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Pelvic pain

Specialties > General practice

Differential Diagnosis Schema 🧠

Gynecological Causes

  • Dysmenorrhea: Painful menstruation, typically crampy and located in the lower abdomen; often accompanied by nausea and fatigue.
  • Endometriosis: Chronic pelvic pain, dysmenorrhea, and dyspareunia; may involve bowel or bladder symptoms.
  • Pelvic inflammatory disease (PID): Acute or chronic pelvic pain with fever, vaginal discharge, and cervical motion tenderness.
  • Ovarian cyst: Sudden, unilateral pain if ruptured; chronic pain if large or causing torsion.
  • Ectopic pregnancy: Acute, sharp pain with amenorrhea and vaginal bleeding; a medical emergency.
  • Adenomyosis: Diffuse pelvic pain, menorrhagia, and a tender, enlarged uterus.
  • Fibroids: Intermittent or constant pelvic pain, often associated with heavy menstrual bleeding.
  • Ovarian torsion: Sudden onset of severe unilateral pelvic pain; may also have nausea and vomiting.

Gastrointestinal Causes

  • Appendicitis: Initially peri-umbilical pain that localizes to the right lower quadrant; may be associated with fever and anorexia.
  • Irritable bowel syndrome (IBS): Recurrent abdominal pain associated with changes in bowel habits, relieved by defecation.
  • Diverticulitis: Left lower quadrant pain, often with fever and altered bowel habits.
  • Inflammatory bowel disease (IBD): Chronic pain, diarrhea, and systemic symptoms such as weight loss; includes Crohn’s disease and ulcerative colitis.
  • Constipation: Chronic or acute pelvic pain due to fecal impaction, often relieved by bowel movement.
  • Gastroenteritis: Diffuse abdominal pain with diarrhea, nausea, and vomiting; usually self-limiting.
  • Bowel obstruction: Cramping pain with vomiting, abdominal distension, and absent bowel movements.

Urological Causes

  • Urinary tract infection (UTI): Suprapubic pain, dysuria, and urinary frequency; may progress to pyelonephritis if untreated.
  • Interstitial cystitis: Chronic pelvic pain, urgency, and frequency without infection; also known as painful bladder syndrome.
  • Kidney stones: Sudden, severe flank pain radiating to the groin; may be associated with hematuria.
  • Bladder cancer: Painless hematuria with pelvic pain in advanced stages.
  • Prostatitis: Pelvic pain, perineal discomfort, dysuria, and urinary frequency in males; may be acute or chronic.
  • Benign prostatic hyperplasia (BPH): Lower urinary tract symptoms with suprapubic discomfort, more common in older men.

Musculoskeletal Causes

  • Pelvic girdle pain: Common in pregnancy; pain localized to the sacroiliac joints and pubic symphysis.
  • Pelvic floor dysfunction: Chronic pelvic pain with difficulty urinating or defecating; often associated with a history of pelvic trauma or surgery.
  • Hernia: Painful swelling in the groin or lower abdomen, which may increase with straining or lifting.
  • Coccygodynia: Pain localized to the coccyx, often exacerbated by sitting.
  • Pubic symphysis dysfunction: Pain in the pubic area, commonly associated with pregnancy.
  • Osteitis pubis: Inflammation of the pubic symphysis causing pelvic pain, often related to overuse or trauma.

Other Causes

  • Psychogenic pelvic pain: Chronic pelvic pain without an identifiable cause; may be associated with a history of trauma, abuse, or psychological conditions.
  • Referred pain: Pain from other organs such as the kidneys, ureters, or gastrointestinal tract, referred to the pelvic area.
  • Pelvic adhesions: Chronic pain due to fibrous bands of tissue that form after surgery or infection, causing organs to stick together.
  • Pelvic masses: Pain due to the presence of a mass such as an ovarian cyst, fibroid, or malignancy, exerting pressure on surrounding structures.
  • Vulvodynia: Chronic pain or discomfort in the vulva without an identifiable cause, often described as burning or stinging.

Key Points in History 🥼

Onset and Duration

  • Acute onset: Suggests conditions such as ectopic pregnancy, ovarian torsion, appendicitis, or renal colic.
  • Chronic or intermittent pain: More consistent with conditions like endometriosis, IBS, or pelvic inflammatory disease.
  • Cyclical pain: Associated with menstrual cycle; often seen in endometriosis or dysmenorrhea.
  • Progressive pain: May indicate a growing mass, such as a fibroid or malignancy.
  • Pain related to specific activities: For example, pain during intercourse (dyspareunia) suggests endometriosis, while pain on urination (dysuria) may suggest a UTI or interstitial cystitis.

Associated Symptoms

  • Fever and chills: Suggests an infectious cause such as pelvic inflammatory disease, appendicitis, or UTI.
  • Vaginal bleeding: Concerning in ectopic pregnancy, miscarriage, or malignancy; also seen in endometriosis and fibroids.
  • Gastrointestinal symptoms: Bloating, diarrhea, or constipation may suggest IBS, IBD, or diverticulitis.
  • Urinary symptoms: Dysuria, frequency, and urgency suggest UTI, interstitial cystitis, or renal colic.
  • Nausea and vomiting: Common in acute conditions like appendicitis, ovarian torsion, or renal colic.
  • Weight loss and systemic symptoms: Concerning for malignancy, especially if accompanied by persistent pain.
  • Dyspareunia: Painful intercourse, often associated with endometriosis, PID, or pelvic adhesions.

Background

  • Obstetric and gynecological history: Includes details of menstrual cycle, pregnancies, miscarriages, and any previous gynecological conditions or surgeries.
  • Sexual history: Important for assessing risk of STIs, PID, and ectopic pregnancy.
  • Family history: Consider familial predispositions to conditions like ovarian cancer, endometriosis, or IBD.
  • Past medical history: Includes previous episodes of similar pain, known conditions like endometriosis, IBS, or hernias.
  • Medication use: Review for use of contraceptives, NSAIDs, or other medications that could influence pain or be associated with side effects like gastrointestinal discomfort.
  • Social history: Includes smoking, alcohol, and substance use, as well as stress levels and support systems.

Possible Investigations 🌡️

Imaging

  • Transvaginal ultrasound: First-line imaging for gynecological causes such as ovarian cysts, fibroids, and ectopic pregnancy.
  • Pelvic ultrasound: Useful for assessing both gynecological and urological causes; can evaluate the size, location, and characteristics of masses or cysts.
  • CT abdomen/pelvis: Considered if there is suspicion of appendicitis, diverticulitis, or other gastrointestinal causes of pelvic pain.
  • MRI pelvis: Particularly useful for detailed assessment of soft tissue structures and for complex gynecological conditions like endometriosis.
  • Laparoscopy: Both diagnostic and therapeutic; used for direct visualization of the pelvic organs, especially in cases of chronic pelvic pain, suspected endometriosis, or adhesions.
  • Cystoscopy: Indicated if there is suspicion of bladder involvement, such as in interstitial cystitis or bladder cancer.

Laboratory Tests

  • Full blood count (FBC): Helps detect infection, anemia, or inflammation.
  • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated in cases of infection or inflammation, such as PID or diverticulitis.
  • Urinalysis and urine culture: Essential for diagnosing UTI or hematuria related to renal stones or bladder pathology.
  • Pregnancy test (Beta-hCG): Essential in women of childbearing age to rule out or confirm pregnancy, particularly ectopic pregnancy.
  • Vaginal swabs: For detecting STIs or pathogens causing PID.
  • Serum electrolytes: Important if there is suspicion of bowel obstruction or metabolic disturbances.
  • CA-125: May be elevated in ovarian cancer and endometriosis, though it is not specific.
  • Liver function tests: Consider in cases where systemic disease or malignancy is suspected.
  • Endometrial biopsy: Indicated if there is abnormal uterine bleeding or suspicion of endometrial cancer.
  • Stool tests: For occult blood if gastrointestinal causes are suspected, such as IBD or colorectal cancer.

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