Pelvic pain

Probability diagnosis

Gynaecological disorders, for example:

• endometriosis

• dysmenorrhoea/mittelschmerz

• pelvic adhesions

• ovarian cyst – torsion, pressure or rupture

Musculoskeletal disorders

Irritable bowel syndrome

Referred spinal pain

Serious disorders not to be missed

Neoplasia/cancer:

• lower bowel

• cervix and uterus

• ovary

Vascular:

• internal iliac artery → claudication

Infection:

• osteomyelitis

• pelvic inflammatory disease

• pelvic abscess

Ectopic pregnancy

Strangulated hernia (femoral or inguinal)

Pitfalls (often missed)

Endometriosis

Constipation/faecal impaction

Paget disease

Stress fractures (incl. SCFE)

Prostatitis/prostatodynia

Misplaced IUCD

Hernia in evolution (e.g. inguinal)

Nerve entrapment

Rectum: proctitis or prolapse

Masquerades checklist

Depression

Spinal dysfunction

UTI

Is the patient trying to tell me something?

Functional disorders possible. Psychosexual dysfunction. Pelvic congestion syndrome.

Key clinical features

As it is almost always seen in women rather than men the focus will be taking a history of pain associated with periods, ovulation and sexual intercourse. It is invariably linked at times with lower abdominal pain (see ‘Lower abdominal pain and pelvic pain in women’).

   In men it is related to trauma, sporting injuries, prostatic disorders and hernias. Examination of the abdomen and pelvis is important, especially rectal and vaginal examinations.

Key investigations

Consider and select from:

• FBE

• ESR/CRP

• urine MC ± chlamydia PCR

• STI tests

• pregnancy test

• plain X-ray

• vaginal or pelvic ultrasound

• colour Doppler US imaging

• colonoscopy/flexible sigmoidoscopy

• laparoscopy if appropriate.

• cutaneous pain mapping

Diagnostic tips

• The incidence of chronic pelvic pain (CPP) is 15% in 18–50 year old women. Endometriosis causes 33% and adhesions 24%.

• CCP in women is the reason for 40% of gynaecological laproscopies and 15% of hysterectomies.

• Pelvic congestion syndrome is regarded as a type of ovarian dysfunction causing unilateral pain, deep dyspareunia and postcoital aching.