeding and acute pelvic pain in nonpregnant women include ovarian cysts, endometrial infection, uterine perforation, and trauma.

Vaginal discharge associated with acute pelvic pain can result from infection, pelvic trauma (eg, traumatic sexual assault), or a retained foreign body (eg, retained tampon).

Constipation or diarrhea can occur with any gastrointestinal process but may also occur in severe dysmenorrhea.

Last menstrual period and possibility of pregnancy – Unless the patient is premenarchal, we ask all patients about the date of their last menstrual period and possibility of pregnancy (table 6). For women who know they are pregnant, we ask about the estimated gestational age, estimated due date, and current and prior obstetric history. Previous spontaneous miscarriage or ectopic pregnancy increases the likelihood of these respective conditions [10,11]. Current infertility treatment increases the risk of ovarian hyperstimulation, heterotopic pregnancy, and ectopic pregnancy [12]. The history of cesarean section increases the possibility of uterine rupture.

Sexual history – Sexual history includes recent sexual contact, previous history of sexually transmitted infections, contraceptive use, and risk of pregnancy. All women are interviewed in private to enable the disclosure of sensitive information like sexual history, recent abortion, abuse, and pregnancy. (See "Screening for sexually transmitted infections", section on 'Sexual history'.)

General medical and surgical history – History of any recent surgical or gynecologic procedures and the nature of these procedures are obtained. For example, onset of pelvic pain soon after uterine instrumentation is concerning for uterine infection or perforation.

Medications and allergies – As with any patient evaluation, we inquire about the patient's medications and allergies, particularly recently started or discontinued medication. For example, a woman who has recently started an anticholinergic medication for urinary leakage related to overactive bladder could develop urinary retention with resultant onset of pelvic pain [13]. We also inquire about use of illicit or controlled substances. Patients with opioid withdrawal or drug-seeking can present with pelvic pain as their chief complaint.

Physical examination

General — The general physical examination includes evaluation of vital signs, a general assessment, and abdominal examination. Tachycardia, hypotension, or evidence of an acute abdomen with rebound or guarding on abdominal examination can indicate a surgical emergency, such as intraabdominal bleeding, ectopic pregnancy, appendicitis, or ovarian torsion, and necessitates immediate referral. If there is no evidence of an acute abdomen and vital signs are unremarkable, evaluation of the patient's chest, back, and extremities is the next step. Once these assessments are completed, the pelvic examination is performed. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

Pelvic — Nonpregnant women with acute pelvic pain undergo a pelvic examination that includes visual inspection of external genitalia, speculum examination of the vagina and cervix, bimanual examination of the uterus and adnexa, and rectal examination. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

Findings can help guide the differential diagnosis. Examples of abnormal findings that are discussed in separate topic reviews and suggest specific diagnoses include:

External genitalia – Vesicles can be caused by herpes simplex infection, vulvar, or perineal abscess (eg, Bartholin's duct abscess) and can contribute to pelvic pain; an imperforate hymen may indicate underlying hematocolpos, and female infundibulation (circumcision) can contribute to UTI [14]. Painful vulvar lesions may result from infectious or dermatologic etiologies. Complete uterovaginal prolapse can cause urinary incontinence and pelvic pain heaviness.

Speculum examination of vagina and cervix

Abnormal vaginal or cervical discharge may be seen in various conditions including cervicitis, endometritis, PID, vaginitis, or retained vaginal foreign body.

Bleeding from the cervix can result from incomplete, threatened, or complete abortion. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

An open cervical os suggests an inevitable or incomplete abortion but does not exclude an ectopic pregnancy. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

Bimanual examination of the uterus and bilateral adnexa

Cervical motion tenderness commonly reflects peritonitis of the reproductive tract, such as with PID, but may also reflect irritation of adjacent structures (eg, bladder, cystitis; appendix, appendicitis) [15].

An enlarged uterus may reflect pregnancy, leiomyoma (fibroids), or both.

Painful unilateral adnexal masses may indicate ectopic pregnancy, tubo-ovarian abscess, ovarian cyst, or ovarian torsion. PID can cause bilateral adnexal pain.

Cervical motion tenderness, uterine tenderness, and adnexal tenderness together suggest PID.

Rectal examination

Rectal pain can be caused by thrombosed hemorrhoids, anal fissure, deep infiltrating endometriosis of the bowel or cul-de-sac, or can be observed in those with pelvic blood.

Rectal mass may be a malignancy or rectal endometriosis.

Laboratory testing — Choice of laboratory test is guided by the findings from the patient's history and physical examination. In general, we find the following tests appropriate for most women:

Pregnancy test – A pregnancy test is required for almost all patients of reproductive age who present with pelvic pain, regardless of reported contraceptive use or sexual history. Exceptions include documented hysterectomy or a woman known to be pregnant.

A positive test result indicates current or recent intrauterine or ectopic pregnancy or, rarely, molar pregnancy or cancer.

Urinalysis – A urinalysis is done on a clean-catch specimen. Important findings include:

Nitrates or pyuria may indicate a UTI. Mild pyuria can be seen with appendicitis.

Hematuria can indicate urolithiasis or hemorrhagic cystitis.

Urinalysis should be performed in all pregnant patients with pelvic pain, regardless of whether they have urinary tract symptoms, because UTI, including asymptomatic bacteriuria, is associated with significant morbidity for both mother and fetus.

Urine tests – Sexually transmitted infections can be detected (eg, gonorrhea and chlamydia cervical infections) from urine antigens. These tests are best done on a first voided "dirty" specimen rather than a typical clean-catch specimen.

Cervix tests – We test patients with risk factors for and symptoms of cervical and/or pelvic infections for gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis. In addition, as described above, urine tests are available for both gonorrhea and chlamydia. (See "Acute cervicitis", section on 'Laboratory evaluation'.)

Complete blood count

Patients bleeding externally or internally should have their complete blood count checked for evidence of anemia. For patients who have profound bleeding or who are hemodynamically unstable from any cause (eg, sepsis, trauma), fibrinogen level and bleeding panels are requested to assess for disseminated intravascular coagulation (DIC). For patients who have signs of infection, complete differential is obtained with the complete blood count.

Type and cross-matching is done for anyone who has substantial hemorrhage.

Pregnant patients with any concern for fetomaternal transfusion require blood typing to identify Rh-negative patients who will require Rho(D) immune globulin. (See "RhD alloimmunization: Prevention in pregnant and postpartum patients".)

Blood cultures are performed in women suspected of having disseminated infection, such as some women with PID. (See "Detection of bacteremia: Blood cultures and other diagnostic tests".)

Imaging — For women with pelvic pain, ultrasound is a basic part of the initial evaluation accompanying the history and physical examination. In most cases, both transvaginal and transabdominal evaluation will be required.

Finding of echogenic or complex intraabdominal or pelvic fluid – Ultrasound findings of echogenic or complex fluid in the abdomen or pelvis are presumed to be blood and should be addressed expeditiously in context with the patient's history, physical examination, and other findings. Common etiologies of free fluid in the abdomen or pelvis include ruptured ectopic pregnancy, ruptured ovarian cyst, or trauma.

Patients with a positive pregnancy test – For any patients with a positive pregnancy test, ultrasound assessment for the location of the pregnancy (ie, ectopic or intrauterine) is required. Ultrasound evaluation of pregnant women should also include assessment and documentation of fetal cardiac activity, when feasible.

If a definite intrauterine pregnancy is seen by ultrasound imaging, ectopic pregnancy is unlikely except for those patients who are undergoing assisted reproduction and may have a heterotopic pregnancy [12]. (See "Ectopic pregnancy: Clinical manifestations and diagnosis", section on 'Heterotopic pregnancy'.)

Ectopic pregnancy is probable if a complex adnexal mass, extrauterine yolk sac or embryo, tubal ring, empty uterus, or hemoperitoneum is observed. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

In a patient with a positive pregnancy test and a transvaginal ultrasound that shows neither an intrauterine pregnancy nor an ectopic pregnancy (ie, pregnancy of unknown location), serum hCG is tested serially to determine the rate of rise. The correlation between ultrasound findings, absolute hCG level, and change in hCG level over time for diagnosis of viable intrauterine pregnancy, early intrauterine pregnancy loss, and/or ectopic pregnancy is complicated and reviewed in detail separately. (See "Approach to the patient with pregnancy of unknown location".)

Patients with a negative pregnancy test – Patients with a negative pregnancy test are evaluated for nongynecologic as well as gynecologic causes. Patients with history and physical examination findings suggestive of small bowel obstruction, appendicitis, nephrolithiasis, or diverticulitis, or patients with equivocal ultrasound findings, generally proceed with computed tomography of the abdomen and pelvis. A detailed discussion of the evaluation for each of these entities is presented in separate topic reviews.

Women who may benefit from pelvic magnetic resonance imaging in addition to the ultrasound include those with evidence of an adnexal malignancy, degenerating fibroid, or pregnant women whose abdominal and pelvic ultrasound evaluations were nondiagnostic for a cause of pain. (See "Acute appendicitis in pregnancy", section on 'Magnetic resonance imaging (MRI)'.)

TREAT INITIAL DIAGNOSES AND REASSESS — Women in whom a likely etiology is identified are treated accordingly. If the pain resolves with the intervention, then no further evaluation or treatment is indicated. Women who do not respond in an appropriate time frame are then reassessed for possible atypical presentation of common diagnoses, worsening of a chronic illness, or less common diagnoses. (See 'Pursue less common diagnoses if symptoms persist' below.)

PURSUE LESS COMMON DIAGNOSES IF SYMPTOMS PERSIST

Our approach — For patients whose acute pelvic pain persists after the evaluation outlined above, we take the following steps:

Reassess for emergency or life-threatening diagnoses and ensure they are addressed (table 1). Some findings, such as evidence of peritonitis, may not be present at the initial evaluation but develop over time.

Consider whether the presentation may be an atypical presentation of a common condition (table 7), a worsening of an underlying chronic disease, or a less common cause of pelvic (table 5) or abdominal (table 8) pain. We repeat the history and physical examination to evaluate for less common etiologies. Subsequent laboratory testing or imaging is directed by new information obtained through this process.

For women who continue to have acute pelvic pain without a clear etiology despite exclusion of emergency and common diagnoses, unusual and rare conditions are considered next. These include, but are not limited to, uncommon medical diseases and toxicity. Examples of diseases with acute pelvic pain as one component of the clinical presentation include, but are not limited to, the following:

Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS), which presents with abdominopelvic pain (see "Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS)")

Familial Mediterranean fever (see "Clinical manifestations and diagnosis of familial Mediterranean fever")

Porphyria (see "Porphyrias: An overview")

Lead toxicity (see "Lead exposure, toxicity, and poisoning in adults", section on 'Acute and subacute exposure symptoms')

In addition, an important aspect of the history and examination is to assess for mental health disorders such as depression, anxiety, substance abuse, and somatization that can confound developing a differential diagnosis and may warrant directed treatment. Depression and anxiety have been associated with increased pain severity in pain disorders [16]. Additionally, women who are victims of intimate partner violence or human trafficking may present repeatedly for evaluation of medical problems that are related, directly or indirectly, to their experiences of trauma [17,18].

(See "Screening for depression in adults".)

(See "Intimate partner violence: Diagnosis and screening".)

(See "Human trafficking: Identification and evaluation in the health care setting".)

Follow-up — For all patients, regularly scheduled follow-up evaluation is advised. Periodic evaluation is repeated, as needed, until the pain is adequately addressed. For some women, no clear etiology of pain is identified. This small subgroup of women may continue with pain that persists for more than three to six months and, by definition, becomes chronic pelvic pain. The continued evaluation and management of these women is presented in separate discussions.

(See "Chronic pelvic pain in nonpregnant adult females: Causes".)

(See "Chronic pelvic pain in adult females: Evaluation".)

(See "Chronic pelvic pain in adult females: Treatment".)

Role of surgical evaluation — We find laparoscopic evaluation of the abdomen and pelvis helpful to confirm, and potentially treat, findings seen on imaging studies and potentially identify pathology that may not have appeared on the imaging studies, particularly for patients with continued significant symptoms despite treatments.

Surgical evaluation and treatment are indicated for women diagnosed with a potential surgical process (eg, ovarian torsion, ruptured ectopic pregnancy). The role of surgery is less clear for women presenting with acute pelvic pain without an identified or suspected etiology. Shared decision making is undertaken. We discuss with the patient that the risks of surgical exploration, typically with laparoscopy, must be balanced against the risks of potentially missing a diagnosis and presumed opportunity for treatment. As an example, approximately 2 percent of patients with clinical appendicitis will have an underlying appendiceal neoplasm [19]. While medical management of appendicitis with antibiotics may be a medically appropriate option, malignancy can only be diagnosed and treated if surgery is performed. The decision is further complicated in women with chronic pain related to endometriosis because long-term medical management of endometriosis, rather than multiple surgeries, is the preferred approach [20,21]. The decision to pursue surgery for women with chronic pelvic pain is discussed elsewhere. (See "Chronic pelvic pain in adult females: Evaluation", section on 'Role of laparoscopy'.)

SPECIAL POPULATIONS

Acute pain superimposed on chronic conditions — At times, patients can present with acute pain from worsening of a chronic condition. Examples from the author's experience include:

Sickle cell crisis initiated by menses – Women with known sickle cell disease can present with a monthly sickle cell crisis that is triggered by the physiologic changes and pain associated with menstruation [22]. Menstrual suppression may be considered for these women. (See "Evaluation of acute pain in sickle cell disease", section on 'Abdominal pain' and "Hormonal contraception for menstrual suppression", section on 'Progestin-only methods'.)

Ruptured endometrioma – Women with known endometriosis can have acute onset of new or worsened pelvic pain from a flare of the underlying disease or rupture of an endometrioma or other adnexal cyst. (See "Endometriosis: Management of ovarian endometriomas".)

Inflammatory bowel disease – Women with Crohn disease or ulcerative colitis can present with acute pelvic pain related to worsening of their underlying disease or from a complication of the disease, such as bowel perforation, intestinal obstruction, abscess, or fistula. (See "Clinical manifestations, diagnosis, and prognosis of Crohn disease in adults" and "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults".)

Atypical postoperative pain — For women who present with acute pelvic pain after a recent gynecologic or other pelvic surgery, we determine which surgery was performed (eg, myomectomy, removal of ectopic pregnancy, hysterectomy, etc) and the potential associated complications. Next, we perform an initial clinical assessment to identify hemodynamic instability or evidence of systemic infection. Women with findings suggestive of either process undergo immediate resuscitation. (See 'Rapid preliminary assessment' above.)

Examples of potential postoperative complications that may cause the patient to present with acute pelvic pain include:

Intraperitoneal fluid, including blood and urine.

Infection, such as wound infection, intraperitoneal abscess, infection of synthetic mesh, or septic abortion.

Uterine perforation can occur with any uterine procedure, including endometrial suction or curettage, intrauterine device insertion, or operative laparoscopy with uterine manipulation.

Urinary retention, which can be functional (eg, after anesthesia) or mechanical (eg, urethral obstruction from midurethral sling).

Ovarian remnant syndrome (monthly pain with ovulation) [23].

Endometrioma of abdominal wall after cesarean delivery [24].

Suspected malignancy — At times, presentation with acute pelvic pain may be the presenting complaint for an undiagnosed malignancy. Those with pelvic pain and:

Cervical cancer may present with vaginal bleeding and be found to have a cervical mass on speculum examination. Kidney damage related to stage III/IV disease warrants assessment. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis".)

Ovarian cancer may present with increasing abdominal girth, early satiety, or constipation, which reflect problems with bowel motility. Alternatively, they may have torsion or bleeding into ovaries related to various tumors. (See "Epithelial carcinoma of the ovary, fallopian tube, and peritoneum: Clinical features and diagnosis".)

Endometrial cancer usually presents with vaginal bleeding. (See "Endometrial carcinoma: Clinical features, diagnosis, prognosis, and screening".)

Rectal cancer may present with rectal pain, change in bowel habits, and bleeding. (See "Clinical presentation, diagnosis, and staging of colorectal cancer".)

Bladder cancer may present with hematuria, including passage of clots. (See "Clinical presentation, diagnosis, and staging of bladder cancer".)

Pregnant or recently postpartum women — The presentation and evaluation of pregnant and postpartum women with pelvic pain including postoperative causes are reviewed separately. (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female pelvic pain".)

SUMMARY AND RECOMMENDATIONS

Definition – Acute pelvic pain is a nonspecific symptom that is generally defined as pain of the low abdomen or pelvis that has lasted less than three months. The pain may be diffuse or focal and, in some cases, includes low back pain. (See 'Definition' above.)

Causes – Most commonly, the causes of acute pelvic pain in women include disease of the gynecologic, gastrointestinal, and urologic systems, although musculoskeletal, vascular, and neurologic diseases can occur as well. Processes can be life-threatening (table 1), common (table 2), and less common or rare (table 5). Because multiple organ systems contribute to and are contained within the pelvis, a broad differential is initially developed in these patients. (See 'Causes' above.)

Exclude life-threatening processes – The goal of the preliminary assessment is to identify patients who need emergency or urgent treatment for their likely source(s) of pain (table 1). We simultaneously develop a general overall impression, identify any vital sign abnormalities, obtain a focused clinical history, and perform a limited physical examination (algorithm 1). Concerning physical examination findings include unstable vital signs, peritoneal signs, or suspected life-threatening pathology (eg, ectopic pregnancy, bowel perforation). (See 'Exclude life-threatening disorders' above.)

Exclude pregnancy – Determining pregnancy status is a critical first step in the management of women of reproductive age to enable expeditious diagnosis of pregnancy-related conditions that warrant rapid assessment and triage. (See 'Rapid preliminary assessment' above.)

Initial evaluation for common conditions – Once life-threatening causes of pain and pregnancy have been excluded, a detailed history and physical examination are performed. (See 'Challenges' above.)

History – We inquire about the pain location, characteristics, associated symptoms (eg, fever and vaginal bleeding), and general medical issues in an attempt to identify the likely cause(s) of the patient's symptoms (algorithm 1). (See 'History' above.)

Physical examination – The general physical examination includes evaluation of vital signs, a general assessment, and abdominal examination. The pelvic examination includes visual inspection of external genitalia, speculum examination of the vagina and cervix, bimanual examination of the uterus and adnexa, and rectal examination. Choice of laboratory test is guided by the findings from the patient's history and physical examination. Most women undergo a pelvic ultrasound. (See 'Physical examination' above.)

Treat identified causes of pain

Patient improves – Women in whom a likely etiology is identified are treated accordingly. If the pain resolves with the intervention, then no further evaluation or treatment is indicated. (See 'Treat initial diagnoses and reassess' above.)

No improvement – Women who do not improve with initial treatment are reevaluated for emergency or life-threatening diagnoses (table 1). Some findings, such as evidence of peritonitis, may not be present at the initial evaluation but can develop over time. Once emergency conditions are excluded, we assess for an atypical presentation of a common condition (table 7), worsening of an underlying chronic disease, or a less common cause of pelvic (table 5) or abdominal (table 8) pain. (See 'Pursue less common diagnoses if symptoms persist' above.)

Role of surgical evaluation – The role of surgery is less clear for women in whom pain persists without an identified or suspected etiology. Shared decision making is undertaken; information is shared with the patient about the risks of surgical exploration, typically with laparoscopy, balanced against the risks of potentially missing a diagnosis, and presumed opportunity for treatment. (See 'Role of surgical evaluation' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Fred Howard, MD, who contributed to an earlier version of this topic review.

  1. Kruszka PS, Kruszka SJ. Evaluation of acute pelvic pain in women. Am Fam Physician 2010; 82:141.
  2. Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med 2017; 52:449.
  3. Tsevat DG, Wiesenfeld HC, Parks C, Peipert JF. Sexually transmitted diseases and infertility. Am J Obstet Gynecol 2017; 216:1.
  4. Herrera FA, Hassanein AH, Bansal V. Atraumatic spontaneous rupture of the non-gravid uterus. J Emerg Trauma Shock 2011; 4:439.
  5. Mostafa-Gharabaghi P, Bordbar S, Vazifekhah S, Naghavi-Behzad M. Spontaneous Rupture of Pyometra in a Nonpregnant Young Woman. Case Rep Obstet Gynecol 2017; 2017:4572379.
  6. Barnhart KT, Sammel MD, Gracia CR, et al. Risk factors for ectopic pregnancy in women with symptomatic first-trimester pregnancies. Fertil Steril 2006; 86:36.
  7. American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium. American College of Emergency Physicians. Ann Emerg Med 2006; 48:487.
  8. American Institute of Ultrasound in Medicine, American College of Emergency Physicians. AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med 2014; 33:2047.
  9. Hart DK, Lipsky AM. Acute Pelvic Pain in Women. In: Rosen's Emergency Medicine, 8th, Marx J, Hockberger R, Walls R (Eds), Saunders, Philadelphia 2013. p.2808.
  10. Ellaithy M, Asiri M, Rateb A, et al. Prediction of recurrent ectopic pregnancy: A five-year follow-up cohort study. Eur J Obstet Gynecol Reprod Biol 2018; 225:70.
  11. Jeve YB, Davies W. Evidence-based management of recurrent miscarriages. J Hum Reprod Sci 2014; 7:159.
  12. Xiao S, Mo M, Hu X, et al. Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles and frozen-thawed cycles. J Assist Reprod Genet 2018; 35:677.
  13. Verhamme KM, Sturkenboom MC, Stricker BH, Bosch R. Drug-induced urinary retention: incidence, management and prevention. Drug Saf 2008; 31:373.
  14. Klein E, Helzner E, Shayowitz M, et al. Female Genital Mutilation: Health Consequences and Complications-A Short Literature Review. Obstet Gynecol Int 2018; 2018:7365715.
  15. Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic Pain. Am Fam Physician 2016; 93:41.
  16. Woo AK. Depression and Anxiety in Pain. Rev Pain 2010; 4:8.
  17. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in health care settings. Health Hum Rights 2011; 13:E36.
  18. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359:1331.
  19. Westfall KM, Brown R, Charles AG. Appendiceal Malignancy: The Hidden Risks of Nonoperative Management for Acute Appendicitis. Am Surg 2019; 85:223.
  20. Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril 2014; 101:927.
  21. ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol 2018; 132:1517. Reaffirmed 2022.
  22. Sharma D, Day ME, Stimpson SJ, et al. Acute Vaso-Occlusive Pain is Temporally Associated with the Onset of Menstruation in Women with Sickle Cell Disease. J Womens Health (Larchmt) 2019; 28:162.
  23. Arden D, Lee T. Laparoscopic excision of ovarian remnants: retrospective cohort study with long-term follow-up. J Minim Invasive Gynecol 2011; 18:194.
  24. Vellido-Cotelo R, Muñoz-González JL, Oliver-Pérez MR, et al. Endometriosis node in gynaecologic scars: a study of 17 patients and the diagnostic considerations in clinical experience in tertiary care center. BMC Womens Health 2015; 15:13.
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