🩺 Pelvic Pain

Pelvic pain in women is a frequent presentation in both primary care and the emergency department. It ranges from acute, life-threatening conditions to chronic, debilitating syndromes. The clinical approach focuses on distinguishing between gynaecological, gastrointestinal, and urological causes. In the UK, management often involves a multidisciplinary approach, particularly for chronic pain, while acute pain requires rapid exclusion of surgical emergencies.

Distinguish between acute, recurrent, and chronic pain. Ask about the site, nature, and radiation; ask specifically about the relationship to the menstrual cycle (cyclical vs. non-cyclical). Associated symptoms are vital: fever/discharge (PID), fainting/shoulder tip pain (ruptured ectopic), or bloating/early satiety (ovarian malignancy). Review obstetric/gynaecological history (last period, contraception, STIs) and surgical history (adhesions). Don't forget to ask about urinary and bowel symptoms to exclude non-gynaecological causes.

Start with a general assessment for signs of shock or sepsis (tachycardia, hypotension, pyrexia). Abdominal palpation should look for guarding, rebound tenderness, or masses. A speculum examination is necessary to visualise the cervix (looking for discharge or polyps) and to obtain swabs. Bimanual examination is the most critical part of the physical assessment, checking for cervical motion tenderness, adnexal masses, or uterine tenderness. Rectal examination may be considered if bowel pathology is suspected.

Gynaecological: Ectopic pregnancy, Pelvic Inflammatory Disease (PID), ovarian cyst accidents (torsion, rupture, haemorrhage), endometriosis, and fibroid degeneration. Non-gynaecological: Acute appendicitis, urinary tract infection, renal stones, irritable bowel syndrome (IBS), and inflammatory bowel disease. In chronic cases, musculoskeletal pain or pelvic floor dysfunction should be considered.

Hypotension and tachycardia (ruptured ectopic/haemorrhage); high fever and rigors (pelvic sepsis); sudden, severe pain with vomiting (ovarian torsion); guarding or rebound tenderness on palpation (peritonitis); post-menopausal bleeding with pain.

Pregnancy test (Beta-hCG) is mandatory for all women of reproductive age. Inflammatory markers (CRP/WBC) and uranalysis should be performed. Triple swabs (or NAAT) for Chlamydia and Gonorrhoea are essential if PID is suspected. Transvaginal Ultrasound (TVUS) is the imaging modality of choice to look for ovarian cysts, ectopic pregnancy, or features of endometriosis/adenomyosis. Diagnostic laparoscopy remains the gold standard for diagnosing endometriosis and chronic pelvic pain where imaging is inconclusive.

In acute pelvic pain, always consider ectopic pregnancy as a life-threatening differential in any woman of childbearing age. Chronic pelvic pain (lasting >6 months) often has a complex, multifactorial etiology including neuropathic components and may not have a clear visceral cause. 'Chandelier sign' on bimanual exam (extreme cervical excitation pain) is classically associated with PID. Endometriosis pain typically cycles with menstruation but can become chronic and non-cyclical over time.

Spans Gynaecology, Emergency Medicine, and General Surgery. Requires an understanding of both acute "surgical" gynaecology and chronic pain management. Students must prioritize the "life-threats" (ectopic, torsion, sepsis) in their diagnostic reasoning. It aligns with the MLA requirements for investigating and managing common abdominal/pelvic conditions.