Pelvic pain

Last updated: January 14, 2025

Summary

Pelvic pain, whether chronic or acute, presents a diagnostic challenge because of its diverse etiologies and potential for significant morbidity. Common causes are gastrointestinal (e.g., appendicitis, diverticulitis), genitourinary (e.g., urinary tract infection, renal colic), and musculoskeletal. In female patients, obstetric and gynecologic causes, such as ectopic pregnancy and ovarian torsion, require urgent attention. Testicular torsion must be ruled out in male patients presenting with testicular pain. Assessment begins with a focused history encompassing surgical, sexual, obstetric, and social history, alongside a physical examination that may include a digital rectal examination, pelvic examination, and palpation of the inguinal canal. Basic diagnostics include urinalysis, POCUS, and β-hCG for female patients of reproductive age. Additional investigations, such as CT pelvis and abdomen with IV contrast or STI workup, may be ordered based on the suspected cause. Chronic pelvic pain typically involves consultation with specialists. Initial management prioritizes stabilization of critically ill patients. Subsequent management options depend on the underlying cause and may include surgical intervention, pharmacotherapy, physical therapy, or lifestyle modifications tailored to the patient's needs and preferences.

See “Acute abdomen” for the management of other related symptoms. See also “Dyspareunia in women.”

Etiology

Non-sex specific

Acute

Gastrointestinal causes
- Appendicitis
- Diverticulitis
- Epiploic appendagitis
- Gastroenteritis
- Colon ischemia
- Mechanical bowel obstruction (MBO)
- Obstructed or strangulated abdominal hernia
- Anorectal abscess
Genitourinary causes
- Urinary tract infection (UTI), including pyelonephritis
- Acute urinary retention (AUR)
- Renal colic
- Sexually transmitted infection (STI)
Musculoskeletal and traumatic causes
- Muscular strain or injury
- Hip fracture
- Pelvic fracture
- Psoas abscess or hematoma
- Abdominal trauma
- Sexual violence
Vascular causes
- Acute mesenteric ischemia (AMI)
- DVT
- Ruptured aneurysm
Other causes: inguinal lymphadenopathy

Chronic

Gastrointestinal causes
- Inflammatory bowel disease (IBD)
- Irritable bowel syndrome (IBS)
- Constipation
- Inguinal or femoral hernias
- Colorectal cancer
Genitourinary causes
- Interstitial cystitis (bladder pain syndrome)
- Bladder cancer
Musculoskeletal causes
- Pelvic floor dysfunction
- Sacroiliac joint dysfunction
- Osteonecrosis of the femoral head
- Osteoarthritis
- Sciatica
- Osteitis pubis
- Sports hernia
Functional anorectal pain ^[2]
- Proctalgia fugax
- Levator ani syndrome
Idiopathic and other causes
- Neuralgia or neuropathy (e.g., after hernioplasty)
- Intraabdominal adhesions (e.g., postoperative)

Individuals with female sex organs

Acute ^[3]

Gynecologic causes
- Pelvic inflammatory disease (PID)
- Endometritis
- Tuboovarian abscess
- Ovarian cyst
- Ovarian torsion
- Ovarian vein thrombosis
- Lower genital tract infections
Obstetric causes

Chronic or cyclical ^[4]

Primary dysmenorrhea
Endometriosis
Adenomyosis
Uterine fibroids
Gynecologic cancers (e.g., cervical cancer)
Pelvic organ prolapse
Post-PID chronic pelvic pain
Pelvic congestion syndrome

Individuals with male sex organs

Acute

Acute bacterial prostatitis
Testicular torsion
Epididymitis
Orchitis
Scrotal abscess
Varicocele
Penile conditions, e.g., paraphimosis, balanitis

Chronic

Initial management

Approach

Perform ABCDE survey and stabilize critically ill patients.
Perform a focused clinical evaluation for pelvic pain.
Obtain a pregnancy test for all female individuals of reproductive age.
Perform a targeted diagnostic workup of pelvic pain.
Obtain specialty consults as needed, e.g., general surgery, OB/GYN, urology.
Provide supportive care for acute abdominal pain as needed.
Initiate empiric antibiotics for intraabdominal infections, if indicated.
Identify and treat the underlying cause.

Red flags

Red flags in pelvic pain

Sudden, severe pain
Peritoneal signs
Signs of shock
↑ bHCG or known pregnancy
Abnormal uterine bleeding
Significant amounts of free fluid on ultrasound

Other

Immediately life-threatening causes

Acute mesenteric ischemia
MBO
Strangulated abdominal hernia
Pelvic fracture with hemorrhage
Ruptured ovarian cyst
Ruptured ectopic pregnancy
Spontaneous abortion complicated by hemorrhage or infection
Complicated labor (e.g., preterm labor, obstructed labor, uterine rupture)

Fertility-threatening causes ^[5]

Any delay in the diagnosis and treatment of the following conditions increases the risk of fertility loss.

Clinical evaluation

Focused history

General history for all patients

Associated symptoms, including:
- Lower urinary tract symptoms (LUTS)
- Nausea, vomiting
- Changes in bowel movement
- Fever, chills
Prior intraabdominal or groin surgery
Sexual history

Gynecologic and obstetric history

Current and prior pregnancies, including ectopic
If pregnant: access to prenatal care
Method of contraception
Menstrual history and irregularities, including:
Prior gynecologic procedures
Use of assisted reproductive technology

Focused physical examination

The physical examination should be tailored to the suspected underlying cause and may include:

Complete abdominal examination
Palpation of the inguinal canal in supine and upright positions
Inspection of external genitals
Bimanual pelvic examination (in female patients)
Digital rectal examination (DRE)
Examination of the bony pelvis, including pelvic stability assessment

Palpation of the inguinal canal in a male patient Bimanual pelvic examination

Pelvic examinations can cause discomfort, particularly in patients with chronic pelvic pain. Obtain informed consent, start with less invasive methods, and progress as tolerated while checking in frequently. ^[6]

Diagnosis

Initial approach ^[5]

Perform a focused clinical evaluation.
Obtain basic laboratory studies.
- CBC, BMP
- Urinalysis with or without urine culture
- β-hCG (serum or urine) for female individuals of reproductive age
Consider point of care ultrasound (POCUS), e.g.:
- FAST to assess for intraabdominal free fluid
- POCUS for early pregnancy to rule in intrauterine pregnancy (IUP)
- Bowel POCUS
- Genitourinary POCUS

Additional diagnostics

Consider formal imaging and additional diagnostics depending on patient characteristics, pregnancy status, and the suspected underlying cause.

Imaging

Female individuals with positive β-hCG: ultrasound pelvis (transabdominal and/or transvaginal) with Doppler ^[7]^[8]
Male individuals, negative b-hcg, or postmenopausal: Obtain further imaging based on suspected underlying condition.
- Gynecologic conditions: ultrasound pelvis (transabdominal and/or transvaginal) with Doppler ^[7]^[8]
- Intraabdominal conditions ^[9]^[10]
  - Consider CT abdomen and pelvis with IV contrast.
  - See also “Diagnostics for acute abdomen.”
- Musculoskeletal and traumatic conditions ^[11]
  - CT and/or x-ray imaging of the affected region
  - See also “Diagnostics in trauma.”
- Genitourinary conditions ^[12]^[13]^[14]
  - Consider CT without contrast or ultrasound of the bladder and kidneys.
  - Scrotal pain: ultrasound with Doppler

Additional laboratory studies for acute pain

STI testing for suspected infectious etiologies (e.g., PID, epididymitis)
Coagulation studies for abnormal bleeding
Type and screen for significant hemorrhage, including antepartum hemorrhage
Emergency preoperative diagnostics if surgical treatment is anticipated

Diagnostics for chronic pain ^[4]^[15]

Obtain a thorough history and physical examination.
Consult relevant specialties (e.g., OB/GYN, urology, general surgery) to determine appropriate diagnostics.

Gynecologic and obstetric causes

Gynecologic causes

Common gynecologic causes of pelvic pain
	Characteristic clinical features	Diagnostic findings	Management
Ovarian cyst rupture ^[16]^[17]	Sudden onset of unilateral pelvic pain Usually after physical activity (exercise, sexual intercourse) Minimal vaginal bleeding can occur.	Ultrasound: fluid in the pelvis, adnexal mass	Emergency laparoscopy in hemodynamically unstable patients See “Treatment” in “Ruptured ovarian cyst.”
Ovarian torsion ^[18]	Sudden severe unilateral pelvic pain Nausea, vomiting Adnexal mass may be palpable.	Pelvic ultrasound or TVUS with Doppler: enlarged, edematous ovaries with decreased blood flow CT pelvis with IV contrast: unilateral enlarged ovary with decreased enhancement	Emergency exploratory laparoscopy See “Management of ovarian torsion.”
Mittelschmerz ^[19]	Midcycle, sudden onset unilateral pelvic pain	Clinical diagnosis Ultrasound may show fluid in the pelvis.	Reassurance Analgesia
Primary dysmenorrhea ^[20]^[21]	Cyclical, spasmodic suprapubic pain Pain may radiate to the back or thighs. Nausea, vomiting, diarrhea, bloating Normal pelvic examination	Diagnosis of exclusion	Symptomatic treatment, hormonal contraceptives See “Treatment” in “Primary dysmenorrhea.”
Endometriosis ^[6]^[22]	Chronic pelvic pain Dysmenorrhea Dyspareunia Infertility Dyschezia Palpable adnexal masses, reduced uterine mobility	TVUS Endometrioma Uterus size is typically normal. Diagnostic laparoscopy: direct visualization of ectopic endometrial tissue	Symptomatic treatment, hormonal contraceptives Laparoscopic ablation of endometrial implants See “Management of endometriosis.”
Pelvic inflammatory disease	Bilateral pelvic pain Cervical motion tenderness Mucopurulent cervical/vaginal discharge Fever	See “Initial evaluation for PID” for basic diagnostics. Additional evaluation for PID if tuboovarian abscess is suspected	Antibiotic treatment See “Treatment of PID.”
Cervicitis ^[23]	Purulent, blood-tinged, and/or malodorous vaginal discharge Postcoital or intermenstrual bleeding Dyspareunia Erythematous, edematous, friable cervix	Clinical diagnosis Microbiological studies similar to PID	Antibiotic treatment See “Treatment of cervicitis.”
Uterine leiomyoma ^[24]^[25]	AUB, dysmenorrhea Chronic back and/or pelvic pain Infertility Urinary tract or bowel symptoms Dyspareunia	TVUS Well-circumscribed hypoechoic solid mass Calcifications and/or cystic areas	See “Management of uterine leiomyoma.”
Adenomyosis ^[26]	Chronic pelvic pain Dysmenorrhea AUB Tender, enlarged uterus	Imaging (TVUS, MRI): asymmetric myometrial wall thickening	Symptomatic treatment, hormonal contraceptives, or surgical management See “Treatment” in “Adenomyosis.”

Obstetric causes

Common obstetric causes of pelvic pain
	Characteristic clinical features	Diagnostic findings	Management
Ovarian hyperstimulation syndrome ^[27]^[28]	History of assisted reproduction Abdominal pain and distention Nausea, vomiting Ascites Oliguria or anuria Dyspnea Severe OHSS: signs of shock	Ultrasound: ascites, enlarged ovaries	Immediate stabilization, supportive care, and monitoring See “Management” in “Ovarian hyperstimulation syndrome.”
Ruptured ectopic pregnancy ^[29]	Sudden severe pelvic pain, guarding, and tenderness Vaginal bleeding or amenorrhea Cervical motion tenderness, closed cervix Enlarged uterus Features of shock in patients with significant hemorrhage	↑ β-hCG TVUS Free fluid within Morison pouch and/or pouch of Douglas Empty uterine cavity, thickened endometrial lining Adnexal mass, tubal ring sign See “POCUS for early pregnancy” for the technique and “Diagnostics for ectopic pregnancy” for additional findings.	Emergency exploratory laparoscopy See “Management of ectopic pregnancy.”
Spontaneous abortion ^[30]^[31]	Vaginal bleeding Pain and/or cramping Cervical os may be dilated. Products of conception may be visible or palpable.	↑ β-hCG TVUS Absent or abnormal sonographic signs of IUP See “POCUS for early pregnancy” for the technique.	Expectant management, medical evacuation, or surgical evacuation See “Management” in “Spontaneous abortion.”
Labor	Obstetric contractions Rupture of membranes	↑ β-hCG Sonographic signs of IUP	See “Normal labor and delivery.” See “Abnormal labor and delivery.”
Postpartum endometritis	Fever Lower abdominal pain, uterine tenderness Chills, malaise Foul-smelling lochia	Primarily clinical diagnosis Retained products of conception or signs of surgical site infection Abdominal CT or ultrasound: signs of intraabdominal abscess	IV antibiotics Curettage if there are retained products of conception See “Postpartum endometritis.”

Urological causes

Non-sex-specific urological causes

Common urological causes of pelvic pain (non-sex specific)
	Characteristic clinical features	Diagnostic findings	Management
Urinary tract infection/pyelonephritis ^[32]^[33]	Irritative LUTS (dysuria, urinary frequency, urgency) Suprapubic tenderness Additional features of pyelonephritis High fever, chills Flank pain with costovertebral angle tenderness	Urinalysis findings of UTI Positive urine culture	Antibiotic treatment See “Treatment of UTIs.” See “Treatment of pyelonephritis.”
Renal colic ^[34]^[35]	Severe unilateral, colicky flank and/or pelvic pain Nausea, vomiting Dysuria, frequency, and urgency	Urine dipstick and urinalysis: gross or microscopic hematuria Urine microscopy: to detect crystals Ultrasound abdomen and pelvis: obstructive uropathy, hyperechoic signal with acoustic shadowing CT abdomen and pelvic without IV contrast: direct visualization of the calculus	Analgesia, medical expulsive therapy, and/or urological interventions for nephrolithiasis See “Management of nephrolithiasis.”
Acute urinary retention ^[13]	Painful inability to void Suprapubic pain Palpable distended bladder Restlessness and/or acute distress	Genitourinary POCUS BMP: ↑ BUN and creatinine in cases of renal failure due to obstruction	Immediate bladder catheterization See “Initial management of AUR.”
Interstitial cystitis ^[36]	Pelvic discomfort, pressure, or pain relieved by voiding the bladder LUTS lasting ≥ 6 weeks	Diagnosis of exclusion Urine cultures: sterile	Multimodal pain management and behavioral modification See “Treatment” in “Interstitial cystitis.”
Sexually transmitted infections ^[23]	Depend on specific pathogen See “Overview of genital lesions.”	See “Diagnostics for STI.”	See “Treatment of STIs.”

Urological causes in male individuals

Common urological causes of pelvic pain in male individuals
	Characteristic clinical features	Diagnostic findings	Management
Testicular torsion ^[37]	Severe pelvic and testicular pain Nausea and vomiting Abnormally elevated position of the testis within the scrotum	Clinical diagnosis Doppler ultrasound: twisting of the spermatic cord, reduced perfusion of the affected testicle	Manual testicular detorsion and exploratory surgery See “Management of testicular torsion.”
Epididymitis ^[38]	Unilateral scrotal pain and swelling Symptoms of UTI, including fever Tenderness along the posterior testis Positive Prehn sign	Urinalysis: pyuria Doppler ultrasound: increased perfusion	Empiric antibiotics for epididymitis See “Treatment of epididymitis.”
Acute prostatitis ^[39]	Irritative or obstructive LUTS Pelvic, rectal, and/or perineal pain Fever, chills, malaise Nausea, vomiting	DRE: tender, boggy, swollen prostate Urinalysis findings of UTI Blood and urine cultures may be positive.	Empiric antibiotics for prostatitis See “Treatment of prostatitis.”
Chronic pelvic pain syndrome ^[40]	Chronic pelvic, back, and/or genital pain Irritative or obstructive LUTS	Diagnosis of exclusion DRE: normal; prostate may be tender. Urine cultures: typically sterile	Multimodal treatment See “Management” in “Chronic pelvic pain syndrome.”

Gastrointestinal causes

Common gastrointestinal causes of pelvic pain
	Characteristic clinical features	Diagnostic findings	Management
Acute appendicitis ^[41]^[42]^[43]	RLQ, epigastric, and/or periumbilical pain (migrating abdominal pain) Nausea, anorexia, vomiting Clinical signs of appendicitis Fever	See “Appendicitis risk scores.” CT abdomen with IV contrast: distended appendix with periappendiceal fat stranding Ultrasound abdomen: noncompressible, distended appendix; Target sign	Antibiotic therapy Appendectomy or nonoperative management of appendicitis See “Management of appendicitis.”
Diverticulitis ^[44]^[45]	LLQ pain Change in bowel habits Tender mass in LLQ Fever	CT abdomen and pelvis with IV contrast: colonic diverticula with pericolic mesenteric fat stranding	Antibiotic therapy Interventional and/or surgical management for complicated diverticulitis See “Management of diverticulitis.”
Constipation ^[46]	< 3 bowel movements per week Straining to defecate Hard stools Sensation of incomplete evacuation	Clinical diagnosis; see “Rome IV criteria for primary constipation in adults.” Abdominal examination and DRE for fecal impaction	High-fiber diet, hydration, laxatives See “Treatment of constipation.”
Inflammatory bowel disease ^[47]^[48]	Crohn disease RLQ pain, chronic diarrhea Low-grade fever, weight loss Ulcerative colitis Abdominal pain and cramps Bloody diarrhea with mucus Fecal urgency	Ileocolonoscopy Cross-sectional imaging to identify complications (e.g., perforation or abscess)	Multimodal treatment See “Treatment of Crohn disease.” See “Treatment of ulcerative colitis.”
Obstructed or strangulated abdominal hernia ^[49]^[50]^[51]	All hernias Acute pain Symptoms of bowel obstruction Nonreducible tender mass Obturator hernia: pain and paresthesia in the inner thigh Perineal hernia: mass on rectovaginal examination Sciatic hernia: mass in the gluteal or intragluteal area	Clinical diagnosis CT abdomen with IV contrast: signs of visceral ischemia, radiological signs of MBO	Emergent surgical repair See “Management of abdominal hernias.”
Colon ischemia ^[52]^[53]	Sudden abdominal cramping, usually in the LLQ Urgent need to defecate Bloody diarrhea or rectal bleeding	CT abdomen with IV and oral contrast Bowel wall thickening Bowel edema Pneumatosis intestinalis	Supportive treatment Surgery if there are complications See “Treatment” in “Ischemic colitis.”
Anorectal abscess ^[54]	Tender mass, induration and fluctuance (subcutaneous or perirectal) Possibly systemic symptoms (e.g., fever)	Clinical diagnosis MRI, CT, or endoscopic ultrasound: visualization of the abscess	Abscess incision and drainage See “Management of anorectal abscesses.”
Inguinal or femoral hernias ^[55]	Palpable, mobile, typically nontender mass in the groin Increases in size with Valsalva maneuver Occult hernia: inguinodynia or inguinal discomfort	Clinical diagnosis Ultrasound groin: visualization of the hernia sac and contents	Surgical repair See “Surgeries for inguinal hernia.”

Musculoskeletal causes

Common musculoskeletal causes of pelvic pain
	Characteristic clinical features	Diagnostic findings	Management
Muscular strain or injury ^[56]^[57]	Acute pain, typically related to exercise Tenderness around affected region	Clinical diagnosis Imaging (ultrasound or MRI) may show edema.	POLICE principle See “Initial management of sports injuries.”
Pelvic and hip fractures ^[5]	Fracture signs, e.g., limb deformity, crepitus, edema Pelvic fractures: pelvic instability, potentially signs of shock	History of trauma X-ray and/or CT pelvis and hip: radiographic fracture signs	Interventions for pelvic hemorrhage control Conservative management, osteosynthesis, or arthroplasty See “Treatment of hip fracture.” See Treatment of pelvic fracture.”
Sacroiliac joint (SIJ) dysfunction ^[58]	Low back, buttock, and/or groin pain Tenderness at the SIJ Positive SIJ pain provocation tests	Clinical diagnosis	Physical therapy Symptomatic treatment (e.g., NSAIDs)
Trauma ^[5]	Signs of blunt trauma, e.g., abdominal bruising Red flags for sexual assault Red flags for intimate partner violence	See “Urgent diagnostics for trauma patients.” See “Diagnostics for sexual violence.” See “Screening for intimate partner violence.”	See “Management of trauma patients.” See “Management of recent sexual violence.” See “Management of intimate partner violence.”

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Pelvic pain

Summary

Etiology

Non-sex specific

Acute

Chronic

Individuals with female sex organs

Acute [3]

Chronic or cyclical [4]

Individuals with male sex organs

Acute

Chronic

Initial management

Approach

Red flags

Red flags in pelvic pain

Other

Immediately life-threatening causes

Fertility-threatening causes [5]

Clinical evaluation

Focused history

General history for all patients

Gynecologic and obstetric history

Focused physical examination

Diagnosis

Initial approach [5]

Additional diagnostics

Imaging

Additional laboratory studies for acute pain

Diagnostics for chronic pain [4][15]

Gynecologic and obstetric causes

Gynecologic causes

Obstetric causes

Urological causes

Non-sex-specific urological causes

Urological causes in male individuals

Gastrointestinal causes

Musculoskeletal causes

Acute ^[3]

Chronic or cyclical ^[4]

Fertility-threatening causes ^[5]

Initial approach ^[5]

Diagnostics for chronic pain ^[4]^[15]