Acute pelvic pain - red flag symptoms

An overview of the causes of pelvic pain in both men and women and indications for referral.

Consider ectopic pregnancy
Consider ectopic pregnancy

Red flags

  • Pelvic mass
  • Pregnancy
  • Vaginal bleed and pain in postmenopausal women
  • Testicular mass/torsion

Acute pelvic pain is defined as pelvic pain lasting for less than three months. It is more common in women than men. 

Most women experience mild pelvic pain at some time during menstrual periods, ovulation or sexual intercourse.

It is the most common reason for urgent laparoscopic examination in the UK.

Multiple organ systems can contribute to pelvic pain. Gastrointestinal, genitourinary, and musculoskeletal systems all must be considered in patients who present with this symptom.

It is a common presentation in primary care. Evaluation can be challenging because of a broad differential diagnosis and many associated signs and symptoms are nonspecific.

Questions to ask

The initial approach to the patient with pelvic pain includes a detailed and thorough history and physical examination. History might not result in exact diagnosis, but helps us to focus the differential diagnosis and guide further evaluation.

Evaluate the location, duration (constant or intermittent), onset, radiation, associated symptoms, severity, quality (sharp or dull ache), alleviating and aggravating factors and previous history of similar pain.

Relevant organ system symptoms (urinary, gastrointestinal and musculoskeletal) should also be reviewed as there are many non-gynaecologic causes of pelvic pain.

A detailed sexual history is of paramount importance in the evaluation of acute pelvic pain, as pelvic inflammatory disease and ectopic pregnancy are major considerations. In male patients, it is important to ask about testicular pain and urethral discharge.

Past medical and surgical histories are also important. Any history of abdominal surgery increases the risk of bowel obstruction. Adnexal pathology (ovarian or paratubal cyst, hydrosalpinx) is a risk factor for adnexal torsion.

Social history may be important, especially if there is any substance abuse, history of domestic violence or high-risk behaviour.

Family history may be relevant (history of coagulation disorders or sickle cell disease).


Vital signs should be obtained immediately. If the patient has marked hypotension, tachycardia or fever, a focused history and a directed physical examination are performed concurrently to expedite emergency treatment.

In women, pelvic examination should be performed besides abdominal examination. The external genitalia should be visually inspected for lesions first. The vagina and cervix should be visualised by speculum examination. The bladder, vaginal walls, and levator muscles should be palpated with 1 or 2 fingers after the speculum examination to assess for tenderness in these regions.

In men, examination of genitalia and prostate should be performed.

In both sexes, the hernia orifices should be examined along with DRE if history suggests. Pelvic floor muscles and thigh muscles should also be examined.

Body habitus plays a role in the quality of examination as palpation of pelvic organs may be limited by obesity.

Examination in women should include abdominal and pelvic examination, taking swabs if indicated.

In both sexes, the hernial orifices should be examined, with rectal examination if appropriate. In men, examination of the external genitalia and prostate should be performed.


  • Urine dipsticks/MSU
  • Full blood count
  • Urine pregnancy test and transvaginal ultrasound (if suspected pelvic mass) in women
  • Endometrial pipette sampling or hysteroscopy (suspected endometrial pathology)
  • Nucleic acid amplification tests for chlamydia and gonococcus
  • In systemically unwell patients, urgent diagnostic laparoscopy


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 or if there is no response to treatment in primary care.

Indications for referral

Emergency referral

  • Suspected ectopic pregnancy or premature labour
  • Suspicion of placental abruption or uterine rupture
  • Evidence of strangulated inguinal or femoral hernia
  • Pain in a haemodynamically unstable patient with signs of sepsis, for example appendicitis, peritonitis

Urgent outpatient referral

  • Suspected gynaecological, gastroenterological or urological malignancy.
Possible causes

Pregnancy related

  • Miscarriage
  • Ectopic pregnancy
  • Rupture of corpus luteal cyst
  • Causes in later pregnancy include premature labour, placental abruption and (rarely) uterine rupture.


  • Ovulation (mid-cycle, may be severe pain)
  • Dysmenorrhoea
  • Pelvic inflammatory disease
  • Rupture or torsion of ovarian cyst
  • Degenerative changes in a fibroid
  • The possibility of a pelvic tumor or pelvic vein thrombosis should also be considered.


  • Diverticulitis
  • Appendicitis
  • Prostatitis
  • Epididymo-orchitis
  • Bowel obstruction
  • Adhesions
  • Strangulated hernia
  • Urolithiasis
  • Musculoskeletal
  • Vascular - pelvic vein thrombosis
  • Pelvic (testicular) tumour
  • Neurogenic - herpes zoster, impingement by arthritis, tumours, syphilis
  • Multiple sclerosis
  • Functional somatic syndromes
  • Pelvic floor muscle dysfunction

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  • Dr Elizabeth Croton is a GP in Birmingham
  • This is an updated version of an article first published in May 2013. The article was reviewed and updated by Dr Anita Somalanka a GP in Surrey

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