Patient Information

Pelvic Pain in Women

The pelvis is the lowest part of your tummy (abdomen). Pelvic pain is more common in women. There are many different causes of pain in your pelvis. They can be separated by when they tend to happen, if you are pregnant and if they are accompanied by other symptoms such as vaginal bleeding. The most common causes are mentioned below. Most will improve with painkillers. Most recurring causes have treatments available.

The pelvis is the lowest part of your tummy (abdomen). Organs in your pelvis include your bowel, bladder, womb (uterus) and ovaries. Pelvic pain usually means pain that starts from one of these organs. In some cases the pain comes from your pelvic bones that lie next to these organs, or from nearby muscles, nerves, blood vessels or joints. So, there are many causes of pelvic pain.

Pelvic pain is more common in women than in men. This leaflet will deal with the most common causes of pelvic pain in women.

Pelvic pain can be acute or chronic. Acute means that it is the first time you have had this type of pain. Chronic means that pain has been a problem for a long time – more than six months.

Miscarriage: miscarriage is the loss of a pregnancy at any time up to the 24th week. 7 or 8 miscarriages out of 10 occur before 13 weeks of pregnancy. The usual symptoms of miscarriage are vaginal bleeding and lower tummy (abdominal) or pelvic cramps. You may then pass some tissue from the vagina, which often looks like a blood clot.

Ectopic pregnancy: an ectopic pregnancy is a pregnancy that tries to develop outside the womb (uterus). It occurs in about 1 in 100 pregnancies. Usual symptoms include pain on one side of the lower abdomen or pelvis. It may develop sharply, or may slowly become worse over several days. It can become severe. Vaginal bleeding often occurs, but not always. It is often darker-coloured than the bleeding of a period.

Rupture of corpus luteum cyst: a corpus luteum makes hormones that help keep you pregnant, until other organs such as the placenta take over. It forms after the release of the egg at ovulation. They are often found, by chance, when you have an ultrasound scan for whatever reason. They often cause no problems at all and clear up without treatment. Sometimes it can become too swollen and may burst. This may cause sharp pain on one side of your pelvis. If you have pain in your pelvis in the first 12 weeks of your pregnancy, see your doctor.

Premature labour: normally labour starts after 37 completed weeks of pregnancy. Normal labour usually starts as tightenings felt across the lower abdomen. These become stronger, more painful and closer together. You may also have a ‘show’. This is the mucous plug from the neck of the womb (cervix). If you have a gush of fluid from the vagina, your waters may have broken. You should contact your midwife immediately. If you have pelvic pains that come and go in a regular pattern, contact your midwife for advice.

Placental abruption: rarely (about 6 times in every 1,000 deliveries), the placenta detaches from the wall of the womb. Before 24 weeks of pregnancy this is a miscarriage; however, after 24 weeks it is called an abruption. When it happens it is an emergency. This is because the baby relies on the placenta for food and oxygen. Without a working placenta, the baby will die. The staff in the maternity department will quickly try to deliver the baby. This is usually by emergency caesarean section.

Gynaecological problems

Ovulation: ovulation means producing an egg from your ovary. Some women develop a sharp pain when an egg is released. This ovulation pain is called ‘Mittelschmerz’ (middle pain – because it occurs mid-cycle). The pain may be on a different side each month, depending on which ovary releases the egg. This pain only lasts a few hours but some women find it is severe.

Period pains (dysmenorrhoea): most women have some pain during their periods. The pain is often mild but, in about 1 in 10 women, the pain is severe enough to affect day-to-day activities. The pain can be so severe that they are unable to go to school or work. Doctors may call period pain ‘dysmenorrhoea’.

Pelvic inflammatory disease (PID): PID is an infection of your womb. Germs (bacteria) that cause the infection usually travel into your womb from your vagina or cervix. Most cases are caused by chlamydia or gonorrhoea. Symptoms of PID include pain in your lower abdomen or pelvis, high temperature (fever), abnormal vaginal bleeding and a vaginal discharge.

Rupture or torsion of ovarian cyst: an ovarian cyst is a fluid-filled sac which develops in an ovary. Most ovarian cysts are non-cancerous (benign) and cause no symptoms. Some cause problems such as pain and irregular bleeding. Pain may happen when they burst (rupture) or twist (called torsion). No treatment may be needed for certain types of ovarian cysts which tend to go away on their own.

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Degenerative changes in a fibroid: fibroids are non-cancerous growths which can occur in your womb. They are common and usually cause no symptoms. However, they can sometimes cause heavy periods, abdominal swelling and urinary problems. Rarely, the fibroid outgrows its blood supply. This can make it shrink (degenerate) which can be very painful.

Endometriosis: this is a condition found in women between the ages of 13 and 50. It is most commonly diagnosed in women in their thirties. It is more common in women who are having trouble conceiving. In these women it can be found in 1 out of 5 of them. It causes pain around the time of your period. It may also cause pain when you have sex.

Chronic pelvic pain: this is the term used when a woman has had pain for at least six months. Chronic pelvic pain can occur in around 1 in 6 women so it is very common. Sometimes a cause is found (such as those above) and sometimes there is no obvious cause. If the source of your chronic pelvic pain can be found, treatment focuses on that cause. Some women never receive a specific diagnosis that explains their pain. If no cause can be found, your treatment will focus on managing the pain. Keeping a symptom diary is helpful. This may identify a pattern to the pain and triggers in your life that may be responsible. Depression, chronic stress or a past history of sexual or physical abuse increases your risk of developing chronic pelvic pain. In addition, any emotional distress often makes pain worse and living with chronic pain contributes to emotional distress. Your doctor will often consider psychological treatments to help with the pain. For more information see references below.

Bowel or bladder problems

Appendicitis: appendicitis means inflammation of your appendix. The appendix is a small pouch that comes off the gut wall. Appendicitis is common. Typical symptoms include abdominal pain and being sick (vomiting) that gradually get worse over 6-24 hours. Some people have less typical symptoms. An operation to remove the inflamed appendix is usually done before it bursts (perforates). A perforated appendix is serious.

Irritable bowel syndrome (IBS): IBS is a common gut disorder. The cause is not known. Symptoms can be quite variable and include abdominal pain, bloating, and sometimes bouts of diarrhoea and/or constipation. Symptoms tend to come and go. There is no cure for IBS but symptoms can often be eased with treatment.

Cystitis: this is a urine infection in the bladder. It is common in women. A short course of antibiotic medication is a common treatment. It may improve spontaneously without the need for antibiotics. Cystitis clears quickly without complications in most cases.

if you have symptoms of cystitis but there are no signs of infection when your urine is tested, you may have Interstitial cystitis. This is a poorly understood condition where the walls of the bladder are inflamed. It is a cause of long-term pain. It is also called ‘painful bladder syndrome’.

Adhesions: adhesions may happen after surgery. As your body tries to heal after surgery, the tissues become sticky. The stickiness may accidentally cause tissues to stick together. The most common organ affected is the bowel. This may cause pain.

Strangulated hernia: a hernia occurs where there is a weakness in the wall of the abdomen. As a result, some of the contents within the abdomen can then push through (bulge) under the skin. You can then feel a soft lump or swelling under the skin. There is a small chance that the hernia might strangulate. A hernia strangulates when too much bowel has come through the gap in the muscle or ligament and then becomes squeezed. This can cut off the blood supply to the portion of intestine in the hernia. This can lead to severe pain and some damage to the part of the intestines in the hernia.

Muscle and bone problems

Problems with your lower back, bones in your pelvis and nearby joints such as your hip joints can cause pain. Often it is clear where the pain is coming from. However, in some cases, the pain can feel like it is in your pelvis and it can be difficult to pinpoint its origin.

There are many different causes of pelvic pain. Some are more serious than others. If you are confident that you know the cause or the pain – for example, period pain – you could try taking a painkiller such as paracetamol or ibuprofen.

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If you are not sure of the cause of the pain or if the pain is severe, you should see a doctor. In particular, some causes are emergencies – for example, an ectopic pregnancy. Seek medical help urgently if you suspect this. You may also want to see a doctor if the pain keeps coming back. For many of the conditions listed above, there are treatments available.

Your doctor will ask you some questions and may examine you. Based on what they find, they may advise you to have some further investigations.

A urine infection is a very common cause of pelvic pain and your doctor may ask for a urine sample. If they think there is a risk of an infection, they may ask to take a sample (swab). A pregnancy test may be advised if you are unsure. They may arrange an urgent ultrasound (if miscarriage or ectopic pregnancy is suspected) at your local hospital. A routine ultrasound scan can be arranged to diagnose problems such as ovarian cysts.

Laparoscopy is commonly undertaken by gynaecologists. In this procedure, a small telescope is put through a small cut in your belly button. This allows the doctor to see inside your pelvis. See separate leaflet called Laparoscopy and Laparoscopic Surgery for more details.

Doctors who specialise in the bowel may use flexible telescopes to look inside your bowel. The gullet and stomach can be seen by gastroscopy. See separate leaflet called Gastroscopy (Endoscopy) for more details. The lower bowel (rectum and colon) are looked at by colonoscopy.

This will depend on the likely cause. Follow the links above to the separate leaflets for more information on this.

If the problem is not an emergency, your doctor may refer you to a consultant for further specialist investigations – as above.

Pelvic pain is both a common presentation in primary care and one of the most common reasons for referral to a gynaecologist. Pelvic pain may be either acute or chronic.

Acute pelvic pain is much more common in women than in men. Most women experience mild pelvic pain at some time due to periods, ovulation or sexual intercourse. In its severest form, it is the most common reason for urgent laparoscopic examination in the UK.

Aetiology

Common causes include pelvic inflammatory disease (PID), urinary tract infection (UTI), miscarriage, ectopic pregnancy and torsion or rupture of ovarian cysts.

  • Pregnancy-related: miscarriage, ectopic pregnancy, rupture of corpus luteum cyst; causes in later pregnancy include premature labour, placental abruption and (rarely) uterine rupture.
  • Gynaecological: ovulation (mid-cycle, may be severe pain), dysmenorrhoea, PID, rupture or torsion of ovarian cyst, degenerative changes in a fibroid; the possibility of a pelvic tumour or pelvic vein thrombosis should also be considered.
  • Other causes: these include appendicitis, irritable bowel syndrome (IBS), adhesions, prostatitis, strangulated hernia.

Investigations

  • Urinalysis, midstream specimen of urine (MSU).
  • High vaginal swab (HVS) for bacteria and endocervical swab.[1]
  • Pregnancy test.
  • FBC.
  • Urgent ultrasound (if miscarriage or ectopic pregnancy is suspected).
  • Laparoscopy.

Management

  • Management is based on identifying and treating the cause.
  • Empirical use of antibiotics and analgesia without a clear diagnosis should be avoided.
  • Referral is required if the diagnosis cannot be established if there is no response to treatment in primary care.
  • Urgent admission is necessary if there is a possibility of urgent treatment being required – eg,  ectopic pregnancy, appendicitis or if the patient is haemodynamically unstable.

Chronic pelvic pain is much more common in women than in men. It may occur in as many as 1 in 6 adult women.[2]

  • Chronic pelvic pain is defined as:
    • Intermittent or constant pain in the lower abdomen or pelvis in women.
    • Lasting for at least six months.
    • Not occurring exclusively with menstruation or sexual intercourse.
    • Not being associated with pregnancy.
  • Chronic pelvic pain is a symptom, not a diagnosis.
  • The prevalence of chronic pelvic pain in general practice has been estimated to range between 5.7% and 26.6%.[3]

Aetiology

  • The aetiology of chronic pelvic pain is still not well understood.
  • There is often more than one cause of the pain.
  • The pain may persist long after the original tissue injury has healed.
  • Psychological, social and physical factors are all important in the aetiology.
  • Persistence of pain may lead to changes within the central nervous system, which magnify the original signal.
  • Sensation and perception of pain can be influenced by previous experiences.
  • Nerve damage following surgery, trauma, inflammation, fibrosis or infection may play a part in pain perception.

Possible causes of chronic pelvic pain include:

  • Endometriosis:
    • Pain usually varies during menstrual cycle.
    • Can be associated with dysmenorrhoea and dyspareunia.
  • Adhesions:
    • May be caused by previous surgery, endometriosis, previous infection.
    • Some adhesions are asymptomatic.
  • IBS.
  • Interstitial cystitis.
  • Musculoskeletal problems.
  • Pelvic organ prolapse.
  • Nerve entrapment:
    • This can occur in scar tissue or fascia.
  • Psychological and social issues:
    • Depression and sleep disorders are common.
    • Women with chronic pelvic pain are more likely to have experienced physical or sexual abuse as children.
  • Other causes in men include epididymo-orchitis and testicular tumours.
  • Chronic pain in the region of the prostate was previously called chronic prostatitis; however, there is a proven bacterial infection in only 10% of these cases. The remaining 90% should now be classified as prostate pain syndrome (PPS), based on the fact that there is no proven infection or other obvious pathology.[4]
  • Initial history should include questions about the pattern of the pain and its association with other problems. These may include bladder and bowel symptoms and the effect of movement and posture on the pain.
  • Questions should be addressed regarding psychological and social issues.
  • Although many symptom complexes (eg, IBS) and pain perception itself may vary a little with the menstrual cycle (50% of women experience a worsening of their symptoms in association with their period), strikingly cyclical pain is usually gynaecological in nature – eg, endometriosis.
  • Suggested red flag symptoms and signs:[2]
    • Bleeding per rectum.
    • New bowel symptoms in patients over 50 years old (see ‘Investigations’, below).
    • New pain after the menopause.
    • Pelvic mass.
    • Suicidal ideation.
    • Excessive weight loss.
    • Irregular vaginal bleeding in patients over 40 years old.
    • Postcoital bleeding.
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NB: women with chronic pelvic pain often present without obvious cause on history, investigations or physical examination.[5]

  • Samples to screen for infection (particularly chlamydia and gonorrhoea) should be considered in all those who are sexually active.
  • If there is any suspicion of PID. Ideally, all sexually active women below the age of 25 years who are being examined should be offered opportunistic screening for chlamydia.
  • Blood tests such as FBC and CRP may be useful for some women.
  • Ca125 measurement is appropriate if symptoms suggesting ovarian cancer are experienced. A new diagnosis of IBS in a woman aged over 50 years is suspicious.[6]
  • Urinalysis and send MSU.
  • Transvaginal scanning (TVS) using ultrasound is an appropriate investigation to screen for and assess adnexal masses.
  • TVS and magnetic resonance imaging (MRI) are useful tests to diagnose adenomyosis. The role of MRI in diagnosing small deposits of endometriosis is uncertain.
  • Diagnostic laparoscopy has been regarded in the past as the gold standard in the diagnosis of chronic pelvic pain. It may be better seen as a second line of investigation if other therapeutic interventions fail.[2]
  • Further urological investigations (eg, cystourethroscopy) and/or bowel investigations (eg, barium enema) may be required.

Management is focused on identifying and treating the cause but the psychosocial causes and effects of chronic pelvic pain should also be considered. The management of chronic pelvic pain is challenging, as despite interventions involving surgery, many women remain in pain without a firm gynaecological diagnosis.[7]

  • The aim of treatment should be to develop a partnership between clinician and patient to plan a management programme.
  • A multidisciplinary approach to assessment and treatment with a focus on improving emotional, physical and social functioning instead of focusing strictly on pain reduction should be undertaken.
  • The woman should be given adequate time to tell her story. A symptom diary may be useful.
  • Appropriate management of any specific underlying disorder.
  • Many women with chronic pelvic pain can be managed in primary care. Referral should be considered when the pain has not been explained to the woman’s satisfaction or when pain is inadequately controlled.
  • If the history suggests a non-gynaecological component to the pain, referral to a gastroenterologist, urologist, genitourinary specialist, physiotherapist, psychologist or psychosexual counsellor should be considered.
  • Women with cyclical pain should be offered a therapeutic trial using the combined oral contraceptive pill or a gonadotrophin-releasing hormone (GnRH) agonist for a period of three to six months before having a diagnostic laparoscopy.[2] The levonorgestrel-releasing intrauterine system (Mirena® coil) could be considered.
  • Division of fine adhesions has not been proven to be beneficial.[2]
  • Appropriate analgesia to control pain, even if no other therapeutic manoeuvres are yet to be initiated. If pain is not adequately controlled, there may be a need to refer the patient to a pain management team or a specialist pelvic pain clinic.
  • For men with PPS, the following are recommended:[4]
    • Alpha-blockers in those with symptoms for less than one year.
    • Antibiotics (quinolones or tetracyclines) for at least six weeks for those with symptoms for less than one year.
    • Non-steroidal anti-inflammatory drugs (NSAIDs) may be effective.
    • Electro-acupuncture or perineal extracorpreal shock wave therapy may be considered for some men.


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