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Jose G. Veliz, M.D. M.S.A.
Medical Director
Palomar Pain Management Center
Pomerado Pain Management Center
Posted April 01, 2008 10:02 PM
 Acute pelvic pain is defined as pain occurring in the pelvis that begins over a short period of time anywhere from a few minutes to a few days. It is often a warning sign that something is wrong and should be evaluated immediately. Pelvic pain that lasts more than six months and does not improve with treatment is classified as chronic pelvic pain. Acute pelvic pain starts over a short time (a few minutes to a few days). Chronic pelvic pain can either be constant or can come and go. Both types of pain require a prompt visit to your doctor.
Acute pelvic pain commonly has a single cause. Many studies show that a diagnosis made by using the history, a physical examination, and laboratory data is frequently wrong. Unfortunately, most of the complications occurring with acute pelvic pain are related to delays in making the correct diagnosis.
Causes of acute pelvic pain include the following:
- Ectopic pregnancy
- Abortion
- Acute pelvic inflammatory disease
- Ovarian cyst
- Endometriosis
- Pelvic neoplasia
- Uterine leiomyoma
- Acute appendicitis especially if the pain is in the right lower quadrant of the abdomen
- Urinary tract infection
- Gastrointestinal problems including diverticulitis and irritable bowel syndrome
- Kidney stones or bladder stones
- Sexual abuse
- Trauma such as bowel or bladder perforation
One of the serious causes of acute pelvic pain is a ruptured tubal (ectopic) pregnancy. Due to the fact that women continue to have menstrual like bleeding, they frequently do not consider this possibility. A very dangerous mistake is to delay the diagnosis of ectopic pregnancy. The best approach is to assume every woman of child bearing age may be pregnant until proven otherwise. Because a tubal pregnancy can be present for months, it is important to have a pregnancy test if a woman with pelvic pain has had intercourse within the last six months.
Most ovarian cysts do not need to be treated emergently. On occasion, an ovarian cyst may twist (undergo torsion) and cut off the blood supply to the ovary. The ovary may die if the cyst is not immediately removed surgically. Although not common an ovarian cyst can rupture leading to internal bleeding which is serious if not promptly treated. Fortunately, there is no danger most of the time if a cyst should rupture. There are certain types of cysts (dermoids) which contain material that can be very irritating leading to peritonitis if not treated urgently. Peritonitis is defined as inflammation of the lining of the abdomen. Despite the fact that most ovarian cysts ruptures are not dangerous, they can be extremely painful. This will obviously require acute pain management until the event subsides.
Another cause of acute pelvic pain which requires urgent treatment is a pelvic infection (pelvic inflammatory disease) caused by chlamydia or gonorrhea. Delaying treatment could result in serious damage to the pelvic organs. Laparoscopy, a procedure in which a small telescope examines the tubes and ovaries, may be needed to make an accurate diagnosis.
Other non-gynecologic causes of acute pelvic pain which should be treated immediately include appendicitis, trauma, kidney infections, etc.
Associated symptoms of acute pelvic pain may include urinary or gastrointestinal symptoms, fever, abnormal bleeding or vaginal discharge. Your doctor will perform a history and important information that he or she may ask include the following:
- Age
- Menstrual history
- Characteristics of pain such as onset , duration or severity
- Urinary symptoms
- Nausea, vomiting
- Vaginal discharge
- Fever
- Abnormal uterine bleeding
- History of pelvic inflammatory disease or ectopic pregnancy
- Method of contraception
- Sexual history including number of sex partners
- Symptoms of urethritis in male partner
The risk for pelvic inflammatory disease is higher in the presence of the following:
- Presence of an IUD
- Age between 15-25 years
- Single with more than one sex partner
- A male partner that has symptoms of urethritis
- History of pelvic inflammatory disease
- History of gonococcal cervicitis
A history of delayed menses, abnormal uterine bleeding or a prior history of ectopic pregnancy should immediately alert your doctor to the possibility of an ectopic pregnancy. Women who reliably use oral contraceptives are at a lower risk for developing an ectopic pregnancy or the complications of a functional ovarian cyst.
Your doctor will perform a careful physical examination focusing mainly on the abdominal and pelvic areas. The physical examination may include the following:
- Temperature check
- Changes in blood pressure and pulse that occur with changes in body position
- Abdominal examination
- Pelvic examination
- Laboratory studies may be ordered. These include a complete blood count which may give information suggesting bleeding or infection. Another laboratory test is the erythrocyte sedimentation rate. A routine urinalysis may provide information suggesting infection or bleeding.
- A cervical gram stain is obtained using material from the cervix and can assist in diagnosing acute pelvic inflammatory disease.
- Examination of the sex partner may provide evidence for the diagnosis of pelvic inflammatory disease.
- A urinary or serum pregnancy test may be performed
- Culdocentesis may be performed. This is a test that checks for abnormal fluid in the space just behind the vagina. A long thin needle is inserted through the vaginal wall just below the uterus and a sample is taken of any fluid found in the space.
- A pelvic ultrasound may be performed to examine the uterus, tubes and ovaries.
- Finally if testing up to this point is inconclusive, diagnostic laparoscopy which involves placing a small telescope into the abdomen and pelvis may be necessary to rule out life threatening disorders such as ectopic pregnancy or acute appendicitis.
In patients who have acute pelvic pain and in whom pregnancy has been ruled out, the next helpful piece of information is whether the pain is unilateral (one side) or bilateral (both sides). For those patients with unilateral pain, the most likely causes are ovarian cysts, acute appendicitis or pelvic inflammatory disease. If the pain is unilateral and left sided acute appendicis is less likely.
If all testing including diagnostic laparoscopy is negative, other tests may be performed to rule out gastrointestinal or urologic causes. These tests include colonoscopy, sigmoidoscopy, barium enema and CT scan of the abdomen. These tests are done to search for gastrointestinal causes of acute pelvic pain. Cystoscopy to examine the bladder may be performed and intravenous pyelography may be performed to examine the urinary tract including the kidneys and ureters.
Acute pelvic pain caused by infections are treated with antibiotics. Pain may be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen . Acetaminophen (Tylenol) can also be used to lessen the pain. For severe cases of pain, narcotics may be prescribed. Birth control pills, anti-depressants and nerve blocks have also been used to treat acute pelvic pain.
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