Pelvic Pain in Women

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Pelvic Pain in Women — Acute & Chronic

Pelvic pain is one of the commonest reasons women come to a gynaecologist. This sheet gives how to find the dangerous cause of acute pain, and how to assess and treat chronic pain when many causes overlap.

🎯 AT A GLANCE — PELVIC PAIN IN WOMEN

Acute pelvic pain is an emergency until ectopic pregnancy, torsion, ruptured cyst, severe PID and appendicitis are considered

Test every woman of reproductive age for pregnancy; a positive test with no intrauterine pregnancy is an ectopic until proven otherwise (AAFP)

Ectopic pregnancy occurs in about 8 per 1,000 pregnancies and causes about 6% of maternal deaths

Transvaginal ultrasound is first-line for gynaecological causes; appendicitis: ultrasound first, then CT if unclear

Chronic pelvic pain is non-cyclical pain lasting more than 6 months; it affects about 1 in 6 women

It is usually multifactorial: gynaecological, bowel, bladder, muscle, nerve and psychological causes overlap, so a single operation or drug rarely cures it

Acute: pregnancy test first, then look for the one that kills. Chronic: listen, examine the muscles and the nerves, treat each part, and avoid opioids and repeated surgery.

🚨 ACUTE PAIN — ADMIT OR CALL THE SENIOR IF…

Pulse over 100, low blood pressure or a history of collapse — think of ruptured ectopic or haemorrhagic cyst

Peritonism, severe pain or pain much worse on movement

Temperature over 38°C, or fever with rigors — think of sepsis, tubo-ovarian abscess, appendicitis

Shoulder-tip pain

Positive pregnancy test with no pregnancy in the uterus on scan

Post-menopausal pain with bleeding — exclude cancer

An adolescent who has not menstruated and has cyclical pain — think of an imperforate hymen

PART A · ACUTE PELVIC PAIN — find the dangerous cause first

🩺 HISTORY AND EXAMINATION

Note the onset, site, radiation, severity, and what makes it better or worse

Ask about the last period, bleeding, discharge, contraception, previous ectopic or pelvic infection, and bowel and urine symptoms

Take a sexual history, and ask about abuse and violence

Record temperature, pulse, blood pressure, respiratory rate and oxygen saturation

Examine the abdomen, then do a speculum and bimanual examination

Cervical motion or adnexal tenderness suggests PID; one-sided adnexal tenderness or mass suggests cyst or torsion; nodular, tender uterosacral ligaments suggest endometriosis

Right iliac fossa tenderness suggests appendicitis; pain that increases when she tenses the abdominal wall (Carnett sign) suggests an abdominal wall cause

🧭 ACUTE PAIN: THE FIRST STEPS

🔍 WHAT IT MAY BE

Cause	Clues	Next step
Ectopic pregnancy	Positive test; pain with or without bleeding; shoulder-tip pain; collapse	Transvaginal ultrasound and hCG; surgical review if unstable
Miscarriage, non-viable pregnancy	Bleeding and cramps in early pregnancy	Ultrasound
Ruptured or haemorrhagic ovarian cyst	Sudden one-sided pain; free fluid; may be unstable	Ultrasound; observe or operate
Ovarian torsion	Sudden one-sided pain with vomiting; adnexal mass or tenderness; any age	Ultrasound and gynaecology; laparoscopy if suspicion is high, even if imaging is normal (from memory)
Pelvic inflammatory disease	Cervical motion tenderness, fever, discharge; a clinical diagnosis	Chlamydia and gonorrhoea swabs; ultrasound for abscess; treat early
Appendicitis	Right iliac fossa pain; McBurney, Rovsing and psoas signs	Ultrasound; CT if unclear
Urinary: UTI, stone	Urine symptoms; loin pain	Urine test and culture
Fibroid, endometriosis, ovulation or period pain	Cyclical pattern, known fibroid	Analgesia; follow-up; ultrasound (from memory)

🧪 INVESTIGATIONS

Pregnancy test; urine dipstick and mid-stream culture; chlamydia and gonorrhoea swabs if infection is suspected

Full blood count and CRP; serum hCG if ectopic is suspected; blood group

Transvaginal ultrasound is the first-line scan for the pelvis; a full bladder helps if a transvaginal scan is not possible

CT for urinary or bowel causes, after pregnancy is excluded; MRI if ultrasound and CT do not settle it

💊 MANAGEMENT

Situation	Action
Severe or unstable	IV access and fluids, full blood count, group and save, analgesia, nil by mouth, sepsis pathway if needed, senior review
Ectopic pregnancy, ruptured or unstable	Urgent surgical consultation
Ectopic suspected, stable, hCG under 2,000 and no mass	Repeat hCG and scan in 48 hours; if hCG rises by less than 66%, call gynaecology
Stable and mild	Simple analgesia, urgent outpatient review, clear instructions to return

PART B · CHRONIC PELVIC PAIN — non-cyclical pain lasting more than 6 months

🔍 THE CAUSES USUALLY OVERLAP

System	Common causes
Gynaecological	Endometriosis, adenomyosis, chronic PID, fibroids, prolapse, adhesions, gynaecological cancer; genital tuberculosis is important in India (from memory)
Bladder	Bladder pain syndrome (interstitial cystitis); it often coexists with endometriosis
Bowel	Irritable bowel syndrome, diverticular disease
Muscle and joint	Myofascial trigger points and pelvic floor tenderness, often overlooked and perhaps more common than visceral causes; sacroiliac joint, back
Nerve	Central sensitisation; neuropathic pain
Mind	Depression, anxiety, past abuse; they both cause and result from chronic pain

🚨 CHRONIC PAIN — REFER URGENTLY IF…

Rectal bleeding, new bowel symptoms over 50, or a pelvic mass

Pain that begins after the menopause, or irregular bleeding over 40, or postcoital bleeding

Marked weight loss, or regular bloating, early satiety or urinary urgency (check CA125)

Suicidal thoughts — respond at once

🩺 ASSESSING CHRONIC PAIN

Ask how the pain changes with periods, sex, passing urine and opening the bowels; ask about abuse, violence, mood and what the pain stops her doing

Keep a pain diary over 2 to 3 cycles

Examine the abdomen, back and sacroiliac joints; feel the pelvic floor muscles with one finger; do the Carnett and FABER tests

Screen for sexually transmitted infections; do a pelvic ultrasound; it does not diagnose endometriosis unless there is an endometrioma

Laparoscopy is the gold standard for endometriosis, but it is done in hospital and is not a routine test

Other tests only if the picture suggests them

💊 TREATING CHRONIC PAIN

Problem	Treatment	Notes
Cyclical pain: endometriosis, adenomyosis	3 to 6 month trial of ovarian suppression: combined pill, progestogen or levonorgestrel IUS	If there is no response after 3 months, refer; the specialist may add a GnRH analogue or laparoscopy
Pain relief	Paracetamol or NSAIDs	Opioids are not recommended
Irritable bowel	Lifestyle advice, low-FODMAP diet; antispasmodic	Refer if bowel red flags
Myofascial and pelvic floor pain	Pelvic floor physiotherapy; trigger-point injection	Botulinum toxin only if physiotherapy fails
Neuropathic component	Amitriptyline, an SNRI, gabapentin or pregabalin	Evidence is limited; the GaPP2 trial found no benefit from gabapentin
Psychological	Cognitive behavioural therapy; psychosexual counselling	Treat depression and anxiety as part of the pain care
Surgery	Do not use uterosacral nerve ablation, presacral neurectomy or adhesiolysis for pain	They do not improve chronic pelvic pain; adhesiolysis may worsen it

Say: “Your pain is real, it has several parts, and we shall treat each of them. It may not go completely, but it can be a lot less.” Refer to a multidisciplinary pain team if there is no progress.

⚠️ COMMON PITFALLS

Missing the pregnancy test in a woman with acute pain

Calling a normal Doppler a reason to exclude torsion (from memory)

Discharging a woman with a positive test and no pregnancy in the uterus without a plan

Treating chronic pain only as gynaecological

Not examining the pelvic floor muscles

Repeated surgery or opioids for chronic pain

Ignoring mood, abuse and what the pain means to her

Forgetting genital tuberculosis in an infertile Indian woman with chronic pain (from memory)

Memory Aid

PELVIC

Six steps for pelvic pain.

P

Pregnancy test first, in every woman of reproductive age

E

Ectopic until proven otherwise

L

Look for torsion, PID and appendicitis; examine carefully

V

Vital signs and red flags decide who is admitted

I

Imaging — transvaginal ultrasound first

C

Chronic pain — treat every part: ovary, bowel, bladder, muscle, nerve, mind

Remember: in acute pain exclude the dangerous cause; in chronic pain listen, examine, and treat in several ways.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the AAFP article “Acute Pelvic Pain” (2023); the NHS Greater Glasgow and Clyde guideline 312 “Acute pelvic pain: initial management” (reviewed 2018, now overdue for review); the AAFP article on chronic pelvic pain (2021); and the Barts Health NHS community gynaecology guidance on chronic pelvic pain (2020). Items marked “from memory” (torsion and Doppler, some differential clues, genital tuberculosis) were not checked. PID antibiotic regimens and detailed ectopic treatment are not given here: follow your local protocol. The sources are from the United States and the United Kingdom; services and drugs differ in India.