Pelvic pain

Introduction

Pelvic pain refers to discomfort felt in the lower abdomen or pelvis. It can be acute (sudden, lasting hours to days) or chronic (persisting for at least 6 months). It is a common complaint in both women and men, though far more frequent in women due to the reproductive organs.

Pelvic pain can arise from multiple organ systems including:

• Gynecological (uterus, ovaries, fallopian tubes, cervix, vagina).

• Urological (bladder, urethra).

• Gastrointestinal (bowel, appendix, rectum).

• Musculoskeletal or neurological.

Because pelvic pain can range from benign to life-threatening (ectopic pregnancy, appendicitis, sepsis), timely evaluation and diagnosis are crucial.

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Classification

1. Acute Pelvic Pain

• Develops suddenly, often severe.

• Causes include ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, urinary tract infection, kidney stones, appendicitis.

2. Chronic Pelvic Pain (CPP)

• Pain lasting ≥6 months, intermittent or constant.

• Often multifactorial, with overlapping gynecological, gastrointestinal, urological, musculoskeletal, and psychological contributions.

• Common in women with endometriosis, adenomyosis, interstitial cystitis, or irritable bowel syndrome (IBS).

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Causes of Pelvic Pain

Gynecological Causes

• Dysmenorrhea: painful menstruation due to prostaglandin excess.

• Endometriosis: ectopic endometrial tissue causing chronic pain.

• Adenomyosis: endometrial glands in myometrium.

• Ovarian cysts: rupture or torsion causes acute pain.

• Ectopic pregnancy: implantation outside uterus, often tubal.

• Pelvic Inflammatory Disease (PID): infection of upper genital tract.

• Fibroids (leiomyomas): submucosal fibroids cause cramping, bulk symptoms.

Urological Causes

• Urinary tract infection (UTI).

• Interstitial cystitis / bladder pain syndrome.

• Urolithiasis (kidney stones).

Gastrointestinal Causes

• Appendicitis.

• Diverticulitis.

• Irritable bowel syndrome (IBS).

• Inflammatory bowel disease (IBD).

• Constipation, bowel obstruction.

Musculoskeletal and Neurological

• Pelvic floor muscle spasm.

• Nerve entrapment (ilioinguinal, pudendal neuralgia).

• Sacroiliac joint dysfunction.

Malignancy

• Ovarian, endometrial, cervical, colorectal, or bladder cancer.

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Pathophysiology

• Acute pelvic pain often results from tissue injury, inflammation, or ischemia.

• Chronic pelvic pain involves complex mechanisms:

  • Persistent nociceptive input (endometriosis, adhesions).

  • Central sensitization: increased spinal cord/brain sensitivity to pain.

  • Hormonal influences (estrogen, progesterone).

  • Psychological overlay (stress, anxiety, depression).

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Clinical Presentation

History

• Onset: sudden vs gradual.

• Duration: acute vs chronic.

• Timing: cyclic (linked to menses) or non-cyclic.

• Character: cramping, sharp, dull, burning, pressure.

• Associated symptoms:

  • Vaginal bleeding or discharge (gynecological).

  • Dysuria, hematuria (urological).

  • Diarrhea, constipation, rectal bleeding (GI).

  • Dyspareunia (painful intercourse).

  • Fever, nausea, vomiting.

Examination

• Abdominal exam: tenderness, guarding, rebound.

• Pelvic exam (in women): cervical motion tenderness (PID), adnexal mass, uterine enlargement.

• Digital rectal exam: assess bowel/rectum, prostate (men).

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Investigations

• Pregnancy test (hCG) – mandatory in all women of reproductive age.

• Blood tests: CBC (infection, anemia), CRP/ESR (inflammation).

• Urine tests: urinalysis, culture.

• Vaginal/cervical swabs: STI screening (gonorrhea, chlamydia).

• Ultrasound pelvis: first-line imaging for gynecological and urological causes.

• CT abdomen/pelvis: appendicitis, diverticulitis, urolithiasis.

• MRI pelvis: deep endometriosis, adenomyosis.

• Laparoscopy: diagnostic and therapeutic in unclear cases of chronic pain.

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Management of Pelvic Pain

1. Acute Pelvic Pain

a) Analgesia

• Paracetamol (acetaminophen): 500–1000 mg orally every 6 hours.

• NSAIDs:

  • Ibuprofen: 400 mg orally every 6–8 hours.

  • Naproxen sodium: 500 mg orally initially, then 250 mg every 6–8 hours.

  • Diclofenac sodium: 50 mg orally every 8 hours, or 75 mg IM/IV.

• Opioids (short-term for severe pain):

  • Morphine sulfate: 2.5–10 mg IV every 4 hours as needed.

  • Tramadol hydrochloride: 50–100 mg orally every 6 hours (max 400 mg/day).

b) Etiology-Specific Treatments

• Ectopic pregnancy:

  • Medical: Methotrexate sodium 50 mg/m² IM single dose (if stable and criteria met).

  • Surgical: laparoscopic salpingostomy or salpingectomy.

• PID:

  • Ceftriaxone sodium 500 mg IM single dose PLUS doxycycline hydrochloride 100 mg orally twice daily × 14 days PLUS metronidazole 400 mg orally twice daily × 14 days.

• Ovarian torsion: emergency surgery (laparoscopic detorsion).

• Appendicitis: appendectomy (surgical).

• UTI:

  • Nitrofurantoin monohydrate/macrocrystals 100 mg orally twice daily × 5 days.

  • Trimethoprim 200 mg orally twice daily × 3 days (where resistance low).

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2. Chronic Pelvic Pain (CPP)

a) Pharmacological Management

• NSAIDs: as above, especially for dysmenorrhea or endometriosis.

• Hormonal therapy (for gynecological causes):

  • Combined oral contraceptives (COCs): Ethinylestradiol 30 µg + levonorgestrel 150 µg orally daily × 21 days, 7-day break.

  • Progestins:

    • Medroxyprogesterone acetate: 10 mg orally daily × 10–14 days/cycle.

    • Dienogest: 2 mg orally daily (for endometriosis).

  • GnRH agonists:

    • Leuprolide acetate: 3.75 mg IM monthly (for refractory endometriosis).

• Neuropathic pain agents (central sensitization component):

  • Amitriptyline: 10–25 mg orally at night, titrated as tolerated.

  • Gabapentin: start 300 mg orally daily, titrate up to 900–1800 mg/day.

  • Pregabalin: 75 mg orally twice daily (max 600 mg/day).

b) Non-Pharmacological Management

• Pelvic floor physiotherapy.

• Cognitive-behavioral therapy (CBT).

• Lifestyle: regular exercise, stress reduction, dietary modifications.

c) Surgical and Interventional Options

• Laparoscopic excision/ablation of endometriosis.

• Hysterectomy (for refractory adenomyosis or fibroids, when fertility not desired).

• Adhesiolysis (if extensive pelvic adhesions).

• Nerve blocks (pudendal or superior hypogastric plexus).

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Complications

• Delayed diagnosis: life-threatening conditions (ectopic pregnancy, sepsis).

• Chronic pain syndrome: central sensitization, depression, reduced quality of life.

• Infertility: due to endometriosis, PID, adhesions.

• Sexual dysfunction: dyspareunia, reduced libido.

• Opioid dependence: if chronic pain not managed holistically.

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Prognosis

• Acute causes: generally good if treated promptly.

• Chronic pelvic pain: may persist even after treating underlying cause due to central sensitization.

• Endometriosis and adenomyosis often require long-term management.

• Prognosis improves with multidisciplinary care (gynecology, gastroenterology, urology, pain specialists, psychology).

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Preventive Measures

• Safe sexual practices to reduce STIs/PID.

• HPV vaccination to reduce risk of genital cancers.

• Early treatment of UTIs and gynecological infections.

• Routine gynecological care and screening.

• Lifestyle measures: healthy weight, exercise, stress management.

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Pharmacological Quick Summary

• Analgesics:

  • Paracetamol 500–1000 mg q6h.

  • Ibuprofen 400 mg q6–8h.

  • Naproxen 250 mg q6–8h.

  • Diclofenac 50 mg q8h.

• Antibiotics:

  • Ceftriaxone 500 mg IM once + doxycycline 100 mg BD × 14d + metronidazole 400 mg BD × 14d (PID).

  • Nitrofurantoin 100 mg BD × 5d (UTI).

• Hormonal therapy:

  • COCs (EE 30 µg + levonorgestrel 150 µg).

  • Dienogest 2 mg OD.

  • Leuprolide 3.75 mg IM monthly.

• Neuropathic pain drugs:

• Amitriptyline 10–25 mg OD.

• Gabapentin 300–900 mg/day.

• Pregabalin 75 mg BD.