Acute pelvic pain - red flag symptoms

Red flag symptoms to look out for in presentations of pelvic pain (in both men and women).

(Photo: Phynart Studio/Getty Images)
(Photo: Phynart Studio/Getty Images)

Red flag symptoms

  • Pelvic mass
  • Pregnancy
  • Vaginal bleed and pain in postmenopausal women
  • Testicular mass/torsion
  • Persistent fever
  • Postcoital bleeding
  • Abdominal distension
  • Inability to pass urine

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.

Acute pelvic pain is the most common reason for urgent laparoscopic examination in the UK.

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

This 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 pain’s location, whether it is constant or intermittent, onset and associated symptoms. Is it severe, and is it sharp or a dull ache? Has it occurred before, and if so what made it worse or better? If this pain was experienced before, what was the outcome?

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

In women, it is important to take a detailed sexual history, as pelvic inflammatory disease and ectopic pregnancy should be considered. In male patients, it is important to ask about testicular pain, haematuria 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.

Enquire whether any previous imaging such as CT scans or ultrasound scans have been undertaken.

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

Examination

If seeing and examining the patient face-to-face, appropriate personal protective equipment should be worn. NHS guidance on donning and doffing PPE should be followed.

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

In women, pelvic examination should be performed besides abdominal examination. With consent and if necessary a chaperone, inspect the external genitalia and use a speculum to visualise the vagina and cervix. Take swabs if indicated. The bladder, vaginal walls, and levator muscles should be palpated after the speculum examination to assess for tenderness.

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

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

Investigations

  • Urine dipsticks/MSU
  • Full blood count
  • All sexually active women should have a pregnancy test
  • Swabs for chlamydia, gonococcus, thrush and trichomonas (evidence suggests patient self-swabs are more reliable than clinician-based swabs)
  • 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 in secondary care
  • UE, PSA and CA125 may be indicated
  • Pelvic ultrasound scan
  • Flexible sigmoidoscopy
  • Colonoscopy
  • CT abdomen/pelvis

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

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, or acute pelvic inflammatory disease.
  • Two-week wait 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
  • Gynaecological
  • Ovulation (mid-cycle pain or mittelschmerz, may be severe pain)
  • Dysmenorrhoea
  • Pelvic inflammatory disease
  • 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
  • Non-gynaecological
  • Diverticulitis
  • Appendicitis
  • Epididymo-orchitis
  • Bowel obstruction
  • Adhesions
  • Strangulated hernia
  • Urolithiasis
  • Musculoskeletal - for example, referred from hip or sacroiliac joint
  • Vascular - pelvic vein thrombosis
  • Sickle cell crisis
  • Pelvic (testicular) tumour
  • Neurogenic - herpes zoster, impingement by arthritis, tumours, syphilis
  • Multiple sclerosis
  • Functional somatic syndromes
  • Pelvic floor muscle dysfunction
  • Urological
  • Acute urinary retention (both men and women)
  • Lower urinary tract infection
  • Upper urinary tract infection
  • Renal calculus
  • Bladder calculus
  • Interstitial cystitis
  • Prostatitis

This article was reviewed and updated by Dr Pipin Singh, a GP in Northumberland in August 2020.

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