2. Objectives
1. Understand the definition & terminology
2. Identify the causes & form a differential diagnosis
3. Clinically evaluate a patient with this problem
3. Introduction
• Pelvic pain is discomfort in the lower abdomen
– Below the umbilicus
• may originate in
– reproductive organs (cervix, uterus, uterine adnexa)
– or other organs
● Urological
● Gastrointestinal
● Musculoskeletal
● Neuropathic
● Other
• Sometimes the cause is unknown
4. Causes
Pelvic pain
Gynae Non-gynae
cause cause
Other
Cyclical Discrete
organs
19. Major Guidelines from Professional Societies for the Diagnosis and Management of
Endometriosis-Related Pain and Infertility
Giudice L. N Engl J Med 2010;362:2389-2398
20. Medical and Surgical Therapies for Endometriosis-Related Pelvic Pain
Giudice L. N Engl J Med 2010;362:2389-2398
22. Definition
• Ectopic endometrial tissue within the myometrium
• Older age group than endometriosis patients
• Associated with any sort of uterine trauma that may
break the barrier between the endometrium and
myometrium
23. Symptoms
• Similar to endometriosis and other pelvic pathology
– Pain more likely to be suprapubic
– More likely to have abnormal bleeding
• Usually older patient
• Less likely to be infertile
• May have secondary infertility
• Previous pregnancies or procedures to uterus
• Mimic fibroids – frequently coexist
30. Definition
• Noncancerous growths of the uterus
• Often appear during childbearing years
• Also called fibromyomas, leiomyomas or myomas
• Mostly discovered incidentally
32. Symptoms
• Heavy menstrual bleeding
– Usually cyclical
– Prolonged menstrual periods — seven days or more of
menstrual bleeding
– More likely to be associated with anaemia
• Pelvic pressure or pain
• Frequent urination
• Constipation
• Backache or leg pains
35. Pain
• Rarely, a fibroid can cause acute pain
– when it outgrows its blood supply
• Deprived of nutrients, the fibroid degenerates
• Causing pain and fever
• Pedunculated fibroids can trigger pain by twisting on its
stalk and cutting off its blood supply
37. Definition
• Pelvic inflammatory disease (PID) - infection of the
female reproductive organs
• Occurs when sexually transmitted bacteria spread from
the vagina to the uterus and upper genital tract
• Important to avoid because it can result in infertility or
ectopic pregnancy
• Prompt treatment of a sexually transmitted disease can
help prevent PID.
38. Causes
• Unsafe sexual practices
• IUDs may increase risk of PID
• Barrier method, such as a condom, reduces the risk
• Bacteria may also enter the reproductive tract as a result
of an IUD insertion, childbirth, miscarriage, abortion or
endometrial biopsy
• Most common
– Chlamydia
– Gut organisms
– Fungal
43. Symptoms
• Pain in the lower abdomen and pelvis
• Heavy vaginal discharge with an unpleasant odor
• Irregular menstrual bleeding
• Dyspareunia
• Low back pain
• Fever, fatigue, diarrhea or vomiting
• Painful or difficult urination
47. HOCI
• Rule out pregnancy
• Gynecologic history
– onset, duration, location, and character of pain
– gravity, parity, menstrual history, history of STI
– Severity of pain & its relationship to the menstrual cycle
• Important associated symptoms
– include vaginal bleeding
– vaginal discharge
– symptoms of hemodynamic instability (eg, dizziness, light-
headedness, syncope or near-syncope)
48. Types of pain
• Visceral pain
• Referred Pain
• Somatic Pain
• Myalgia
• Hyperalgesia
• Neuroinflammation
49. System review
• Seek symptoms suggesting possible causes
– morning sickness, breast swelling or tenderness, or missed
menses (pregnancy)
– fever and chills (infection)
– abdominal pain, nausea, vomiting, or change in stool habits
(GI disorders)
– urinary frequency, urgency, or dysuria (urinary disorders)
50. Past history
• Note history of
– Infertility
– ectopic pregnancy
– pelvic inflammatory disease
– Urolithiasis
– Diverticulitis/GI prolems
• Any previous abdominal or pelvic surgery should be
noted
51. Physical examination
• Begins with review of vital signs for signs of instability
– eg, fever, hypotension
• Focus on abdominal and pelvic examinations
• Begin with inspection
52. Thrombosis of the Inferior Vena Cava and Dilated Veins of the Trunk
Roncato C, Lefant PY. N Engl J Med 2011;364:2535-2535.
53. Abdominal examination
• Palpation for
– Tenderness
– Masses
– peritoneal signs
• Location of pain and any associated findings may
provide clues to the cause
• Rectal examination is done to check for tenderness,
mass, and occult blood.
54. Pelvic examination
• Inspection of external genitals, speculum examination,
and bimanual examination
• Cervix - inspected for discharge, uterine prolapse, and
cervical stenosis or lesions
• Bimanual examination - assess cervical motion
tenderness, adnexal masses or tenderness, and uterine
enlargement or tenderness
59. Key points
1. Pelvic pain is common and may have a gynecologic or
nongynecologic cause.
2. Pregnancy should be ruled out in women of
childbearing age.
3. Quality, severity, and location of pain and its
relationship to the menstrual cycle can suggest the most
likely causes.
4. Dysmenorrhea is a common cause of pelvic pain but is a
diagnosis of exclusion
60. References
• The Merck Manual – Pelvic Pain
• Mayo Clinic - mayoclinic.com/health/chronic-pelvic-
pain/DS0