💡 Pelvic pain is a common but complex symptom with gynaecological, urological, gastrointestinal, musculoskeletal, and even neurological causes. It may be acute (surgical emergency such as ectopic pregnancy or ovarian torsion) or chronic (endometriosis, interstitial cystitis). A structured approach is essential to avoid missing life-threatening pathology.

📝 Clinical History

Site & Radiation: Localised (e.g., right iliac fossa in appendicitis) or diffuse. Radiation to back, thighs, or shoulder tip (ectopic rupture).
Onset & Duration: Sudden (torsion, rupture) vs gradual (PID, endometriosis).
Character: Cramping (dysmenorrhoea, IBS), sharp (torsion, ectopic), dull (fibroids).
Associated Symptoms:
- Menstrual: heavy bleeding, dysmenorrhoea, missed period
- Urinary: dysuria, frequency, haematuria
- GI: constipation, diarrhoea, anorexia
- Gynaecological: vaginal discharge, dyspareunia, infertility
Aggravating/Relieving Factors: Movement, urination, menstruation, intercourse.
PMH: PID, endometriosis, surgeries, STIs, anticoagulation use.
FH: Ovarian, bowel, or breast cancer (think hereditary syndromes).

🩺 Physical Examination

General: Pallor, cachexia, fever, haemodynamic status.
Abdomen: Distension, scars, masses, guarding, rebound.
Pelvic exam:
- Speculum: discharge, cervical pathology
- Bimanual: uterine size, adnexal tenderness, cervical motion tenderness (PID)
Other: CVA tenderness (renal colic), rectal exam if appendicitis/rectal mass suspected.

🔬 Investigations

Bloods: CBC, CRP/ESR, β-hCG, renal & liver function, coagulation profile.
Urine: Urinalysis, culture (exclude UTI).
Microbiology: Cervical swabs for chlamydia/gonorrhoea if PID suspected.
Imaging:
- Transvaginal + transabdominal ultrasound (first line)
- Doppler (suspect torsion)
- CT/MRI (complex cases, suspected malignancy, appendicitis/diverticulitis)
Special: Diagnostic laparoscopy (endometriosis, uncertain cases).

📊 Causes of Pelvic Pain

Cause	Clinical Features	Diagnostic Tests	Management
🤰 Ectopic Pregnancy	Acute pelvic pain, missed period, vaginal bleeding, shoulder tip pain if rupture	β-hCG ↑, TVUS: no intrauterine pregnancy	Methotrexate (stable, unruptured); laparoscopy (ruptured)
🦠 Pelvic Inflammatory Disease	Bilateral pelvic pain, fever, discharge, dyspareunia, cervical motion tenderness	Cervical swabs, CBC ↑, USS ± tubo-ovarian abscess	Broad-spectrum antibiotics, hospitalise if severe, treat partner
⛔ Ovarian Torsion	Sudden severe unilateral pain, nausea, vomiting, adnexal tenderness	USS with Doppler: ↓ blood flow	Emergency laparoscopy: detorsion or oophorectomy
🌿 Endometriosis	Chronic pelvic pain, dysmenorrhoea, dyspareunia, infertility	USS (endometriomas), laparoscopy = gold standard	Hormonal therapy; laparoscopic excision; ART if infertility
💥 Ovarian Cyst Rupture	Sudden unilateral pain, spotting, worsens with exertion	USS: free fluid, cyst remnants; CBC for blood loss	Analgesia; observe if stable; laparoscopy if unstable
⚡ Appendicitis	RLQ pain, migrates from umbilicus, fever, N&V	CBC ↑ WCC; CT/USS = inflamed appendix	Appendectomy (laparoscopic preferred)
💧 UTI	Suprapubic pain, dysuria, frequency, haematuria	Urinalysis, urine culture	Antibiotics; hydration
🌸 Fibroids	Pelvic pressure, heavy bleeding, infertility	USS; MRI for large/complex fibroids	Hormonal therapy, myomectomy, hysterectomy
🚻 Interstitial Cystitis	Chronic pelvic pain, urgency, frequency, relief after voiding	Urinalysis normal; cystoscopy (Hunner’s ulcers)	Bladder training; pentosan polysulfate; intravesical therapy

⚠️ Red Flags

Haemodynamic instability → ruptured ectopic, massive haemorrhage
Fever + sepsis → tubo-ovarian abscess, perforated appendix
Postmenopausal woman with new pelvic pain → malignancy
Unexplained weight loss or ascites → ovarian cancer

💉 Management Principles

Stabilise first: IV access, fluids, analgesia, resuscitate if unstable.
Investigate while resuscitating: β-hCG, bloods, USS.
Treat underlying cause: surgery for ectopic/torsion/appendicitis; antibiotics for PID/UTI; hormonal therapy for endometriosis/fibroids.
Refer appropriately: gynaecology, general surgery, or urology.

🧑‍⚕️ Case Vignettes

Case 1: 👩 A 24-year-old woman with 6 weeks amenorrhoea presents with severe left iliac fossa pain and vaginal spotting. She collapses in the ED. ✅ Diagnosis: Ruptured ectopic pregnancy. ⚡ Immediate resuscitation, urgent laparoscopy.

Case 2: 👵 A 40-year-old woman with a history of infertility and dysmenorrhoea reports deep dyspareunia and chronic pelvic pain. TVUS shows a left “chocolate cyst.” ✅ Diagnosis: Endometriosis (endometrioma). 📌 Management: Hormonal suppression (OCP/GnRH agonist), laparoscopic excision, consider fertility support.

📚 References

NICE NG88: Heavy Menstrual Bleeding & Pelvic Pain Guidelines
RCOG GTG No. 21: Management of Acute Pelvic Pain in Women
Kumar & Clark’s Clinical Medicine, 10th Ed.

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Pelvic Pain