Pelvic Pain

You may assume that pelvic pain always comes from the womb or ovaries, or that severe pain must have one visible cause on a scan. Pelvic pain can arise from reproductive organs, the urinary tract, bowel, muscles, nerves or the abdominal wall. Pregnancy related emergencies, infection and sudden ovarian problems must be considered before a longer term pain diagnosis is made.

Pelvic pain is felt below the abdomen Pelvic pain is pain in the lower abdomen, between the hip bones and sometimes extending into the lower back, groin, vagina or rectum. It may be sudden or gradual, constant or intermittent, one sided or central, sharp, aching, burning or cramping, related to periods, triggered by sex, urination, bowel movements or movement, or accompanied by bleeding, discharge or urinary symptoms. The character of pain helps organise possibilities but cannot diagnose the cause alone. Several systems occupy the pelvis Pelvic pain may arise from the womb, ovaries or fallopian tubes, cervix or vagina, bladder and urinary tract, bowel and appendix, pelvic floor muscles, hip or abdominal wall structures, nerves, or blood vessels. More than one source can contribute at the same time. Pregnancy testing is a safety step If pregnancy is biologically possible, clinicians commonly test for pregnancy because the result changes the urgent differential diagnosis. This remains relevant when contraception is used, bleeding resembles a period, periods are irregular, there is no known pregnancy, pain is mild, or fertility treatment has been used. A negative test taken extremely early may occasionally need repeating when symptoms continue. Ectopic pregnancy can present in different ways An ectopic pregnancy develops outside the main cavity of the womb, most often in a fallopian tube. Possible features include missed or unusual period, positive pregnancy test, one sided pelvic or abdominal pain, vaginal bleeding or brown watery discharge, shoulder tip pain, pain when opening your bowels, urinary discomfort, or dizziness or faintness. Symptoms often develop between about 4 and 12 weeks, but the presentation varies. Collapse may occasionally be the first clear sign. Call 999 for severe pain, shoulder tip pain, collapse or signs of major internal bleeding. A miscarriage can also cause pain and bleeding Miscarriage may cause vaginal spotting or heavier bleeding, cramping, passage of clots or tissue, or reduction in pregnancy symptoms. Bleeding does not always mean that a pregnancy is miscarrying, and the severity of bleeding does not reliably distinguish miscarriage from ectopic pregnancy. Early pregnancy assessment may involve ultrasound and serial pregnancy hormone tests. Sudden one sided pain may arise from an ovary An ovarian cyst can stretch the ovary, bleed, rupture, cause pressure, or twist the ovary. Ovarian torsion occurs when the ovary twists around its supporting tissues, reducing its blood supply. A typical concerning pattern is sudden severe one sided pain, nausea or vomiting, rapidly worsening pain, or dizziness or faintness. Urgent assessment is required because torsion may need emergency surgery. A cyst rupture can produce sudden pelvic or lower abdominal pain, one sided pain, light bleeding, nausea, or dizziness. Many cyst ruptures settle with observation and pain relief, but internal bleeding, severe pain, pregnancy and circulatory symptoms require emergency assessment. A scan finding of an ovarian cyst does not prove that every future pain episode is caused by it. Pelvic inflammatory disease requires prompt treatment Pelvic inflammatory disease, or PID, is infection and inflammation affecting the upper reproductive tract. Possible symptoms include pelvic or lower abdominal pain, deep pain during sex, abnormal vaginal discharge, bleeding between periods, bleeding after sex, pain when passing urine, fever, or nausea or vomiting. Symptoms may be mild, and not everyone has fever or discharge. Untreated PID can contribute to chronic pain, fertility problems and increased ectopic pregnancy risk. Chlamydia and gonorrhoea are important possible causes, but other bacteria can also produce PID. A diagnosis should not be treated as proof of a particular sexual event or infidelity. Testing, partner notification and treatment are handled confidentially and without judgement. Call 999 or attend A&E when pelvic pain associated with possible PID is severe or worsening, accompanied by heavy bleeding, sharp and sudden, associated with faintness, or accompanied by high fever, vomiting or marked illness. Pregnancy also lowers the threshold for urgent hospital review. Endometriosis can cause cyclical or persistent pain Endometriosis should be considered when you have one or more of chronic pelvic pain, period pain affecting daily activities, deep pain during or after sex, cyclical pain when opening your bowels, cyclical urinary pain, or fertility difficulties. Pain can occur during and between periods. A normal examination or ultrasound does not exclude endometriosis. Clinicians are advised to consider the diagnosis from symptoms, including in young people aged 17 and under. Adenomyosis and fibroids may produce pressure or pain Adenomyosis can cause painful periods, heavy bleeding, persistent pelvic aching, pain during sex, or a bulky or tender womb. The symptom pattern overlaps with endometriosis and fibroids. Fibroids can produce heavy bleeding, pelvic pressure, abdominal enlargement, constipation, urinary frequency, pain during sex, or pain from degeneration in some circumstances. Many fibroids do not cause pain. Period pain can occur without a separate disease Primary dysmenorrhoea is period pain caused by womb contractions without an identified pelvic disease. It usually begins around the start of bleeding, lasts one to three days, may spread to the back or thighs, and improves with anti inflammatory treatment when safe. Pain that begins later in life, progressively worsens, occurs between periods or is accompanied by deep sexual pain, bowel symptoms or heavy bleeding warrants assessment for a secondary cause. Some people experience short lived mid cycle pain around ovulation, usually one sided, mild to moderate, brief, and unaccompanied by major illness. Severe, prolonged or recurrent pain should not be assumed to be normal ovulation without assessment. Pelvic pain can come from the bladder or bowel Possible urinary causes include UTI, kidney or ureteric stone, urinary retention, or bladder pain syndrome. Clues may include burning during urination, frequency, urgency, blood in urine, side or back pain, or pain related to bladder filling. Fever and loin pain may indicate kidney infection. Possible bowel causes include constipation, irritable bowel syndrome, gastroenteritis, inflammatory bowel disease, diverticulitis, or appendicitis. Features such as vomiting, diarrhoea, blood in stool, abdominal swelling or inability to pass stool or wind may change urgency. Appendicitis can begin with central abdominal pain before moving towards the lower right abdomen. Muscles and nerves may contribute Pelvic floor muscles can become tight, tender, poorly coordinated, or painful after injury, surgery, childbirth or prolonged guarding. Possible symptoms include pain during penetration, pain after sex, pain when sitting, urinary urgency, difficulty opening the bowels, or pain without abnormal scans. Musculoskeletal and nerve pain should be considered after urgent organ related causes have been assessed. Long lasting pain may become influenced by altered nerve sensitivity, muscle guarding, poor sleep, fear of movement, stress, repeated painful examinations, loss of activity, or mood changes. This does not mean the pain is imaginary. A person centred plan may need gynaecological, pelvic health, pain management and psychological components. Menopause does not make pelvic pain automatically normal After menopause, new pelvic pain may arise from genitourinary tissue changes, urinary infection, bowel disease, pelvic floor problems, ovarian or uterine disease, or cancer. Persistent pain with bloating, early fullness, reduced appetite or urinary frequency warrants assessment for ovarian disease. Primary care testing for persistent or frequent pelvic or abdominal pain suggestive of ovarian cancer is recommended, particularly in people aged 50 or over. Concern increases when bloating is persistent, frequent, new, accompanied by pelvic pain, associated with early fullness, or accompanied by weight loss or urinary frequency. These symptoms are common and usually have non cancerous explanations, but they require evaluation when persistent. Assessment, examination and imaging Useful details include: Exact location. Sudden or gradual onset. Relationship to periods. Pregnancy possibility. Bleeding or discharge. Pain during sex. Urinary symptoms. Bowel symptoms. Nausea or vomiting. Fever. Previous surgery or pregnancy. Contraception. Fertility treatment. Effect on sleep and daily activity A symptom diary may help with recurrent pain. Assessment may involve vital signs, abdominal examination, urine testing, pregnancy testing, speculum examination, internal pelvic examination, sexual health testing, or rectal examination in selected circumstances. You should be told why each examination is proposed. You can request a chaperone and discuss alternatives when an internal examination is unsuitable or declined. Possible imaging includes pelvic ultrasound, transvaginal ultrasound, abdominal ultrasound, CT, MRI, or laparoscopy in selected cases. Ultrasound may identify pregnancy location, cysts, fibroids or masses. A normal scan does not exclude all causes, particularly endometriosis, PID, pelvic floor pain or bowel disease. Paracetamol or an anti inflammatory medicine may be appropriate for some non emergency pain patterns. However, seek advice before anti inflammatory medicines if you may be pregnant, have stomach ulcers, have kidney disease, take anticoagulants, have certain forms of asthma, or have significant heart disease. Severe pain requiring repeated high doses needs reassessment rather than indefinite self treatment.

Pelvic pain is assessed through five questions: did the pain begin suddenly or gradually, could you be pregnant, are infection, bleeding or a surgical emergency present, does the pain follow a cyclical, urinary, bowel, sexual or movement related pattern, and how is pain affecting function over time. The first task is to identify immediate danger. The next is to understand the pattern rather than assume one organ is responsible.