Pelvic Pain

Yuanyuan Hua
® Any pain below the level of umbilicus in the
abdominal cavity and above the legs may be referred
to as pelvic pain.

® It may originate in pelvic or extrapelvic organs, or it

may be secondary to a systematic disease.

® Structures present include the ovaries, fallopian

tubes, uterus, bladder, colon, appendix, peritoneum
lining the abdominal cavity.
 Cause of Pelvic Pain
Genital tract causes Non-genital tract
Ø Pregnancy-related causes
Abortion, Ectopic
pregnancy, Molar Ø Gastrointestinal tract
pregnancy, Acute growth Appendicitis, Meckel’s
or degeneration of a
leiomyoma during diverticulitis, Bowel
pregnancy perforation and obstruction
Ø Ovary
Ø Urinary tract
Ruptured cyst,Torsion of
a cyst, Bleeding corpus Acute infection,Renal
luteum
calculus
Ø Uterus
Degeneration of a fibroid, Ø Vascular
Tortion of a fibroid, Mesenteric disease,Aortic
Pyometria,
Dysmenorrhea aneurysm
Ø Acute pelvic Ø Others
inflammatory disease
Assessment of Pelvic Pain
HISTORY
v Onset
v Site of the pain
v Character
v Intensity of the Pain
v Duration of the Pain (stable or increasing or decreasing
in severity)
v Radiation
v factors exacerbate or alleviate the pain, related to
menses
v Related to menses, movement, micturition, defecation,
sexual activity, sleep or eating
v Associated Symptoms
Onset of Pelvic Pain
Acute Onset usually indicates an intraperitoneal
event that exposes the pelvic peritoneum to
blood,pus,bowel contents,or contents of an
ovarian cysts;or ischemic infarction of a pelvic
structure
Ø Hemorrhage
Ø Torsion or rupture of an ovarian cyst
Ø Bleeding from an ectopic pregnancy
Ø Bowel perforation or obstruction
Ø Ureteric calculi or infection
 Onset of Pelvic Pain

Insidious Onset usually indicate inflammatory

conditions of genital tract or tumors,and the
pain will gradually intensify.
Ø pelvic inflammatory disease(PID)

Ø sarcoma of uterus

Ø ovary carcinomas
Site of the Pain
Ø Central pelvic pain :usually from uterus, such
as dysmenorrhea,abortion, uterine
leiomyoma(bleeding,degeneration),torsion of
a pedunculated subserous myoma, uterine
contraction of caused by a submucous
myoma
Ø Unilateral pain:rupture of an ovarian cyst,
ruptured corpus luteum cyst
Ø Right lower quadrant pain:acute appendicitis
Ø Pelvic pain or lower abdominal pain:PID or
ectopic pregnancy
Ø Pain localized in loin,radiating down to the
groin:renal calculus
Character of Pelvic Pain
Ø Constant dull pain: inflammation or
intraperitoneal fluid
Ø Intermittent colicky pain: obstruction of a hollow
viscus such as ureter,bowel,uterus or fallopian tube
Ø Acute sharpe pain: rupture of an ovarian cyst,
rupture of fallopian of ectopic pregnancy
Ø Cramping pain:contraction of uterus such as
abortion, submucous myoma
Ø Intractractadle pain：late stage tumor
Intensity of the Pain
Ø Assessed by both subjective and objective
criteria
Ø It is uncommon for a woman with a major
organic problem to not appear distressed,
drawn,pale,and sweaty.
Ø Subsequent physical examination permits
the detection of organic lesions
Duration of the Pain
v Acute pain：present shortly after the onset ,
unlikely to have had symptoms for more than 24
to 48 hours.
eg. Infarction of a adnexal structures,rupture of an
ovarian cyst,or perforation of a viscus
v Chronic pelvic pain:much more variable ,may
present for years before the attention of a
physician is sought
v Inflammatory conditions:usually have had more
indolent onset with the pain more likely to have
been present for a longer period of time
eg. PID,acute appendicitis
Relationship to Menstrual Cycle
Ø Pain that occurs during the reproductive years following a
short period of amenorrhea must be assumed to be a
complication of early pregnancy until disproved
eg.Abortion,Ectopic pregnancy
Ø Unilateral pain that occurs at midcycle is probably related
to ovulation
eg.Mittelschmerz
Ø Pain occuring with menstruation is called dysmenrrhea
eg.primary dysmenrrhea,endometriosis
Ø Cyclical pain without menses indicates the obstruction of
menstrual flow
eg.Imperforate hymen,Transverse vaginal septum,
Acquired cervical stenosis
Associated symptoms
Ø gastrointestinal tract lesion: vomiting, diarrhea,
tenesmus
Blood in the stool in any form suggests a bowel lesion.
Ø Urinary tract lesion: frequency,dysuria, hesitancy or
hematuria
v Symptoms of gastrointestinal or Urinary tract
may be secondarily involved in inflammatory
processes originating in the genital tract
Ø With intraperitoneal bleeding: fainting, shouldertip
pain (irritation of the diaphragm by blood,pus)
Ø Vaginal bleeding:abortion,ectopic pregnancy
Ø Tenesmus: cul-de-sac is full of blood ,content of
viscus,or pus
Ø vaginal discharge:acute pelvic inflammatory disease
PHYSICAL FINDINGS-
GENERAL INSPECTION
Ø Temperature:usually above 38℃ in an
acute pelvic inflammatory disease
Ø Anemia,syncope or shock: intra-
peritoneal bleeding such as ectopic
pregnancy ,rupture of corpus luteum
cyst
Ø Distressed,drawn,pale,or sweaty:
common for woman with a major
organic problem
PHYSICAL FINDINGS
Systematicallly assess the abdomen by
inspection ,percussion,palpation and
auscultation
v localization of tenderness,
v determination of guarding,
v rebound tenderness,
v bowl sounds,
v ascitic fluid
v a palpable mass
PHYSICAL FINDINGS
Systematicallly and thoroughly exam the pelvic by
bimanual examination and vagino-recto-abdominal
examination
Ø Abortion:cervical dilatation,extrusion of products of
conception
Ø Ectopic pregnancy: cul-de-sac is full and
tender;cervix is tender with swing pain;uterus is
normal size or enlarged, less than gestational day ,
boggy, levitated; adnexa is tender in the affected side,
sometimes with touching mass
Ø Interstitial pregnancy:the size of uterus is the same
as gestational day, but the uterus is asymmetry, one
cornu is protruding, having tenderness
ØRuptured cyst:cystic tender adnexal mass
ØRuptured corpus luteum cyst:tenderness over
affected ovary. No masses. Uterus firm and not
enlarged
ØAcute pelvic inflammatory disease: associated
with vaginal discharge, abdominal, uterine,
adnexal and cervical motion tenderness
ØAdenomyosis: the presence of a bulky ,
symmetrical ,tender uterus
Diagnostic Aids
Ø Pregnancy tests:
v Spontaneous Abortion: negative pregnancy
test or quantitative ß-hCG that is not properly
increasing
v Ectopic Pregnancy: Consecutive testing of
hCG ,Progesterone Assay
Ø Culdocentesis:positive results only show
hemoperitoneum, it needs to diagnosis the
cause of bleeding.
v Acute Pelvic Inflammatory Disease :purulent
material (WBC)from peritoneal cavity
Diagnostic Aids
Ø Blood cell count:
v White Blood Cell:higher than normal in acute
pelvic inflammatory disease, appendicitis,
induced abortion(infection) and some ectopic
pregnancy cases
v Red Cell: low if blood loss is large

Ø Ultrasonography:
v Spontaneous Abortion: empty gestational sac,
fetal disorganization , lack of fetal growth
v ectopic pregnancy: enlarge of uterus, no sac in
cavity. abnormal echo in one side of uterus, if
there is some fluid in the cul-de-sac, diagnosis
can be made. if embryo sac or heart beat can be
seen the diagnosis is confirmed
Ø Laparoscopy ,Hysteroscope or Laparotomy：
comfirmative diagnosis and therapy