Evaluation of Acute Pelvic Pain in Nonpregnant Adult Women

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Evaluation of acute pelvic pain in nonpregnant adult women

Author: Pamela Stratton, MD
Section Editor: Howard T Sharp, MD
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2020. | This topic last updated: May 09, 2019.
INTRODUCTION
Acute pelvic pain is generally defined as lower abdominal or pelvic pain that has lasted less than three months. Over one-third of
reproductive-aged women will experience nonmenstrual pelvic pain at some point. While most acute pelvic pain is caused by
reproductive, urinary, or gastrointestinal tract disorders, abnormalities of musculoskeletal, vascular, and neurologic processes can
contribute as well. Excluding pregnancy is a critical step, as the causes and management of pelvic pain in pregnant women differ
significantly; women diagnosed with pregnancy are referred for immediate evaluation. Pelvic pain frequently occurs with abdominal pain
and can be a challenging complaint because of the need to consider a wide array of possible conditions.
This topic presents a framework for the evaluation of nonpregnant adult women with acute pelvic pain, with an emphasis on gynecologic
conditions.
Related topics for adult women that are covered separately include:
● (See "Evaluation of the adult with abdominal pain".)
● (See "Approach to acute abdominal pain in pregnant and postpartum women".)
● (See "Evaluation of chronic pelvic pain in females".)
Related topics for pediatric and adolescent patients include:
● (See "Causes of acute abdominal pain in children and adolescents".)
● (See "Emergency evaluation of the child with acute abdominal pain".)
● (See "Evaluation of acute pelvic pain in the adolescent female".)
DEFINITION
Acute pelvic pain is a nonspecific symptom that is generally defined as pain of the low abdomen or pelvis that has lasted less than three
months. The pain may be diffuse or focal and, in some cases, includes musculoskeletal and low back pain. The pain can be sharp or dull,
focal or diffuse, and sporadic or constant. Most commonly, the cause is some pelvic pathology, including disease of the gynecologic,
gastrointestinal, and urologic systems. A patient can simultaneously have pain both in the pelvis and abdomen or have pain that starts in
one location and radiates to another. Importantly, a patient with chronic pelvic pain, of known or unknown etiology, can present with an
acute process arising de novo or a pain exacerbation that is related to the chronic condition. (See "Causes of chronic pelvic pain in
nonpregnant women".)
Pain that is exclusive to the mid or upper abdomen, low back, and external urogenital tissue (eg, vulva, rectum) is not considered pelvic
pain. Information on these topics is presented separately:
● (See "Evaluation of the adult with abdominal pain".)
● (See "Causes of abdominal pain in adults".)
● (See "Evaluation of low back pain in adults".)
● (See "Clinical manifestations and diagnosis of vulvodynia (vulvar pain of unknown cause)".)
● (See "Vulvar lesions: Diagnostic evaluation".)
https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 1/34

● (See "Evaluation and management of female lower genital tract trauma".)
● (See "Differential diagnosis of sexual pain in women".)
● (See "Hemorrhoids: Clinical manifestations and diagnosis".)
CAUSES
Life-threatening — Common processes that are potentially life-threatening must be quickly diagnosed and treated. These include (table
1):
● Gynecologic – Common gynecologic conditions include ruptured ectopic pregnancy, ruptured ovarian cyst (any kind), ovarian
torsion, pelvic inflammatory disease (PID), tubo-ovarian abscess (TOA), and ruptured uterus (rare in nonpregnant women) [1].
Ectopic pregnancy and ovarian cysts can result in uncontrolled intraperitoneal hemorrhage should rupture occur. Ovarian torsion
needs to be diagnosed and corrected quickly to preserve ovarian function [2]. Both PID and its severe manifestation, TOA, can result
in acute sepsis and long-term infertility [3]. Ruptured uterus can occur in the nonpregnant woman, but this is uncommon [4,5].
Detailed information on the evaluation of each of these processes is presented separately:
• (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)
• (See "Evaluation and management of ruptured ovarian cyst".)
• (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)
• (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)
● Gastrointestinal – Common diagnoses include appendicitis and diverticulitis. Both can cause intestinal perforation and result in
sepsis.
• (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)
• (See "Clinical manifestations and diagnosis of acute diverticulitis in adults".)
● Urinary – Ureteral obstruction (eg, from kidney stone or surgery) and complicated urinary tract infections (UTIs) can result in renal
damage (both) and sepsis (complicated UTI) if not diagnosed and treated.
• (See "Clinical manifestations and diagnosis of urinary tract obstruction and hydronephrosis".)
• (See "Acute complicated urinary tract infection (including pyelonephritis) in adults".)
Common — The female pelvis contains the uterus, ovaries and fallopian tubes, vagina, urinary bladder and ureters, sigmoid colon, and
rectum, as well as supporting vascular, neurologic, and musculoskeletal structures (figure 1 and figure 2 and figure 3 and figure 4). While
acute pelvic pain is a presenting symptom for many common gynecologic, gastrointestinal, and urinary tract disorders, common causes
of acute pelvic pain also span the musculoskeletal, vascular, and neurologic systems.
Pain may result from infection and/or inflammation; organ ischemia or distention; or leakage of pus, blood, feces, or other material into
the pelvis. Visceral pain afferents innervating the reproductive organs arise from spinal segments that share innervation with other pelvic
viscera including the appendix, lower ileum, colon, bladder, and ureters. Similarly, neural cross-talk happens between the visceral
(organs) and somatic (muscles/fascia) systems such that pain from myofascial structures is referred to viscera and vice versa. These
physiologic factors make the accurate clinical diagnosis of adult women presenting with acute pelvic pain challenging. Because multiple
organ systems contribute to and are contained within the pelvis, a broad differential is initially developed for these patients. (See "Causes
of abdominal pain in adults", section on 'Pathophysiology of abdominal pain'.)
● A range of potential causes of acute pelvic pain in adult women, by organ system, are presented in the table (table 2).
● Both the age and reproductive status of the patient impacts the likelihood of various causes of acute pelvic pain (table 3).
● Acute pelvic pain may present in combination with abdominal pain of various etiologies (table 4A-D).
Other — Less common and rare medical causes are pursued if the common etiologies have been excluded and the patient continues to
have pain (table 5).

EXCLUDE LIFE-THREATENING DISORDERS
Rapid preliminary assessment — The goal of the preliminary assessment is to identify patients who need emergency or urgent
treatment for their likely source(s) of pain (table 1). We simultaneously develop a general overall impression, identify any vital sign
abnormalities, obtain a focused clinical history, and perform a limited physical examination (algorithm 1). Concerning physical
examination findings include unstable vital signs, peritoneal signs, or suspected life-threatening pathology (eg, ectopic pregnancy, bowel
perforation).
We take the following approach:
● Obtain focused history – In addition to questions relating to the onset and nature of the patient's pain, we ask about the date of her
last menstrual period, other medical conditions (including pregnancy or delivery), any recent surgery, medications, and allergies.
(See "Evaluation of the adult with abdominal pain in the emergency department", section on 'History'.)
● Assess for pregnancy – We perform a pregnancy test on any patient who has the potential to be pregnant. As both age and
hormonal status can be difficult to assess in an emergency setting, we perform pregnancy testing on most patients except those who
are clearly currently pregnant, prepubertal, or who are known to have no uterus. Determining pregnancy status is a critical first step
in the management of women of reproductive age to enable expeditious diagnosis of conditions that warrant rapid assessment and
triage. For example, among women with pelvic pain or vaginal bleeding (or both) visiting the emergency department in the first
trimester of pregnancy, as many as 18 percent will have an ectopic pregnancy [6]. (See "Clinical manifestations and diagnosis of
early pregnancy", section on 'Diagnosis'.)
● Assess hemodynamic status – We obtain vital signs, including temperature and orthostatic vital signs, on all women. Women with
hemodynamic instability are immediately resuscitated. (See "Initial management of moderate to severe hemorrhage in the adult
trauma patient", section on 'Resuscitation and transfusion'.)
● Perform abbreviated physical examination – We perform an abdominal examination to assess for peritoneal signs, location of
pain, and palpable masses. Transabdominal palpation of the uterine fundus can identify advanced pregnancy, which can be
especially useful in settings where pregnancy testing is not available (figure 5). Next, we perform a pelvic examination that includes
visual inspection of external genitalia, speculum examination of the vagina and cervix, and bimanual examination of the uterus and
adnexal structures. However, for women who could be pregnant and are hemodynamically stable, we defer intravaginal digital
examination until pregnancy has been definitely excluded or ultrasound has provided information about the pregnancy such as the
location of the placenta (eg, to exclude placenta and vasa previa). For women with hemodynamic instability or a suspected critical
condition, such as intraperitoneal bleeding from any etiology, physical examination may be deferred in favor of immediate imaging,
typically with rapid assessment ultrasound (see the bullet below).
● Perform rapid assessment ultrasound – A Focused Assessment with Sonography for Trauma (FAST) ultrasound can quickly
assess for intraperitoneal fluid and blood (even in non-trauma patients) [7,8]. Individuals trained in ultrasound technique may also
evaluate for intrauterine pregnancy and adnexal mass. More detailed assessment of the uterus and adnexa often requires a
transvaginal approach. While trace-free pelvic fluid can result from ovulation, larger volumes of fluid are generally not caused by
ovulation and warrant consideration of type and source of fluid (eg, blood, urine, pus). (See "Emergency ultrasound in adults with
abdominal and thoracic trauma", section on 'Abdominal examination' and "Indications for bedside ultrasonography in the critically-ill
adult patient".)
● Obtain emergency blood work – We request an urgent complete blood count (CBC) and type and cross for patients with
suspected hemorrhage or who will likely require surgical treatment. For patients who have profound bleeding or are
hemodynamically unstable from sepsis, trauma, or other causes, fibrinogen level and bleeding panels are requested to assess for
disseminated intravascular coagulation (DIC). For women with suspected sepsis who have signs of hemodynamic instability and
infection, we request CBC with differential, chemistries, liver function tests, coagulation studies including D-dimer level, and
peripheral blood cultures.
• (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis".)
• (See "Evaluation and management of suspected sepsis and septic shock in adults".)
Management — Women diagnosed with, or suspected of having, a life-threatening condition (table 1) are stabilized and referred
expeditiously to a facility with the staff and resources to appropriately treat the patient. Women with frank trauma are evaluated and
treated for such. Women with hemodynamic instability and/or peritoneal findings suggesting a surgical emergency (eg, appendicitis,

bowel perforation, intraperitoneal hemorrhage, and/or ovarian torsion) are referred immediately for surgical evaluation. Pregnancy-related
life-threatening emergencies, such as placental abruption or uterine rupture, also necessitate immediate referral.
Fortunately, in most circumstances, the patient will not have a dangerous or life-threatening problem. The rapid preliminary history and
physical examination may not conclusively lead to a diagnosis. In this scenario, the patient then proceeds through the complete initial
evaluation for common conditions. (See 'Initial evaluation for common conditions' below.)
INITIAL EVALUATION FOR COMMON CONDITIONS
Challenges — The goal of the routine evaluation is to determine the most likely source(s) of the symptom. This process is often
challenging since there are many organ systems that can cause pelvic pain, the differential diagnosis is impacted by the patient's age
and reproductive status, common diseases may manifest in uncommon ways, more than one disease may be present, or a particular
finding may not entirely explain the patient's presentation. As examples, pyuria may occur in appendicitis and not all ovarian cysts are
symptomatic [9]. In some diseases, like endometriosis, the patient's history, including prior and current treatment, may be important to
guiding diagnosis and approaches to treatment.
Initially, we evaluate for both gynecologic and intra-abdominal causes of pain in parallel, especially if the initial history and physical
examination do not provide clear guidance (algorithm 1). Findings and test results are considered and interpreted in the context of each
patient's presentation. A synthesis of the history, physical examination, and diagnostic tests guides the clinician to the diagnosis of the
etiology of pelvic pain.
History — We inquire about the pain location, characteristics, associated symptoms such as fever and vaginal bleeding, and general
medical issues in an attempt to identify the likely cause(s) of the patient's symptoms.
● Pain location – We ask the patient to describe the location of her pain and how that location may have changed over time.
• Lateral pelvic pain may be related to a process in the ovary or fallopian tube. Lateral pain is also observed with a ureteral stone,
especially if it is at the ureterovesical junction. Right-sided pain is generally associated with appendicitis while left-sided pain is
common with diverticulitis and colitis, especially in patients over 40 years.
• Pain radiating to the rectum may occur when fluid or blood pools in the cul-de-sac or with rectovaginal endometriosis.
• Central pelvic pain is observed with disorders of the uterus, both adnexa, or the bladder.
• Diffuse pain may occur with peritonitis from intra-abdominal hemorrhage or infection or with a bilateral or central process like
pelvic inflammatory disease (PID).
● Timing of pain onset
• Sudden onset – Pain with an abrupt onset suggests an acute process such as intrapelvic hemorrhage, ovarian torsion,
urolithiasis, or ovarian cyst rupture.
• Gradual onset – Gradual-onset pain is more common with inflammatory or infectious processes such as PID or appendicitis.
● Pain characteristics – We also ask the patient what makes the pain better or worse (ie, provocative and palliative factors), if the
pain radiates to another location, if the pain has occurred in the past, the timing relative to her menses, and if the pain is cyclic in
nature. As examples, pain that improves with voiding suggests bladder pain syndrome, while pain that worsens with voiding is
suggestive of infectious cystitis. Appendicitis classically begins with periumbilical pain and moves to the right lower quadrant. Pain
that is related to inflammatory bowel disease, painful bladder syndrome, or endometriosis usually presents with similar
characteristics when it recurs. Pain that worsens in relation to changes in the menstrual cycle can be Mittelschmerz (pain related to
ovulation), dysmenorrhea (pain related to menstruation), or endometriosis.
● Associated symptoms – As part of the history, we also try to elicit other symptoms or processes that may be associated with the
patient's pain. We generally inquire about the following conditions and then ask follow-up questions as directed by the initial
answers.
• Fever and chills are more common with an infectious or inflammatory process, such as PID, cystitis with or without
pyelonephritis, or diverticulitis.
• Nausea and vomiting frequently accompany a gastrointestinal process but may also occur in any severe pain or any pain of
visceral origin such as ureteral colic or ovarian torsion.

• Dysuria can occur with urinary tract infections (UTIs), but if pain occurs when the urine touches the vulva, it may indicate vulvar
and vaginal diseases such as herpes simplex infection, vulvovaginal candidiasis, or bacterial vaginosis. Urinary frequency can
occur with UTI, urethral diverticulum, and bladder pain syndrome, all of which can also cause pelvic pain.
• Common processes that can cause vaginal bleeding and acute pelvic pain in nonpregnant women include ovarian cysts,
endometrial infection, uterine perforation, and trauma.
• Vaginal discharge associated with acute pelvic pain can result from infection, pelvic trauma (eg, traumatic sexual assault), or a
retained foreign body (eg, retained tampon).
• Constipation or diarrhea can occur with any gastrointestinal process but may also occur in severe dysmenorrhea.
● Last menstrual period and possibility of pregnancy – Unless the patient is premenarchal, we ask all patients about the date of
their last menstrual period and possibility of pregnancy (table 6). For women who know they are pregnant, we ask about the
estimated gestational age, estimated due date, and current and prior obstetric history. Previous spontaneous miscarriage or ectopic
pregnancy increases the likelihood of these respective conditions [10,11]. Current infertility treatment increases the risk of ovarian
hyperstimulation, heterotopic pregnancy, and ectopic pregnancy [12]. The history of cesarean section increases the possibility of
uterine rupture.
● Sexual history – Sexual history includes recent sexual contact, previous history of sexually transmitted infections, contraceptive
use, and risk of pregnancy. All women are interviewed in private to enable the disclosure of sensitive information like sexual history,
recent abortion, abuse, and pregnancy. (See "Screening for sexually transmitted infections", section on 'Sexual history'.)
● General medical and surgical history – History of any recent surgical or gynecologic procedures and the nature of these
procedures are obtained. For example, onset of pelvic pain soon after uterine instrumentation is concerning for uterine infection or
perforation.
● Medications and allergies – As with any patient evaluation, we inquire about the patient's medications and allergies, particularly
recently started or discontinued medication. For example, a woman who has recently started an anticholinergic medication for
urinary leakage related to overactive bladder could develop urinary retention with resultant onset of pelvic pain [13]. We also inquire
about use of illicit or controlled substances. Patients with opioid withdrawal or drug-seeking can present with pelvic pain as their
chief complaint.
Physical examination
General — The general physical examination includes evaluation of vital signs, a general assessment, and abdominal examination.
Tachycardia, hypotension, or evidence of an acute abdomen with rebound or guarding on abdominal examination can indicate a surgical
emergency, such as intra-abdominal bleeding, ectopic pregnancy, appendicitis, or ovarian torsion, and necessitates immediate referral. If
there is no evidence of an acute abdomen and vital signs are unremarkable, evaluation of the patient's chest, back, and extremities is the
next step. Once these assessments are completed, the pelvic examination is performed. (See "The gynecologic history and pelvic
examination", section on 'Pelvic examination'.)
Pelvic — Nonpregnant women with acute pelvic pain undergo a pelvic examination that includes visual inspection of external
genitalia, speculum examination of the vagina and cervix, bimanual examination of the uterus and adnexa, and rectal examination. (See
"The gynecologic history and pelvic examination", section on 'Pelvic examination'.)
Findings can help guide the differential diagnosis. Examples of abnormal findings that are discussed in separate topic reviews and
suggest specific diagnoses include:
● External genitalia – Vesicles can be caused by herpes simplex infection, vulvar, or perineal abscess (eg, Bartholin's duct abscess)
and can contribute to pelvic pain; an imperforate hymen may indicate underlying hematocolpos, and female infundibulation
(circumcision) can contribute to UTI [14]. Painful vulvar lesions may result from infectious or dermatologic etiologies. Complete
uterovaginal prolapse can cause urinary incontinence and pelvic pain heaviness.
● Speculum examination of vagina and cervix
• Abnormal vaginal or cervical discharge may be seen in various conditions including cervicitis, endometritis, PID, vaginitis, or
retained vaginal foreign body.
• Bleeding from the cervix can result from incomplete, threatened, or complete abortion. (See "Pregnancy loss (miscarriage): Risk
factors, etiology, clinical manifestations, and diagnostic evaluation".)

• An open cervical os suggests an inevitable or incomplete abortion but does not exclude an ectopic pregnancy. (See "Pregnancy
loss (miscarriage): Risk factors, etiology, clinical manifestations, and diagnostic evaluation".)
● Bimanual examination of the uterus and bilateral adnexa
• Cervical motion tenderness commonly reflects peritonitis of the reproductive tract, such as with PID, but may also reflect
irritation of adjacent structures (eg, bladder, cystitis; appendix, appendicitis) [15].
• An enlarged uterus may reflect pregnancy, leiomyoma (fibroids), or both.
• Painful unilateral adnexal masses may indicate ectopic pregnancy, tubo-ovarian abscess, ovarian cyst, or ovarian torsion. PID
can cause bilateral adnexal pain.
• Cervical motion tenderness, uterine tenderness, and adnexal tenderness together suggest PID.
● Rectal examination
• Rectal pain can be caused by thrombosed hemorrhoids, anal fissure, deep infiltrating endometriosis of the bowel or cul-de-sac,
or can be observed in those with pelvic blood.
• Rectal mass may be a malignancy or rectal endometriosis.
Laboratory testing — Choice of laboratory test is guided by the findings from the patient's history and physical examination. In general,
we find the following tests appropriate for most women:
● Pregnancy test – A pregnancy test is required for almost all patients of reproductive age who present with pelvic pain, regardless of
reported contraceptive use or sexual history. Exceptions include documented hysterectomy or a woman known to be pregnant.
• A positive test result indicates current or recent intrauterine or ectopic pregnancy or, rarely, molar pregnancy or cancer.
● Urinalysis – A urinalysis is done on a clean-catch specimen. Important findings include:
• Nitrates or pyuria may indicate a UTI. Mild pyuria can be seen with appendicitis.
• Hematuria can indicate urolithiasis or hemorrhagic cystitis.
• Urinalysis should be performed in all pregnant patients with pelvic pain, regardless of whether they have urinary tract symptoms,
because UTI, including asymptomatic bacteriuria, is associated with significant morbidity for both mother and fetus.
● Urine tests – Sexually transmitted infections can be detected (eg, gonorrhea and chlamydia cervical infections) from urine antigens.
These tests are best done on a first voided "dirty" specimen rather than a typical clean-catch specimen.
● Cervix tests – We test patients with risk factors for and symptoms of cervical and/or pelvic infections for gonorrhea, chlamydia,
trichomoniasis, and bacterial vaginosis. In addition, as described above, urine tests are available for both gonorrhea and chlamydia.
(See "Acute cervicitis", section on 'Laboratory evaluation'.)
● Complete blood count
• Patients bleeding externally or internally should have their complete blood count checked for evidence of anemia. For patients
who have profound bleeding or who are hemodynamically unstable from sepsis, trauma, or other causes, fibrinogen level and
bleeding panels are requested to assess for disseminated intravascular coagulation (DIC). For patients who have signs of
infection, complete differential is obtained with the complete blood count.
● Type and cross-matching is done for anyone who has substantial hemorrhage.
• Pregnant patients with any concern for fetomaternal transfusion require blood typing to identify Rh-negative patients who will
require Rho(D) immune globulin. (See "Prevention of RhD alloimmunization in pregnancy".)
● Blood cultures are performed in women suspected of having disseminated infection, such as some women with PID. (See
"Bacteremia: Blood cultures and other diagnostic tools".)
Imaging — For women with pelvic pain, ultrasound is a basic part of the initial evaluation accompanying the history and physical
examination. In most cases, both transvaginal and transabdominal evaluation will be required. (See "Ultrasound examination in obstetrics
and gynecology", section on 'Gynecologic sonography'.)

● Free intra-abdominal or pelvic fluid observed on ultrasound is presumed to be blood and should be addressed expeditiously in
context with the patient's history, physical examination, and other findings. Common etiologies of free fluid in the abdomen or pelvis
include ruptured ectopic pregnancy, ruptured ovarian cyst, or trauma.
● For any patients with a positive pregnancy test, ultrasound assessment for the location of the pregnancy, ectopic or intrauterine, is
required (algorithm 2). Ultrasound evaluation of pregnant women should also include assessment and documentation of fetal heart
tones.
• If a definite intrauterine pregnancy is seen by ultrasound imaging, ectopic pregnancy is unlikely except for those patients who
are undergoing assisted reproduction and may have a heterotopic pregnancy [12]. (See "Abdominal pregnancy, cesarean scar
pregnancy, and heterotopic pregnancy", section on 'Heterotopic pregnancy'.)
• Ectopic pregnancy is probable if a complex adnexal mass, extrauterine yolk sac or embryo, tubal ring, empty uterus, or free fluid
is observed. (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)
In addition, in patients with a negative pregnancy test, if the suspicion for nongynecologic causes is greater than for gynecologic causes,
as in women with a history and findings suggestive of small bowel obstruction, appendicitis, nephrolithiasis, diverticulitis, or equivocal,
ultrasound findings may also benefit from computed tomography of the abdomen and pelvis. A detailed discussion of the evaluation for
each of these entities is presented in separate topic reviews.
Women who may benefit from pelvic magnetic resonance imaging in addition to the ultrasound include those with evidence of an adnexal
malignancy, degenerating fibroid, or pregnant women whose abdominal and pelvic ultrasound evaluations were nondiagnostic for a
cause of pain. (See "Acute appendicitis in pregnancy", section on 'Magnetic resonance imaging'.)
TREAT INITIAL DIAGNOSES AND REASSESS
Women in whom a likely etiology is identified are treated accordingly. If the pain resolves with the intervention, then no further evaluation
or treatment is indicated. Women who do not respond in an appropriate time frame are then reassessed for possible atypical presentation
of common diagnoses, worsening of a chronic illness, or less common diagnoses. (See 'Pursue less common diagnoses if symptoms
persist' below.)
PURSUE LESS COMMON DIAGNOSES IF SYMPTOMS PERSIST
Our approach — For patients whose acute pelvic pain persists after the evaluation outlined above, we take the following steps:
● Reassess for emergency or life-threatening diagnoses and ensure they are addressed (table 1). Some findings, such as evidence of
peritonitis, may not be present at the initial evaluation but develop over time.
● Consider whether the presentation may be an atypical presentation of a common condition (table 7), a worsening of an underlying
chronic disease, or a less common cause of pelvic (table 5) or abdominal (table 8) pain. We repeat the history and physical
examination to evaluate for less common etiologies. Subsequent laboratory testing or imaging is directed by new information
obtained through this process.
● For women who continue to have acute pelvic pain without a clear etiology despite exclusion of emergency and common diagnoses,
unusual and rare conditions are considered next. These include, but are not limited to, uncommon medical diseases and toxicity.
Examples of diseases with acute pelvic pain as one component of the clinical presentation include, but are not limited to, the
following:
• Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS), which presents with abdominopelvic pain (see "Tumor
necrosis factor receptor-1 associated periodic syndrome (TRAPS)")
• Familial Mediterranean fever (see "Clinical manifestations and diagnosis of familial Mediterranean fever")
• Porphyria (see "Porphyrias: An overview")
• Lead toxicity (see "Lead exposure and poisoning in adults", section on 'Acute and subacate exposure symptoms')
In addition, an important aspect of the history and examination is to assess for mental health disorders such as depression, anxiety,
substance abuse, and somatization that can confound developing a differential diagnosis and may warrant directed treatment.
Depression and anxiety have been associated with increased pain severity in pain disorders [16]. Additionally, women who are victims of

intimate partner violence or human trafficking may present repeatedly for evaluation of medical problems that are related, directly or
indirectly, to their experiences of trauma [17,18].
● (See "Screening for depression in adults".)
● (See "Intimate partner violence: Diagnosis and screening".)
● (See "Human trafficking: Identification and evaluation in the health care setting".)
Follow-up — For all patients, regularly scheduled follow-up evaluation is advised. Periodic evaluation is repeated, as needed, until the
pain is adequately addressed. For some women, no clear etiology of pain is identified. This small subgroup of women may continue with
pain that persists for more than three to six months and, by definition, becomes chronic pelvic pain. The continued evaluation and
management of these women is presented in separate discussions.
● (See "Causes of chronic pelvic pain in nonpregnant women".)
● (See "Evaluation of chronic pelvic pain in females".)
● (See "Treatment of chronic pelvic pain in women".)
Role of surgical evaluation — In our evaluation of women with acute pelvic pain, we find diagnostic surgery via laparoscopy helpful
when it is beneficial in determining treatment options to confirm what has been seen (or not seen) with imaging studies, a surgical
treatment is a therapeutic option, or the patient continues to have significant symptoms that have not responded to initial treatments.
Surgical evaluation and treatment are indicated for women diagnosed with a potential surgical process (eg, ovarian torsion, ruptured
ectopic pregnancy). The role of surgery is less clear for women presenting with acute pelvic pain without an identified or suspected
etiology. Shared decision making is undertaken. We discuss with the patient that the risks of surgical exploration, typically with
laparoscopy, must be balanced against the risks of potentially missing a diagnosis and presumed opportunity for treatment. As an
example, approximately 2 percent of patients with clinical appendicitis will have an underlying appendiceal neoplasm [19]. While medical
management of appendicitis with antibiotics may be a medically appropriate option, malignancy can only be diagnosed and treated if
surgery is performed. The decision is further complicated in women with chronic pain related to endometriosis because long-term
medical management of endometriosis, rather than multiple surgeries, is the preferred approach [20,21]. The decision to pursue surgery
for women with chronic pelvic pain is discussed elsewhere. (See "Evaluation of chronic pelvic pain in females", section on 'Role of
laparoscopy'.)
SPECIAL POPULATIONS
Acute pain superimposed on chronic conditions — At times, patients can present with acute pain from worsening of a chronic
condition. Examples from the author's experience include:
● Sickle cell crisis initiated by menses – Women with known sickle cell disease can present with a monthly sickle cell crisis that is
triggered by the physiologic changes and pain associated with menstruation [22]. Menstrual suppression may be considered for
these women. (See "Evaluation of acute pain in sickle cell disease", section on 'Abdominal pain' and "Hormonal contraception for
suppression of menstruation", section on 'Progestin-only methods'.)
● Ruptured endometrioma – Women with known endometriosis can have acute onset of new or worsened pelvic pain from a flare of
the underlying disease or rupture of an endometrioma or other adnexal cyst. (See "Endometriosis: Management of ovarian
endometriomas".)
● Inflammatory bowel disease – Women with Crohn disease or ulcerative colitis can present with acute pelvic pain related to
worsening of their underlying disease or from a complication of the disease, such as bowel perforation, intestinal obstruction,
abscess, or fistula. (See "Clinical manifestations, diagnosis, and prognosis of Crohn’s disease in adults" and "Clinical manifestations,
diagnosis, and prognosis of ulcerative colitis in adults".)
Atypical postoperative pain — For women who present with acute pelvic pain after a recent gynecologic or other pelvic surgery, we
determine which surgery was performed (eg, myomectomy, removal of ectopic pregnancy, hysterectomy, etc) and the potential
associated complications. Next, we perform an initial clinical assessment to identify hemodynamic instability or evidence of systemic
infection. Women with findings suggestive of either process undergo immediate resuscitation. (See 'Rapid preliminary assessment'
above.)
Examples of potential postoperative complications that may cause the patient to present with acute pelvic pain include:

● Intraperitoneal fluid, including blood and urine
● Infection, such as wound infection, intraperitoneal abscess, infection of synthetic mesh, or septic abortion
● Uterine perforation can occur with any uterine procedure, including endometrial suction or curettage, intrauterine device insertion, or
operative laparoscopy with uterine manipulation
● Urinary retention, which can be functional (eg, after anesthesia) or mechanical (eg, urethral obstruction from midurethral sling)
● Ovarian remnant syndrome (monthly pain with ovulation) [23]
● Endometrioma of abdominal wall after cesarean delivery [24]
Suspected malignancy — At times, presentation with acute pelvic pain may be the presenting complaint for an undiagnosed
malignancy. Those with pelvic pain and:
● Cervical cancer may present with vaginal bleeding and be found to have a cervical mass on speculum examination. Kidney damage
related to stage III/IV disease warrants assessment. (See "Invasive cervical cancer: Epidemiology, risk factors, clinical
manifestations, and diagnosis".)
● Ovarian cancer may present with increasing abdominal girth, early satiety, or constipation, which reflect problems with bowel motility.
Alternatively, they may have torsion or bleeding into ovaries related to various tumors. (See "Epithelial carcinoma of the ovary,
fallopian tube, and peritoneum: Clinical features and diagnosis".)
● Endometrial cancer usually presents with vaginal bleeding. (See "Endometrial carcinoma: Clinical features, diagnosis, prognosis,
and screening".)
● Rectal cancer may present with rectal pain, change in bowel habits, and bleeding. (See "Clinical presentation, diagnosis, and staging
of colorectal cancer".)
● Bladder cancer may present with hematuria, including passage of clots. (See "Clinical presentation, diagnosis, and staging of
bladder cancer".)
Pregnant or recently postpartum women — The presentation and evaluation of pregnant and postpartum women with pelvic pain
including postoperative causes are reviewed separately. (See "Approach to acute abdominal pain in pregnant and postpartum women".)
SUMMARY AND RECOMMENDATIONS
● Acute pelvic pain is a nonspecific symptom that is generally defined as pain of the low abdomen or pelvis that has lasted less than
three months. The pain may be diffuse or focal and, in some cases, includes low back pain. (See 'Definition' above.)
● Most commonly, the causes of acute pelvic pain in women include disease of the gynecologic, gastrointestinal, and urologic
systems, although musculoskeletal, vascular, and neurologic diseases can occur as well. Processes can be life-threatening (table 1),
common (table 2), and less common or rare (table 5). Because multiple organ systems contribute to and are contained within the
pelvis, a broad differential is initially developed in these patients. (See 'Causes' above.)
● The goal of the preliminary assessment is to identify patients who need emergency or urgent treatment for their likely source(s) of
pain (table 1). We simultaneously develop a general overall impression, identify any vital sign abnormalities, obtain a focused clinical
history, and perform a limited physical examination (algorithm 1). Concerning physical examination findings include unstable vital
signs, peritoneal signs, or suspected life-threatening pathology (eg, ectopic pregnancy, bowel perforation). (See 'Exclude life-
threatening disorders' above.)
● Determining pregnancy status is a critical first step in the management of women of reproductive age to enable expeditious
diagnosis of pregnancy-related conditions that warrant rapid assessment and triage. (See 'Rapid preliminary assessment' above.)
● For women without life-threatening causes of pain, we inquire about the pain location, characteristics, associated symptoms (eg,
fever and vaginal bleeding), and general medical issues in an attempt to identify the likely cause(s) of the patient's symptoms
(algorithm 1). The general physical examination includes evaluation of vital signs, a general assessment, and abdominal
examination. The pelvic examination includes visual inspection of external genitalia, speculum examination of the vagina and cervix,
bimanual examination of the uterus and adnexa, and rectal examination. Choice of laboratory test is guided by the findings from the
patient's history and physical examination. Most women undergo a pelvic ultrasound. (See 'Initial evaluation for common conditions'
above.)

● Women in whom a likely etiology is identified are treated accordingly. If the pain resolves with the intervention, then no further
evaluation or treatment is indicated. (See 'Treat initial diagnoses and reassess' above.)
● Women who do not improve with initial treatment are reevaluated for emergency or life-threatening diagnoses (table 1). Some
findings, such as evidence of peritonitis, may not be present at the initial evaluation but can develop over time. Once emergency
conditions are excluded, we assess for an atypical presentation of a common condition (table 7), worsening of an underlying chronic
disease, or a less common cause of pelvic (table 5) or abdominal (table 8) pain. (See 'Pursue less common diagnoses if symptoms
persist' above.)
● The role of surgery is less clear for women in whom pain persists without an identified or suspected etiology. Shared decision
making is undertaken; information is shared with the patient about the risks of surgical exploration, typically with laparoscopy,
balanced against the risks of potentially missing a diagnosis, and presumed opportunity for treatment. (See 'Role of surgical
evaluation' above.)
ACKNOWLEDGMENT
The editorial staff at UpToDate would like to acknowledge Fred Howard, MD, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
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2. Robertson JJ, Long B, Koyfman A. Myths in the Evaluation and Management of Ovarian Torsion. J Emerg Med 2017; 52:449.
3. Tsevat DG, Wiesenfeld HC, Parks C, Peipert JF. Sexually transmitted diseases and infertility. Am J Obstet Gynecol 2017; 216:1.
4. Herrera FA, Hassanein AH, Bansal V. Atraumatic spontaneous rupture of the non-gravid uterus. J Emerg Trauma Shock 2011;
4:439.
5. Mostafa-Gharabaghi P, Bordbar S, Vazifekhah S, Naghavi-Behzad M. Spontaneous Rupture of Pyometra in a Nonpregnant Young

Woman. Case Rep Obstet Gynecol 2017; 2017:4572379.
6. Barnhart KT, Sammel MD, Gracia CR, et al. Risk factors for ectopic pregnancy in women with symptomatic first-trimester
pregnancies. Fertil Steril 2006; 86:36.
7. American College of Emergency Physicians. Emergency ultrasound imaging criteria compendium. American College of Emergency
Physicians. Ann Emerg Med 2006; 48:487.
8. American Institute of Ultrasound in Medicine, American College of Emergency Physicians. AIUM practice guideline for the
performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med 2014; 33:2047.
9. Hart DK, Lipsky AM. Acute Pelvic Pain in Women. In: Rosen's Emergency Medicine, 8th, Marx J, Hockberger R, Walls R (Eds), Sau
nders, Philadelphia 2013. p.2808.
10. Ellaithy M, Asiri M, Rateb A, et al. Prediction of recurrent ectopic pregnancy: A five-year follow-up cohort study. Eur J Obstet
Gynecol Reprod Biol 2018; 225:70.
11. Jeve YB, Davies W. Evidence-based management of recurrent miscarriages. J Hum Reprod Sci 2014; 7:159.
12. Xiao S, Mo M, Hu X, et al. Study on the incidence and influences on heterotopic pregnancy from embryo transfer of fresh cycles
and frozen-thawed cycles. J Assist Reprod Genet 2018; 35:677.
13. Verhamme KM, Sturkenboom MC, Stricker BH, Bosch R. Drug-induced urinary retention: incidence, management and prevention.
Drug Saf 2008; 31:373.
14. Klein E, Helzner E, Shayowitz M, et al. Female Genital Mutilation: Health Consequences and Complications-A Short Literature
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17. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in health care settings. Health Hum Rights
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18. Campbell JC. Health consequences of intimate partner violence. Lancet 2002; 359:1331.
19. Westfall KM, Brown R, Charles AG. Appendiceal Malignancy: The Hidden Risks of Nonoperative Management for Acute
Appendicitis. Am Surg 2019; 85:223.
20. Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a
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21. ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol 2018;
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Women with Sickle Cell Disease. J Womens Health (Larchmt) 2019; 28:162.
23. Arden D, Lee T. Laparoscopic excision of ovarian remnants: retrospective cohort study with long-term follow-up. J Minim Invasive
Gynecol 2011; 18:194.
24. Vellido-Cotelo R, Muñoz-González JL, Oliver-Pérez MR, et al. Endometriosis node in gynaecologic scars: a study of 17 patients
and the diagnostic considerations in clinical experience in tertiary care center. BMC Womens Health 2015; 15:13.
Topic 5473 Version 18.0

GRAPHICS
Potentially life-threatening causes of acute pelvic pain in nonpregnant adult women
Causative Atypical or
Associated Supporting Physical
disorder or Pain history Useful tests additional
symptoms history examination
condition aspects
Ectopic pregnancy Classically severe, Vaginal bleeding Missed period Classically, unilateral Pelvic US Cannot reliably
(critical if ruptured) sharp, lateral pelvic (often spotting or History of previous adnexal tenderness, Quantitative beta- exclude diagnosis
pain, but severity, light, but can be ectopic pregnancy, adnexal mass, CMT hCG based on history and
location, and quality absent) infertility, pelvic T&C physical examination
highly variable surgery, PID, or IUD Severe pain,
Laparoscopy
use hypotension, or
peritonitis suggests
rupture
Ruptured ovarian Abrupt moderate to Light-headedness if Pain may begin Hypotension and Pelvic US Physical examination
cyst (critical with severe lateral pain bleeding is severe spontaneously or tachycardia if blood CBC findings often do not
significant Rectal pain arises with intercourse loss is significant T&C correlate with volume
hemorrhage; from fluid in cul-de- Menstrual history Possible peritonitis of blood in pelvis at
otherwise, sac may indicate LMP US
emergency) was two or more
Nausea and vomiting
may occur weeks ago
Ovarian torsion Acute onset of Nausea and vomiting History of ovarian Adnexal mass and US with Doppler Torsion can be
(emergency) moderate to severe mass or cyst tenderness flow studies intermittent, which
lateral pain Possible peritonitis Laparoscopy causes symptoms to
come and go
Appendicitis Duration often <48 Low-grade fever, Migration of pain to RLQ tenderness US Early in course,
(emergency) hours, generalized nausea, vomiting, RLQ from center Possible peritonitis CT tenderness may be
followed by localized anorexia Abdominal pain MRI minimal or poorly
RLQ pain before vomiting localized
PID (urgent- Without TOA, pain is Fever, vaginal Vaginal discharge Pus from cervical os, CBC History and physical
emergency), TOA usually bilateral; may discharge History of PID CMT, adnexal ESR examination may be
(emergency) manifest acutely tenderness CRP inaccurate for
History of a new sex
within 48 hours, but Peritonitis suggests diagnosis,
partner, more than Pelvic US
PID may also be TOA or severe PID particularly in
one partner, or a Cervical cultures
chronic patients with
partner who has Cervical smear for subacute
other sex partners or WBCs presentation
a sexually
transmitted infection
Complicated UTI Pain with urination Urinary urgency and Recent urologic Suprapubic Urinalysis WBCs can be present
(urgent) Patient may have frequency procedure tenderness, flank Urine culture in urine with PID and
flank pain from Fever and vomiting if Prior history of UTI tenderness, and appendicitis
associated patient has fever with RBCs present in urine
pyelonephritis associated pyelonephritis with hemorrhagic
pyelonephritis cystitis
Ureteral obstruction Acute onset, Nausea and vomiting History of surgery Patient often appears Urinalysis, If obstruction or
(urgent) manifests within that could cause uncomfortable, but hematuria present stone is at uretero-
hours ureteral obstruction physical examination in approximately vesicle junction,
Pain is lateral, or prior history of can be otherwise 80% of cases patient can have
usually moderate to kidney stones unremarkable Renal ultrasound localized pain that
severe for hydronephrosis can mimic
Abdominal CT appendicitis or other
Often radiates into
acute pelvic
the groin or
pathology
costovertebral angle
or flank
PID: pelvic inflammatory disease; IUD: intrauterine device; CMT: cervical motion tenderness; US: ultrasound; hCG: beta-human chorionic gonadotropin; T&C: type and
screen; LMP: last menstrual period; CBC: complete blood count; RLQ: right lower quadrant; CT: computed tomography; MRI: magnetic resonance imaging; TOA: tubo-
ovarian abscess; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein; WBCs: white blood cells; UTI: urinary tract infection; RBCs: red blood cells.
Courtesy of Pamela Stratton, MD.
Graphic 120879 Version 1.0

Cross section of female pelvis
Reproduced with permission from: Moore KL, Dalley AF, Agur AMR. Pelvis and perineum. In: Clinically Oriented
Anatomy, 6th ed, Lippincott Williams & Wilkins, Baltimore, 2010. Copyright © 2010 Lippincott Williams &
Wilkins. www.lww.com.

Blood supply of the pelvis

Somatic nerves of the pelvis
Reproduced with permission from: Moore KL, Dalley AR. Clinically Oriented Anatomy, 5th ed,
Lippincott Williams & Wilkins, Philadelphia 2006. Copyright © 2006 Lippincott Williams & Wilkins.
www.lww.com.

Bones and ligaments of the pelvis
(A) The joints of the adult pelvic girdle include the sacroiliac joints and the pubic
symphysis. The lumbosacral and sacrococcygeal are joints of the axial skeleton
directly related to the pelvic girdle.
(B and C) The ligaments of the pelvis are shown.
* Inferior pelvic aperture.
Reproduced with permission from: Moore KL, Dalley AR. Clinically Oriented Anatomy, 5th
ed, Lippincott Williams & Wilkins, Philadelphia 2006. Copyright © 2006 Lippincott Williams
& Wilkins. www.lww.com.

Causes of acute pelvic pain in adult women by organ system
Reproductive tract Gastrointestinal

Gynecologic: Infectious Appendicitis
Pelvic inflammatory disease Irritable bowel syndrome
Diverticulitis
Endometritis
Inflammatory bowel disease
Salpingitis
Fecal impaction or constipation
Tubo-ovarian abscess
Gastroenteritis
Gynecologic: Noninfectious
Mesenteric lymphadenitis
Dysmenorrhea Abdominopelvic adhesions
Ovarian cyst (ruptured or intact) Perforated viscus
Endometriosis Bowel obstruction
Incarcerated or strangulated hernia

Uterine leiomyoma (fibroid): Degenerating or not
Ischemic bowel
Adenomyosis
Hirschsprung disease [1]
Mittelschmerz (midcycle ovulatory pain)
Intussusception [2]
Adnexal torsion (ovary and/or fallopian tube) Meckel's diverticulum [3]
Ovarian hyperstimulation syndrome Volvulus [4]
Endosalpingiosis Urinary tract
Uterine perforation (in women who have undergone a uterine Cystitis

procedure) Pyelonephritis
Asherman's syndrome Painful bladder syndrome
Neoplasm Kidney stones
Urinary retention
Pregnancy-related
Malignancy (bladder cancer)
First trimester
Vascular
Threatened abortion
Abdominal aortic aneurysm and dissection
Ectopic pregnancy, including heterotopic pregnancy
Sickle cell disease crisis
Corpus luteum hematoma
Septic pelvic thrombophlebitis
Incomplete abortion Ovarian vein thrombosis
Septic abortion Pelvic congestion syndrome
Uterine impaction Musculoskeletal
Second and third trimesters Muscular strain or sprain
Preterm labor Abdominal wall hematoma or infection
Hernia (inguinal or femoral)

Chorioamnionitis
Pelvic fracture
Placental abruption
Myofascial pain
Degenerating uterine leiomyoma (fibroid)
Neurologic
Medical complications during pregnancy, such as appendicitis
Herpes zoster
Round ligament stretch Anterior cutaneous nerve entrapment syndrome
Postpartum Abdominal epilepsy [5]
Endometritis Abdominal migraine [6]
Wound infection (cesarean section, laceration, or episiotomy repair) Psychiatric
Ovarian vein thrombosis or septic pelvic thrombophlebitis Depression
Somatization disorder
Narcotic seeking
Sexual and interpersonal

Domestic violence
Sexual abuse
Other
Familial Mediterranean Fever
Porphyria [7]
Lead poisoning
TNF receptor-associated periodic syndrome (ie, TRAPS)
This table presents common etiologies but is not meant to be exhaustive.
TNF: tumor necrosis factor; TRAPS: tumor necrosis factor receptor-associated periodic syndrome.
References:
1. Qiu JF, Shi YJ, Hu L, et al. Adult Hirschsprung's disease: report of four cases. Int J Clin Exp Pathol 2013; 6:1624.
2. Lu T. Adult Intussusception. Perm J 2015; 19:79.
3. Dumper J, Mackenzie S, Mitchell P, et al. Complications of Meckel's diverticula in adults. Can J Surg 2006; 49:353.

4. Li X, Zhang J, Li B, et al. Diagnosis, treatment and prognosis of small bowel volvulus in adults: A monocentric summary of a rare small intestinal obstruction. PLoS
One 2017; 12:e0175866.
5. Harshe DG, Harshe SN, Harshe GR, Harshe GG. Abdominal Epilepsy in an Adult: A Diagnosis Often Missed. J Clin Diagn Res 2016; 10:VD01.
6. Kunishi Y, Iwata Y, Ota M, et al. Abdominal Migraine in a Middle-aged Woman. Intern Med 2016; 55:2793.
7. Klobucic M, Sklebar D, Ivanac R, et al. Differential diagnosis of acute abdominal pain - acute intermittent porphyria. Med Glas (Zenica) 2011; 8:298.
Adapted from: Lipsky AM, Hart D. Acute pelvic pain. In: Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed, Walls RM, Hockberger RS, Gausche M, et al
(Eds), Elsevier, Philadelphia 2018.

Potential causes of acute pelvic pain in nonpregnant adult women by age group
Patient category Common diagnoses Less common diagnoses Rare diagnoses
Reproductive age (not pregnant) Dysmenorrhea Adenomyosis Asherman's syndrome (months

Endometriosis or endometrioma, Ovarian torsion postprocedure or delivery)
including ruptured Endometritis (postprocedure) Endosalpingiosis
Ovarian cyst, including ruptured Leiomyoma (degenerating) Neoplasm/malignancy, including
Pelvic inflammatory disease, Mittelschmerz gynecologic, gastrointestinal, and
including salpingitis or tubo-ovarian urologic
Sickle cell crisis in menstruating
abscess women with sickle cell disease Ovarian vein thrombosis, including
septic pelvic thrombophlebitis
Urinary retention (related to
medications or underlying Pelvic congestion syndrome
conditions, such as surgery) Torsion of subserosal fibroid
Uterine perforation (typically after
uterine procedure or intrauterine
device insertion)
Reproductive age (undergoing fertility Ectopic pregnancy Ovarian torsion Heterotopic pregnancy
treatment) Ovarian follicular cyst
Ovarian hyperstimulation syndrome
Reproductive age (postpartum or Wound infection Abdominal wall hematoma, Anterior cutaneous nerve
postprocedure) Endometritis infection, seroma, dehiscence entrapment syndrome
Ureteral obstruction Ovarian vein thrombosis
Postmenopausal women Malignancy (gynecologic, Ischemic colitis Endometriosis

gastrointestinal, or urologic) Pelvic inflammatory disease, tubo-
ovarian abscess
All groups Appendicitis Bowel obstruction Abdominal epilepsy

Diverticulitis Fecal impaction or constipation Abdominal migraine
Gastroenteritis Inguinal or femoral hernia Abdominal aortic aneurysm
Inflammatory bowel disease Interstitial cystitis/painful bladder Bladder cancer
Irritable bowel syndrome Muscular strain or sprain Depression (while depression is
Musculoskeletal pelvic pain Pelvic adhesive disease common, it is uncommonly a cause
Urinary tract infection (cystitis, (postoperative scarring) of acute pelvic pain)
pyelonephritis) Perforated viscus Domestic violence
Urolithiasis Perirectal abscess Fracture of pelvis or hip
Postoperative pelvic abscess Familial Mediterranean Fever
Urethral diverticulum Herpes Zoster
Ureteral obstruction Hirschsprung disease
Urinary retention Incarcerated or strangulated hernia
Intussusception
Lead poisoning
Malingering
Meckel's diverticulum
Mesenteric adenitis
Narcotic seeking
Ovarian torsion
Ovarian vein thrombosis
Pelvic congestion syndrome
Porphyria
Sexual abuse
Sickle cell crisis
Somatization disorder
TRAPS
Uterine rupture
Volvulus
Vulvar varicosities
Wandering spleen
TRAPS: tumor necrosis factor receptor-associated periodic syndrome.
Adapted from: Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic Pain. Am Fam Physician 2016; 93:41.

Causes of right upper quadrant (RUQ) abdominal pain
RUQ Clinical features Comments
Biliary
Biliary colic Intense, dull discomfort located in the RUQ or Patients are generally well-appearing.
epigastrium. Associated with nausea, vomiting, and
diaphoresis. Generally lasts at least 30 minutes,
plateauing within one hour. Benign abdominal
examination.
Acute cholecystitis Prolonged (>4 to 6 hours) RUQ or epigastric pain,

fever. Patients will have abdominal guarding and
Murphy's sign.
Acute cholangitis Fever, jaundice, RUQ pain. May have atypical presentation in older adults or
immunosuppressed patients.
Sphincter of Oddi dysfunction RUQ pain similar to other biliary pain. Biliary type pain without other apparent causes.
Hepatic
Acute hepatitis RUQ pain with fatigue, malaise, nausea, vomiting, Variety of etiologies include hepatitis A, alcohol, and
and anorexia. Patients may also have jaundice, dark drug-induced.
urine, and light-colored stools.
Perihepatitis (Fitz-Hugh-Curtis syndrome) RUQ pain with a pleuritic component, pain is Aminotransferases are usually normal or only slightly
sometimes referred to the right shoulder. elevated.
Liver abscess Fever and abdominal pain are the most common Risk factors include diabetes, underlying hepatobiliary
symptoms. or pancreatic disease, or liver transplant.
Budd-Chiari syndrome Symptoms include fever, abdominal pain, abdominal Variety of causes.
distention (from ascites), lower extremity edema,
jaundice, gastrointestinal bleeding, and/or hepatic
encephalopathy.
Portal vein thrombosis Symptoms include abdominal pain, dyspepsia, or Clinical manifestations depend on extent of
gastrointestinal bleeding. obstruction and speed of development. Most
commonly associated with cirrhosis.

Causes of epigastric abdominal pain
Epigastric Clinical features Comments
Acute myocardial infarction May be associated with shortness of breath and Consider particularly in patients with risk factors for
exertional symptoms. coronary artery disease.
Acute pancreatitis Acute-onset, persistent upper abdominal pain

radiating to the back.
Chronic pancreatitis Epigastric pain radiating to the back. Associated with pancreatic insufficiency.
Peptic ulcer disease Epigastric pain or discomfort is the most prominent Occasionally, discomfort localizes to one side.
symptom.
Gastroesophageal reflux disease Associated with heartburn, regurgitation, and

dysphagia.
Gastritis/gastropathy Abdominal discomfort/pain, heartburn, nausea, Variety of etiologies including alcohol and
vomiting, and hematemesis. nonsteroidal antiinflammatory drugs (NSAIDs).
Functional dyspepsia The presence of one or more of the following: Patients have no evidence of structural disease.
postprandial fullness, early satiation, epigastric pain,
or burning.
Gastroparesis Nausea, vomiting, abdominal pain, early satiety, Most causes are idiopathic, diabetic, or postsurgical.
postprandial fullness, and bloating.

Causes of left upper quadrant (LUQ) abdominal pain
LUQ Clinical features Comments
Splenomegaly Pain or discomfort in LUQ, left shoulder pain, and/or Multiple etiologies.
early satiety.
Splenic infarct Severe LUQ pain. Atypical presentations common. Associated with a
variety of underlying conditions (eg, hypercoagulable
state, atrial fibrillation, and splenomegaly).
Splenic abscess Associated with fever and LUQ tenderness. Uncommon. May also be associated with splenic
infarction.
Splenic rupture May complain of LUQ, left chest wall, or left shoulder Most often associated with trauma.
pain that is worse with inspiration.

Causes of lower abdominal pain
Lower abdomen Localization Clinical features Comments
Appendicitis Generally right lower quadrant Periumbilical pain initially that radiates Occasional patients present with
to the right lower quadrant. Associated epigastric or generalized abdominal
with anorexia, nausea, and vomiting. pain.
Diverticulitis Generally left lower quadrant; right Pain usually constant and present for Clinical presentation depends on
lower quadrant more common in Asian several days prior to presentation. May severity of underlying inflammatory
patients have associated nausea and vomiting. process and whether or not
complications are present.
Nephrolithiasis Either Pain most common symptom, varies Cause symptoms as stone passes from
from mild to severe. Generally flank renal pelvis to ureter.
pain, but may have back or abdominal
pain.
Pyelonephritis Either Associated with dysuria, frequency,

urgency, hematuria, fever, chills, flank
pain, and costovertebral angle
tenderness.
Acute urinary retention Suprapubic Present with lower abdominal pain and
discomfort; inability to urinate.
Cystitis Suprapubic Associated with dysuria, frequency,

urgency, and hematuria.
Infectious colitis Either Diarrhea as the predominant symptom, Patients with Clostridioides (formerly
but may also have associated Clostridium) difficile infection can
abdominal pain, which may be severe. present with an acute abdomen and
peritoneal signs in the setting of
perforation and fulminant colitis.

Less common etiologies of acute pelvic pain in nonpregnant adult women
Associated Supporting Physical Atypical or additional

Suspected cause Pain history Useful tests
symptoms history examination aspects
Gynecologic
Mittelschmerz Cyclic unilateral Midway between Recurrent Adnexal mass US May be associated with
lower quadrant menstrual midcycle pain CBC significant
pain, usually mild periods and lasts in females with hemoperitoneum
pain for a few hours to regular
a couple of days ovulatory
cycles
Leiomyoma Focal constant pain Low-grade fever, Known history Focal uterine US Discomfort usually self-
(degenerating) elevated white of fibroids, tenderness with limited, lasting from days
blood cell count, especially palpation to a few weeks, and
or peritoneal larger ones usually responds to
signs NSAIDs
Can occur with uterine
growth during pregnancy
Adenomyosis Dysmenorrhea Heavy menstrual May have Mobile, diffusely US Endometriosis commonly
bleeding chronic pelvic enlarged (often MRI coexists
pain but not referred to as Possible increased risk of
dyspareunia "globular" preterm birth in women
enlargement) and with adenomyosis,
soft (often diagnosed by either US or
referred to as MRI
"boggy") uterus
Imperforate hymen Cyclic abdominal Primary Adolescent Hematocolpos US Mucocolpos, or

or pelvic pain amenorrhea without prior bulging pyohematocolpos if the
(sometimes menses obstruction of the hymen has any
referred to as vagina, may give perforations
crypto- the hymenal Marked vaginal distension
menarche) membrane a may result in back pain,
bluish pain with defecation, or
discoloration difficulties with urination
Pelvic organ Sensation of pelvic Protrusion of Increasing Cystocele, Physical Obstructed urination or
prolapse pressure/heaviness tissue from the parity, rectocele, examination only defecation or
vagina advancing age, enterocele, hydronephrosis from
Other pelvic floor obesity, prior uterine prolapse, chronic ureteral kinking
disorders, hysterectomy, vaginal vault are indications for
including urinary, chronic prolapse treatment, regardless of
bowel, and constipation degree of prolapse
sexual Have job that
complaints involves heavy
lifting
Gastrointestinal
Inflammatory bowel RLQ pain with Loose stools or Chronic watery Abdominal CBC with Perianal disease (fistulae,
disease Crohn disease bloody diarrhea, diarrhea examination for differential anal skin tags, or
Rectal tenesmus abdominal pain, Chronic focal tenderness ESR fissures), or occult blood
with ulcerative or tenesmus abdominal pain Rectal CRP in stool
colitis Fever and examination for Albumin Fulminant disease
fatigue are tenesmus and presents with severe
Stool tests for
common at perianal abdominal pain, frankly
gross or occult
presentation abscesses/fissures bloody diarrhea,
blood
and during tenesmus, fever,
Fecal calprotectin
disease flares leukocytosis, and
Perianal hypoalbuminemia
abscesses, Subacute illness
fistulae, and characterized by diarrhea
fissures, oral that usually contains
ulcers, or blood, fatigue, anemia,
arthritis and sometimes weight
loss
Rectal obstruction Pain in low pelvis Focal abdominal No passage or Abdominal CBC with Evaluate for systemic
pain may indicate stool; change examination for differential, signs of dehydration,
peritoneal in bowel habits distension electrolytes shock, or abdominal
irritation due to or stool caliber Rectal tenesmus including BUN compartment syndrome
ischemia or Abdominal and creatinine from severe colonic
colonic necrosis distention or Imaging with distention
A sudden relief of increased plain radiographs Laboratories assess
pain followed by abdominal or CT presence and severity of
a progressive girth hypovolemia or other
worsening of pain metabolic abnormalities,
may occur with and for leukocytosis with a
intestinal leftward shift
perforation Progressive change in
Progressive bowel habits associated
change in bowel with unintentional weight
habits associated loss over months
with suggestive of malignancy
unintentional If malignancy of the colon
weight loss over is suspected, obtain CEA

months suggests level
malignancy
Inguinal or femoral Heaviness or dull Presentations Congenital or Bulge in the groin Groin US or Inguinal more common
hernia discomfort in the range from a acquired while standing herniography than femoral
groin bulge in the groin Older age, and patient (peritoneography) Risk of
Moderate to severe region with or chronic cough, coughs or does CT or MRI incarceration/strangulation
pain is unusual and without pain to chronic Valsalva low
suggests emergent, life- constipation, maneuver If
strangulation of threatening due smoking incarcerated/strangulated
bowel to bowel If acquired, hernia, imaging generally
strangulation associated with not necessary prior to
Groin discomfort connective surgical repair
most pronounced tissue Women more likely to
with increased abnormalities, present emergently due to
intra-abdominal chronic a higher incidence of
pressure as with abdominal wall femoral hernias, which are
heavy lifting, injury, or more likely to strangulate
straining, or possibly drug
prolonged effects
standing
Strangulated
hernias may
manifest with
symptoms of
bowel obstruction
and possibly
systemic
symptoms if
bowel necrosis
occurred
Urinary tract
Bladder pain Discomfort with Urinary Bothersome Variable Urinalysis with Other chronic pain
syndrome/interstitial bladder filling and frequency, sensations are tenderness of the microscopy to symptoms (eg, irritable
cystitis a relief with urgency, and worsened by abdominal wall, exclude infection bowel syndrome,
voiding nocturia often bladder filling hip girdle, pelvic and hematuria vulvodynia, endometriosis,
Pain location is accompany the and/or relieved floor, bladder Chlamydia testing dysmenorrhea,
suprapubic or discomfort or by emptying base, and urethra fibromyalgia) present in
urethral, although pain Allodynia (as with many patients
can be unilateral other patients Exacerbation of IC/BPS
lower abdominal with chronic pain) symptoms may occur after
pain or low back Tenderness or intake of certain foods or
pain tightness of the drinks, during stress, after
pelvic floor certain activities (eg,
muscles exercise, sexual
intercourse, prolonged
sitting), or during the
luteal phase of the
menstrual cycle
Urinary retention Lower abdominal Inability to pass Previous Pelvic Urine sample for Presence of hematuria,
and/or suprapubic urine history of examination for urinalysis and dysuria, overflow
discomfort retention or uterus size and urine culture incontinence, fever, low
lower urinary location Bladder US or back pain, neurologic
tract Rectal catheterization symptoms, or rash
symptoms, examination to for diagnosis Obtain a complete list of
pelvic surgery, evaluate for medications (including
radiation, or masses, fecal over-the-counter
pelvic trauma impaction, medications)
perineal Urethral catheterization
sensation, and contraindicated in patients
rectal sphincter who had recent urologic
tone surgery (eg,
reconstruction)
With catheterization, if
greater than 200 mL of
urine, record volume
drained in the first 10 to
15 minutes
If this volume exceeds 400
mL, catheter typically left
in place
Urethral Dysuria or Postvoid dribbling Chronic or Anterior vaginal Urinalysis if Classic triad of dysuria,
diverticulum dyspareunia recurrent UTIs wall mass, dysuria, dyspareunia and postvoid
Urinary particularly a frequency, dribbling often not present
frequency tender mass hematuria Anterior vaginal wall
and/or urgency MRI preferable, visualized for mass by
Hematuria US if MRI using a half speculum to
Bloody urethral unavailable retract the posterior
discharge vaginal wall
Urinary The anterior vaginal wall is

incontinence inspected for mass while
the patient rests and then
Urinary
does a Valsalva maneuver
retention
Pelvic or
urethral pain
Vaginal mass

Musculoskeletal
Aseptic necrosis of Groin pain is most Weightbearing or Use of Hip range of Plain film Although rare, pain in
femoral head common in motion-induced glucocorticoids motion, radiographs, multiple joints suggests a
patients with pain is found in and excessive particularly with radionuclide multifocal process
femoral head most cases alcohol intake forced internal scans, and MRI Early diagnosis of
disease, followed Rest pain occurs rotation and osteonecrosis may provide
by thigh and in approximately abduction the opportunity to prevent
buttock pain two-thirds of collapse and, ultimately,
patients, and the need for joint
night pain occurs replacement
in one-third A limp may be present
late in the course of lower
extremity disease
Ehlers-Danlos Vulvodynia Joint Chronic Pelvic floor Genetic testing Pain management using a
syndrome (joint Generalized pelvic hypermobility widespread dysfunction multidisciplinary approach
hypermobility pain Skin pain Beighton of the type advocated for
syndromes) hyperextensibility Fatigue hypermobility patients with fibromyalgia
Mitral valve Mood disorders score or chronic centralized pain
prolapse (anxiety and
depression)
Palpitations,
chest pain, and
near-syncope
or syncope due
to postural
tachycardia
Orthostatic
symptoms,
including
(near)
blackouts due
to postural
hypotension
Varicose veins
Eye
abnormalities
Hip osteoarthritis or Pain is usually felt Pain, aching, Generalized or Joint examination US Differential diagnosis for
inflammatory deep in the stiffness, and restricted to a for mobility, MRI osteoarthritis depends
arthritis anterior groin but restricted few joints warmth, swelling Radiography largely on the location of
may involve the movement the affected site as well as
Synovial fluid
anteromedial or the presence or absence
assessment
upper lateral thigh of additional systemic
and occasionally symptoms
the buttocks
Fibromyalgia Widespread Symptoms Pain is often Tenderness in None or to Multiple nonspecific

musculoskeletal suggestive of IBS chronic and soft-tissue exclude other symptoms of fibromyalgia
pain Pelvic pain and associated with anatomic conditions (eg, can mimic many other
bladder numbness, locations CBC, ESR, CRP conditions, and
symptoms of tingling, and antinuclear consideration of the
frequency and other abnormal antibody and differential diagnosis is
urgency sensations rheumatoid important coexisting with
suggestive of the Fatigue and factor) other common functional
interstitial poor sleep somatic syndromes,
cystitis/painful Cognitive and including chronic fatigue
bladder psychiatric syndrome, irritable bowel
syndrome symptoms syndrome, endometriosis
(formerly female migraine, and
Headache
urethral temporomandibular
syndrome) disorder, as well as chronic
bladder and pelvic pain
syndromes
Vascular
Ovarian vein Pain localizes to Acutely ill, with Nausea, ileus, Pelvis is tender to CBC for Leukocytosis of
thrombophlebitis the side of the fever and and other palpation, and leukocytosis >12,000/microL occurs in
affected vein abdominal pain gastrointestinal some patients CT with contrast 70 to 100% of patients
(usually the right) within 1 week symptoms may may have a Dedicated venous with SPT
but can be felt in after delivery or occur but are tender rope-like imaging OVT is most often right-
the flank or back pelvic surgery usually mild mass on sided, as that vein is
examination that longer and more likely to
extends centrally be compressed by the
from the uterus to uterus
the upper lateral
abdomen
Septic pelvic Intermittent or With fever in the Recent vaginal Tenderness to Optimal imaging Leukocytosis of
thrombophlebitis mild early postpartum or cesarean palpation is modality is >12,000/microL occurs in
abdominopelvic or postoperative delivery or typically absent uncertain 70 to 100% of patients
pain period (usually pelvic surgery CT with contrast with SPT
within 3 to 5 Patients may Dedicated venous If the patient presents
days, but onset present imaging MRI with with persistent fever after
may be delayed following gadolinium- vaginal or cesarean
to up to 3 weeks vaginal or enhanced delivery or pelvic surgery
following cesarean magnetic despite adequate antibiotic
delivery) delivery or resonance therapy and no other
pelvic surgery apparent cause is

with persistent venography to identified, treat for
fever despite highlight any possible SPT with addition
antibiotic pelvic vein-filling of anticoagulation, even if
therapy for defect no thrombosis identified
presumed on imaging
endometritis Imaging findings
and no other suggestive of pelvic
apparent cause venous thrombosis can be
seen in absence of
suspected SPT, making
clinical correlation
essential; many patients
with SPT have
unrecognized involvement
of other pelvic veins
Vulvar varicosities Vulvar discomfort, Aggravated by Chronic pelvic Perineal No imaging Vulvar varices are often
swelling, and menses discomfort examination necessary asymptomatic
pressure that are exacerbated by
exacerbated by prolonged
prolonged standing and
standing, exercise, coitus in
and coitus women who
have
periovarian
varicosities on
imaging
studies
US: ultrasound; CBC: complete blood count; NSAIDs: nonsteroidal anti-inflammatory drugs; MRI: magnetic resonance imaging; RLQ: right lower quadrant; ESR:
erythrocyte sedimentation rate; CRP: C-reactive protein; BUN: blood urea nitrogen; CT: computed tomography; CEA: carcinoembryonic antigen; IC/BPS: interstitial
cystitis/painful bladder syndrome; UTI: urinary tract infection; IBS: irritable bowel syndrome; SPT: septic pelvic thrombophlebitis; OVT: ovarian vein thrombosis.

Evaluation of acute pelvic pain* in adult, nonpregnant women
CBC: complete blood count.

* Acute pelvic pain is defined as less than three months duration.
¶ For more information, refer to related UpToDate content on the emergency evaluation of adults with abdominal pain.
Δ The minimal rapid assessment typically includes a focused history, limited physical examination, rapid assessment ultrasound, and emergency CBC
and type and crossmatch.
◊ For women whose pelvic pain persists after initial diagnosis and treatment, we reassess for emergency diagnoses and atypical presentations of
common diagnoses and evaluate for rare conditions. More information can be found in the UpToDate content on the evaluation of acute pelvic pain in
women.
§ Ectopic pregnancy is a common obstetric cause of acute pelvic pain, which should be excluded in women with a positive pregnancy test.

Estimation of gestational age by fundal height
The solid lines indicate the height of the fundus by weeks of gestation in a
normally grown singleton gestation.

Questions used to assess the possibility of pregnancy
The provider can be reasonably certain that the woman is not pregnant if she has no symptoms or signs of pregnancy and meets any of the following
criteria:
1. She has not had intercourse since her last normal menses.
2. She has been correctly and consistently using a reliable method of contraception.
3. She is within the first 7 days after normal menses.
4. She is within 4 weeks postpartum (for nonlactating women).
5. She is within the first 7 days postabortion or miscarriage.
6. She is fully or nearly fully breastfeeding, amenorrheic, and less than 6 months postpartum.
A systematic review of studies evaluating the performance of a pregnancy checklist compared with urine pregnancy test to rule out pregnancy concluded the
negative predictive value of a checklist similar to the one above was 99 to 100%.
Data from:
Tepper NK, Marchbanks PA, Curtis KM. Use of a checklist to rule out pregnancy: A systematic review. Contraception 2013; 87:661.
Curtis KM, Tepper NK, Jatlaoui TC, et al. United States Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.

Algorithm: Diagnosis of ectopic pregnancy
hCG: human chorionic gonadotropin; TVUS: transvaginal ultrasound; FAST: Focused Assessment with Sonography for Trauma; IUP: intrauterine pregnancy.
* Nondiagnostic findings on ultrasound include no findings in the uterus or adnexa, a potential gestational sac in the uterus with no yolk sac or embryo, or an adnexal
mass with no yolk sac or embryo. An intrauterine sac and an adnexal mass suspicious for an ectopic pregnancy may both be present. If so, this may be an intrauterine
pseudosac, but a rare heterotopic pregnancy must be excluded.
¶ The discriminatory zone is the serum hCG level above which a gestational sac should be visualized by TVUS if an IUP is present. In most institutions, the
discriminatory zone is a serum hCG level of 2000 international units/L; however, some data suggest that an IUP may not be visible until a higher level is reached (3510
international units/L). Because fibroids, body habitus, and multiple gestations can occur, no single value of hCG should be used to treat for ectopic pregnancy in a
stable patient with a pregnancy of unknown location.
Δ Other etiologies of elevated hCG include trophoblastic or nontrophoblastic tumors (eg, testicular cancer), pituitary hCG, false positive, or exogenous hCG.

Causes of abdominal pain by location
Right upper quadrant Left upper quadrant

Hepatitis Splenic abscess
Cholecystitis Splenic infarct
Cholangitis Gastritis
Biliary colic Gastric ulcer
Pancreatitis Pancreatitis
Budd-Chiari syndrome Left lower quadrant

Pneumonia/empyema pleurisy Diverticulitis
Subdiaphragmatic abscess Salpingitis
Right lower quadrant Ectopic pregnancy
Appendicitis Inguinal hernia
Salpingitis Nephrolithiasis
Ectopic pregnancy Irritable bowel syndrome
Inguinal hernia Inflammatory bowel disease
Nephrolithiasis Diffuse
Inflammatory bowel disease Gastroenteritis
Mesenteric adenitis (yersina) Mesenteric ischemia
Epigastric Metabolic (eg, DKA, porphyria)
Peptic ulcer disease Malaria
Gastroesophageal reflux disease Familial Mediterranean fever
Gastritis Bowel obstruction
Pancreatitis Peritonitis
Myocardial infarction Irritable bowel syndrome
Pericarditis
Ruptured aortic aneurysm
Periumbilical
Early appendicitis
Gastroenteritis
Bowel obstruction
Ruptured aortic aneurysm
DKA: diabetic ketoacidosis.

Less common causes of abdominal pain
Abdominal aortic aneurysm
Abdominal compartment syndrome
Abdominal migraine
Acute intermittent porphyria
Angioedema (either hereditary or angiotensin-converting enzyme [ACE] inhibitor-related)
Celiac artery compression syndrome
Chronic abdominal wall pain
Colonic pseudo-obstruction (acute or chronic)
Eosinophilic gastroenteritis
Epiploic appendagitis
Familial Mediterranean fever
Helminthic infections
Herpes zoster
Hypercalcemia
Hypothyroidism
Lead poisoning
Meckel's diverticulum
Narcotic bowel syndrome
Paroxysmal nocturnal hemoglobinuria
Pseudoappendicitis
Pulmonary etiologies
Rectus sheath hematoma
Renal infarction
Rib pain
Sclerosing mesenteritis
Somatization
Wandering spleen

Contributor Disclosures
Pamela Stratton, MD Grant/Research/Clinical Trial Support: Allergan [Pelvic pain from endometriosis (Botulinum toxin)]. Howard T Sharp,
MD Nothing to disclose Kristen Eckler, MD, FACOG Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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06/02/2020 Evaluation of acute pelvic pain in nonpregnant adult women - UpToDate

Official reprint from UpToDate®

● (See "Evaluation of the adult with abdominal pain".)

● (See "Approach to acute abdominal pain in pregnant and postpartum women".)

● (See "Evaluation of chronic pelvic pain in females".)

Related topics for pediatric and adolescent patients include:

● (See "Causes of acute abdominal pain in children and adolescents".)

● (See "Emergency evaluation of the child with acute abdominal pain".)

● (See "Evaluation of acute pelvic pain in the adolescent female".)

● (See "Evaluation of the adult with abdominal pain".)

● (See "Causes of abdominal pain in adults".)

● (See "Evaluation of low back pain in adults".)

● (See "Vulvar lesions: Diagnostic evaluation".)

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 1/34

● (See "Differential diagnosis of sexual pain in women".)

● (See "Hemorrhoids: Clinical manifestations and diagnosis".)

Detailed information on the evaluation of each of these processes is presented separately:

• (See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

• (See "Evaluation and management of ruptured ovarian cyst".)

• (See "Pelvic inflammatory disease: Clinical manifestations and diagnosis".)

• (See "Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess".)

• (See "Acute appendicitis in adults: Clinical manifestations and differential diagnosis".)

• (See "Clinical manifestations and diagnosis of acute diverticulitis in adults".)

• (See "Acute complicated urinary tract infection (including pyelonephritis) in adults".)

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 2/34

EXCLUDE LIFE-THREATENING DISORDERS

We take the following approach:

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 3/34

INITIAL EVALUATION FOR COMMON CONDITIONS

● Timing of pain onset

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 4/34

● Speculum examination of vagina and cervix

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 5/34

● Bimanual examination of the uterus and bilateral adnexa

• An enlarged uterus may reflect pregnancy, leiomyoma (fibroids), or both.

• Rectal mass may be a malignancy or rectal endometriosis.

● Urinalysis – A urinalysis is done on a clean-catch specimen. Important findings include:

• Hematuria can indicate urolithiasis or hemorrhagic cystitis.

● Complete blood count

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 6/34

TREAT INITIAL DIAGNOSES AND REASSESS

PURSUE LESS COMMON DIAGNOSES IF SYMPTOMS PERSIST

• Porphyria (see "Porphyrias: An overview")

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 7/34

● (See "Screening for depression in adults".)

● (See "Intimate partner violence: Diagnosis and screening".)

● (See "Causes of chronic pelvic pain in nonpregnant women".)

● (See "Evaluation of chronic pelvic pain in females".)

● (See "Treatment of chronic pelvic pain in women".)

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 8/34

● Ovarian remnant syndrome (monthly pain with ovulation) [23]

● Endometrioma of abdominal wall after cesarean delivery [24]

SUMMARY AND RECOMMENDATIONS

https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-nonpregnant-adult-women/print?search=acute pelvic pain&source=search… 9/34

Use of UpToDate is subject to the Subscription and License Agreement.

5. Mostafa-Gharabaghi P, Bordbar S, Vazifekhah S, Naghavi-Behzad M. Spontaneous Rupture of Pyometra in a Nonpregnant Young

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Topic 5473 Version 18.0

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Potentially life-threatening causes of acute pelvic pain in nonpregnant adult women

Courtesy of Pamela Stratton, MD.

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