Acute pelvic pain is a common presentation defined as noncyclic, intense pain localized to the lower abdomen and/or pelvis, with a duration of less than three months.^1–3 Diagnosis is challenging because the differential diagnosis is broad, and signs and symptoms are often nonspecific and vary across etiologies.

Although many etiologies of pelvic pain are non–life-threatening, life- and fertility-threatening diagnoses should be considered. A retrospective review of pregnancies from 2006 to 2013 showed that 8.3 of 1,000 pregnancies were ectopic, a condition responsible for 6% of maternal deaths.^4,5 Adnexal torsion represents approximately 3% of abdominal pain cases in women.⁵ Appendicitis is the most common abdominal surgical emergency, with an incidence of 100 cases per 100,000 patients per year.⁶

This article provides an approach to the evaluation of acute pelvic pain in patients with natal female anatomy. Acute abdominal pain in a patient with known intrauterine pregnancy is beyond the scope of this article.

Differential Diagnosis

Acute pelvic pain in women encompasses a broad differential diagnosis spanning multiple organ systems. The patient's pregnancy status should be assessed first, followed by stratification of presenting symptoms into gynecologic vs. nongynecologic etiologies. Symptoms can be further stratified by organ system, including reproductive, gastrointestinal, urinary, and musculoskeletal.

Gynecologic causes are common in patients with acute pelvic pain.⁷ Urgent evaluation for ectopic pregnancy, ruptured ovarian cyst, adnexal torsion, and pelvic inflammatory disease (PID) is important.^2,3,8 Approximately 40% of ectopic pregnancies are misdiagnosed at the presenting visit.⁹ PID is underdiagnosed and undertreated, with significant sequelae.⁸ Approximately 15% of untreated chlamydial infections lead to PID.⁸

Less urgent etiologies of pelvic pain in women include pelvic floor myofascial pain, dysmenorrhea, vaginal atrophy, vaginismus and dyspareunia, muscle strain, and abdominal wall pain.^10–12 Patients undergoing fertility treatment can have ovarian hyperstimulation syndrome with enlarged ovaries and multiple follicular cysts.⁷

Gastrointestinal etiologies of pelvic pain in women include appendicitis (most common), diverticulitis, volvulus, and epiploic appendagitis.^7,13 Musculoskeletal etiologies include muscle strain, tendinopathy, hernia of the abdominal musculature, abdominal wall pain, and abdominal nerve entrapment. Urinary etiologies include urinary tract infection, pyelonephritis, and urolithiasis. Other diagnoses to consider in patients with pelvic pain include physical and sexual abuse, trauma, psychogenic causes, and vascular etiologies such as aortic or iliac artery dissection or rupture and thrombosis of the iliac, mesenteric, or ovarian veins.⁷

History

History findings can guide the physical examination, laboratory studies, imaging, and management. Questions should focus on the quality, onset, location, and radiation of pain; timing and duration of symptoms; and aggravating and relieving factors.²

A review of the patient's medical history should include episodes of similar symptoms, gynecologic conditions, and surgeries of the relevant organ systems. A social history should include sexual history (e.g., sexually transmitted infections, sex partners), sexual abuse, use of contraceptives, pregnancies, age of menarche, last menstrual period, number of bleeding days, and use of menstrual products.^1,2,14,15