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: May 2022. | This topic last updated: Mar 02, 2022.
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/pelvic pain in pregnant and postpartum patients".)
● (See "Chronic pelvic pain in adult females: Evaluation".)
Related topics for pediatric and adolescent patients include:
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● (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 "Chronic pelvic pain in nonpregnant adult females:
Causes".)
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 "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)
● (See "Vulvar lesions: Diagnostic evaluation".)
● (See "Evaluation and management of female lower genital tract trauma".)
● (See "Female sexual pain: Differential diagnosis".)
● (See "Hemorrhoids: Clinical manifestations and diagnosis".)
CAUSES
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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 (UTO) 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
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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 the last menstrual period, other medical
conditions (including pregnancy or delivery), any recent surgery, medications, and
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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
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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
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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 intraabdominal 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 the 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 intraabdominal 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.
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● 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 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
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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 intraabdominal 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'.)
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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): Terminology, risk factors, and etiology".)
• An open cervical os suggests an inevitable or incomplete abortion but does not exclude
an ectopic pregnancy. (See "Pregnancy loss (miscarriage): Terminology, risk factors,
and etiology".)
● 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.
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• 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.
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• Pregnant patients with any concern for fetomaternal transfusion require blood typing
to identify Rh-negative patients who will require Rho(D) immune globulin. (See "RhD
alloimmunization: Prevention in pregnant and postpartum patients".)
● Blood cultures are performed in women suspected of having disseminated infection,

such as some women with PID. (See "Detection of bacteremia: Blood cultures and other
diagnostic tests".)
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.
● Free intraabdominal 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 "Ectopic pregnancy: Clinical manifestations and
diagnosis", 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
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women whose abdominal and pelvic ultrasound evaluations were nondiagnostic for a cause of
pain. (See "Acute appendicitis in pregnancy", section on 'Magnetic resonance imaging (MRI)'.)
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")
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• 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 "Chronic pelvic pain in nonpregnant adult females: Causes".)
● (See "Chronic pelvic pain in adult females: Evaluation".)
● (See "Chronic pelvic pain in adult females: Treatment".)
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
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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 "Chronic pelvic pain in adult females: Evaluation", 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 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
6/19/22, 5:27 PM 5473
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".)
6/19/22, 5:27 PM 5473
● 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/pelvic pain in pregnant and postpartum
patients".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Female pelvic pain".)
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.)
6/19/22, 5:27 PM 5473
● 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 UpToDate editorial staff acknowledges Fred Howard, MD, who contributed to an earlier
version of this topic review.
Use of UpToDate is subject to the Terms of Use.
REFERENCES
6/19/22, 5:27 PM 5473
1. Kruszka PS, Kruszka SJ. Evaluation of acute pelvic pain in women. Am Fam Physician 2010;
82:141.
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, Mar
x J, Hockberger R, Walls R (Eds), Saunders, 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 Review. Obstet Gynecol Int 2018; 2018:7365715.
15. Bhavsar AK, Gelner EJ, Shorma T. Common Questions About the Evaluation of Acute Pelvic
Pain. Am Fam Physician 2016; 93:41.
16. Woo AK. Depression and Anxiety in Pain. Rev Pain 2010; 4:8.
6/19/22, 5:27 PM 5473
17. Baldwin SB, Eisenman DP, Sayles JN, et al. Identification of human trafficking victims in
health care settings. Health Hum Rights 2011; 13:E36.
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 committee opinion. Fertil Steril 2014; 101:927.
21. ACOG Committee Opinion No. 760 Summary: Dysmenorrhea and Endometriosis in the
Adolescent. Obstet Gynecol 2018; 132:1517. Reaffirmed 2022.
22. Sharma D, Day ME, Stimpson SJ, et al. Acute Vaso-Occlusive Pain is Temporally Associated
with the Onset of Menstruation in 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 26.0
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GRAPHICS
Potentially life-threatening causes of acute pelvic pain in nonpregnant

adult women
Causative
disorder Pain Associated Supporting Physical
Useful tests
or history symptoms history examination
condition
Ectopic Classically Vaginal Missed period Classically, Pelvic US

pregnancy severe, sharp, bleeding unilateral Quantitative
History of
(critical if lateral pelvic (often adnexal beta-hCG
previous
ruptured) pain, but spotting or tenderness, T&C
ectopic
severity, light, but can adnexal mass,
pregnancy, Laparoscopy
location, and be absent) CMT
infertility,
quality highly
pelvic surgery,
variable
PID, or IUD
use
Ruptured Abrupt Light- Pain may Hypotension Pelvic US

ovarian cyst moderate to headedness if begin and CBC
(critical with severe lateral bleeding is spontaneously tachycardia if T&C
significant pain severe or with blood loss is
hemorrhage; intercourse significant
Rectal pain
otherwise,
arises from Menstrual Possible
emergency)
fluid in cul-de- history may peritonitis
sac indicate LMP
was two or
Nausea and
more weeks
vomiting may
ago
occur
Ovarian Acute onset of Nausea and History of Adnexal mass US with

torsion moderate to vomiting ovarian mass and tenderness Doppler flow
(emergency) severe lateral or cyst studies
Possible
pain Laparoscopy
peritonitis
Appendicitis Duration Low-grade Migration of RLQ tenderness US

often <48 fever, nausea, pain to RLQ
6/19/22, 5:27 PM 5473
p Q
(emergency) hours, vomiting, from center Possible CT
generalized anorexia peritonitis MRI
Abdominal
followed by
pain before
localized RLQ
vomiting
pain
PID (urgent- Without TOA, Fever, vaginal Vaginal Pus from CBC
emergency), pain is usually discharge discharge cervical os, ESR
TOA bilateral; may CMT, adnexal CRP
History of PID
(emergency) manifest tenderness
Pelvic US
acutely within History of a
Peritonitis Cervical
48 hours, but new sex
suggests TOA cultures
PID may also partner, more
or severe PID Cervical smear
be chronic than one
partner, or a for WBCs
partner who
has other sex
partners or a
sexually
transmitted
infection
Complicated Pain with Urinary Recent Suprapubic Urinalysis

UTI (urgent) urination urgency and urologic tenderness, Urine culture
frequency procedure flank
Patient may
tenderness,
have flank Fever and Prior history
and fever with
pain from vomiting if of UTI
pyelonephritis
associated patient has
pyelonephritis associated
pyelonephritis
Ureteral Acute onset, Nausea and History of Patient often Urinalysis,

obstruction manifests vomiting surgery that appears hematuria
(urgent) within hours could cause uncomfortable, present in
ureteral but physical approximately
Pain is lateral,
obstruction or examination 80% of cases
usually
prior history can be Renal
moderate to
of kidney otherwise ultrasound for
severe
stones unremarkable hydronephrosis
Often radiates
Abdominal CT
into the groin
or
costovertebral
angle or flank
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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
6/19/22, 5:27 PM 5473
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.
6/19/22, 5:27 PM 5473
Blood supply of the pelvis
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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.
6/19/22, 5:27 PM 5473
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.
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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.
6/19/22, 5:27 PM 5473
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
Bowel obstruction
Endometriosis
Incarcerated or strangulated hernia
Uterine leiomyoma (fibroid):
Degenerating or not Ischemic bowel
Hirschsprung disease[1]
Adenomyosis
Intussusception[2]
Mittelschmerz (midcycle ovulatory
Meckel's diverticulum[3]
pain)
Volvulus[4]
Adnexal torsion (ovary and/or fallopian
tube) Urinary tract
Cystitis
Ovarian hyperstimulation syndrome
Pyelonephritis
Endosalpingiosis
Painful bladder syndrome
Uterine perforation (in women who
Kidney stones
have undergone a uterine procedure)
Urinary retention
Asherman's syndrome
Malignancy (bladder cancer)
Neoplasm
Vascular
Pregnancy-related Abdominal aortic aneurysm and dissection
First trimester Sickle cell disease crisis
Threatened abortion Septic pelvic thrombophlebitis
Ectopic pregnancy, including Ovarian vein thrombosis

heterotopic pregnancy Pelvic congestion syndrome
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Corpus luteum hematoma Musculoskeletal
Incomplete abortion Muscular strain or sprain
Abdominal wall hematoma or infection

Septic abortion
Hernia (inguinal or femoral)
Uterine impaction
Pelvic fracture
Second and third trimesters
Myofascial pain
Preterm labor
Neurologic
Chorioamnionitis
Herpes zoster
Placental abruption Anterior cutaneous nerve entrapment
syndrome
Degenerating uterine leiomyoma
(fibroid) Abdominal epilepsy[5]
Abdominal migraine[6]
Medical complications during
pregnancy, such as appendicitis Psychiatric
Round ligament stretch Depression
Postpartum Somatization disorder
Narcotic seeking
Endometritis
Sexual and interpersonal
Wound infection (cesarean section,
laceration, or episiotomy repair) Domestic violence
Ovarian vein thrombosis or septic Sexual abuse

pelvic thrombophlebitis
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.
6/19/22, 5:27 PM 5473
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.
6/19/22, 5:27 PM 5473
Potential causes of acute pelvic pain in nonpregnant adult women by age

group
Common Less common

Patient category Rare diagnoses
diagnoses diagnoses
Reproductive age Dysmenorrhea Adenomyosis Asherman's syndrome

(not pregnant) Endometriosis or Ovarian torsion (months
endometrioma, Endometritis postprocedure or
including ruptured (postprocedure) delivery)
Ovarian cyst, Leiomyoma Endosalpingiosis
including ruptured (degenerating) Neoplasm/malignancy,
Pelvic Mittelschmerz including gynecologic,
inflammatory gastrointestinal, and
Sickle cell crisis in
disease, including urologic
menstruating
salpingitis or tubo- women with sickle Ovarian vein
ovarian abscess cell disease thrombosis, including
septic pelvic
Urinary retention
thrombophlebitis
(related to
medications or Pelvic congestion
underlying syndrome
conditions, such as Torsion of subserosal
surgery) fibroid
Uterine perforation
(typically after uterine
procedure or
intrauterine device
insertion)
Reproductive age Ectopic pregnancy Ovarian torsion Heterotopic pregnancy

(undergoing fertility Ovarian follicular
treatment) cyst
Ovarian
hyperstimulation
syndrome
Reproductive age Wound infection Abdominal wall Anterior cutaneous

(postpartum or Endometritis hematoma, nerve entrapment
postprocedure) infection, seroma, syndrome
dehiscence Ovarian vein
Ureteral thrombosis
obstruction Septic pelvic
thrombophlebitis
Postmenopausal Malignancy Ischemic colitis Endometriosis

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women (gynecologic, Pelvic inflammatory

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

Diverticulitis Fecal impaction or Abdominal migraine
Gastroenteritis constipation Abdominal aortic
Inflammatory Inguinal or femoral aneurysm
bowel disease hernia Bladder cancer
Irritable bowel Interstitial Depression (while
syndrome cystitis/painful depression is
Musculoskeletal bladder common, it is
pelvic pain Muscular strain or uncommonly a cause
Urinary tract sprain of acute pelvic pain)
infection (cystitis, Pelvic adhesive Domestic violence
pyelonephritis) disease Fracture of pelvis or
Urolithiasis (postoperative hip
scarring) Familial
Perforated viscus Mediterranean Fever
Perirectal abscess Herpes Zoster
Postoperative Hirschsprung disease
pelvic abscess Incarcerated or
Urethral strangulated hernia
diverticulum Intussusception
Ureteral Lead poisoning
obstruction
Malingering
Urinary retention
Meckel's diverticulum
Mesenteric adenitis
Narcotic seeking
Ovarian torsion
Ovarian vein
thrombosis
Pelvic congestion
syndrome
Porphyria
Septic pelvic
thrombophlebitis
Sexual abuse
Sickle cell crisis
Somatization disorder
TRAPS
Uterine rupture
Volvulus
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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.
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Causes of right upper quadrant (RUQ) abdominal pain
RUQ Clinical features Comments
Biliary
Biliary colic Intense, dull discomfort located Patients are generally well-
in the RUQ or epigastrium. appearing.
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 RUQ pain similar to other biliary Biliary type pain without other
dysfunction pain. apparent causes.
Hepatic
Acute hepatitis RUQ pain with fatigue, malaise, Variety of etiologies include
nausea, vomiting, and anorexia. hepatitis A, alcohol, and drug-
Patients may also have induced.
jaundice, dark urine, and light-
colored stools.
Perihepatitis (Fitz-Hugh- RUQ pain with a pleuritic Aminotransferases are usually

Curtis syndrome) component, pain is sometimes normal or only slightly elevated.
referred to the right shoulder.
Liver abscess Fever and abdominal pain are Risk factors include diabetes,
the most common symptoms. underlying hepatobiliary or
pancreatic disease, or liver
transplant.
Budd-Chiari syndrome Symptoms include fever, Variety of causes.

abdominal pain, abdominal
distention (from ascites), lower
extremity edema, jaundice,
gastrointestinal bleeding,
and/or hepatic encephalopathy.
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Portal vein thrombosis Symptoms include abdominal Clinical manifestations depend

pain, dyspepsia, or on extent of obstruction and
gastrointestinal bleeding. speed of development. Most
commonly associated with
cirrhosis.
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Causes of epigastric abdominal pain
Epigastric Clinical features Comments
Acute myocardial infarction May be associated with Consider particularly in patients

shortness of breath and with risk factors for coronary
exertional symptoms. artery disease.
Acute pancreatitis Acute-onset, persistent upper

abdominal pain radiating to the
back.
Chronic pancreatitis Epigastric pain radiating to the Associated with pancreatic

back. insufficiency.
Peptic ulcer disease Epigastric pain or discomfort is Occasionally, discomfort

the most prominent symptom. localizes to one side.
Gastroesophageal reflux Associated with heartburn,

disease regurgitation, and dysphagia.
Gastritis/gastropathy Abdominal discomfort/pain, Variety of etiologies including

heartburn, nausea, vomiting, alcohol and nonsteroidal
and hematemesis. antiinflammatory drugs
(NSAIDs).
Functional dyspepsia The presence of one or more of Patients have no evidence of

the following: postprandial structural disease.
fullness, early satiation,
epigastric pain, or burning.
Gastroparesis Nausea, vomiting, abdominal Most causes are idiopathic,

pain, early satiety, postprandial diabetic, or postsurgical.
fullness, and bloating.
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Causes of left upper quadrant (LUQ) abdominal pain
LUQ Clinical features Comments
Splenomegaly Pain or discomfort in LUQ, left Multiple etiologies.

shoulder pain, and/or 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 Uncommon. May also be
tenderness. associated with splenic
infarction.
Splenic rupture May complain of LUQ, left chest Most often associated with
wall, or left shoulder pain that trauma.
is worse with inspiration.
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Causes of lower abdominal pain
Lower abdomen Localization Clinical features Comments
Appendicitis Generally right lower Periumbilical pain Occasional patients

quadrant initially that radiates to present with epigastric
the right lower or generalized
quadrant. Associated abdominal pain.
with anorexia, nausea,
and vomiting.
Diverticulitis Generally left lower Pain usually constant Clinical presentation

quadrant; right lower and present for several depends on severity of
quadrant more days prior to underlying
common in Asian presentation. May have inflammatory process
patients associated nausea and and whether or not
vomiting. complications are
present.
Nephrolithiasis Either Pain most common Cause symptoms as

symptom, varies from stone passes from
mild to severe. renal pelvis to ureter.
Generally flank 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 Patients with

predominant Clostridioides
symptom, but may also difficile infection can
have associated present with an acute
abdominal pain, which abdomen and
may be severe. peritoneal signs in the
6/19/22, 5:27 PM 5473
setting of perforation
and fulminant colitis.
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Less common etiologies of acute pelvic pain in nonpregnant adult women
Associated Supporting Ph
Suspected cause Pain history
symptoms history exam
Gynecologic
Mittelschmerz Cyclic unilateral Midway between Recurrent Adne

lower quadrant menstrual midcycle pain
pain, usually mild periods and lasts in females with
pain for a few hours to regular
a couple of days ovulatory
cycles
Leiomyoma Focal constant pain Low-grade fever, Known history Focal

(degenerating) elevated white of fibroids, tende
blood cell count, especially palpa
or peritoneal larger ones
signs
Adenomyosis Dysmenorrhea Heavy menstrual May have Mobi

bleeding chronic pelvic enlar
pain but not refer
dyspareunia "glob
enlar
soft (
refer
"bogg
Imperforate hymen Cyclic abdominal Primary Adolescent Hema

or pelvic pain amenorrhea without prior bulgi
(sometimes menses obstr
referred to as vagin
crypto-menarche) the h
mem
bluish
disco
Pelvic organ Sensation of pelvic Protrusion of Increasing Cysto

prolapse pressure/heaviness tissue from the parity, recto
vagina advancing age, enter
Other pelvic floor obesity, prior uterin
disorders, hysterectomy, vagin
including urinary, chronic prola
bowel, and constipation
6/19/22, 5:27 PM 5473
sexual Have job that

complaints involves heavy
lifting
Gastrointestinal
Inflammatory bowel RLQ pain with Loose stools or Chronic watery Abdo
disease Crohn disease bloody diarrhea, diarrhea exam
Rectal tenesmus abdominal pain, Chronic focal
with ulcerative or tenesmus abdominal pain Recta
colitis Fever and exam
fatigue are tenes
common at peria
presentation absce
and during
disease flares
Perianal
abscesses,
fistulae, and
fissures, oral
ulcers, or
arthritis
Rectal obstruction Pain in low pelvis Focal abdominal No passage or Abdo

pain may indicate stool; change exam
peritoneal in bowel habits diste
irritation due to or stool caliber Recta
ischemia or Abdominal
colonic necrosis distention or
A sudden relief of increased
pain followed by abdominal
a progressive girth
worsening of
pain may occur
with intestinal
perforation
Progressive
change in bowel
habits associated
with
unintentional
weight loss over
months suggests
malignancy
Inguinal or femoral Heaviness or dull Presentations Congenital or Bulge

hernia discomfort in the range from a acquired while
6/19/22, 5:27 PM 5473
groin bulge in the groin Older age, and p

Moderate to severe region with or chronic cough, coug
pain is unusual and without pain to chronic Valsa
suggests emergent, life- constipation, mane
strangulation of threatening due smoking
bowel to bowel If acquired,
strangulation associated with
Groin discomfort connective
most pronounced tissue
with increased abnormalities,
intra-abdominal chronic
pressure as with abdominal wall
heavy lifting, injury, or
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 Varia

syndrome/interstitial bladder filling and frequency, sensations are tende
cystitis a relief with urgency, and worsened by abdo
voiding nocturia often bladder filling hip g
Pain location is accompany the and/or relieved floor,
suprapubic or discomfort or by emptying base,
urethral, although pain Allod
can be unilateral other
lower abdominal with
pain or low back Tend
pain tightn
pelvic
musc
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Urinary retention Lower abdominal Inability to pass Previous Pelvic

and/or suprapubic urine history of exam
discomfort retention or uteru
lower urinary locat
tract Recta
symptoms, exam
pelvic surgery, evalu
radiation, or mass
pelvic trauma impa
perin
sensa
recta
tone
Urethral Dysuria or Postvoid Chronic or Anter

diverticulum dyspareunia dribbling recurrent UTIs wall m
Urinary partic
frequency tende
and/or urgency
Hematuria
Bloody urethral
discharge
Urinary
incontinence
Urinary
retention
Pelvic or
urethral pain
Vaginal mass
Musculoskeletal
Aseptic necrosis of Groin pain is most Weightbearing or Use of Hip ra

femoral head common in motion-induced glucocorticoids motio
patients with pain is found in and excessive partic
femoral head most cases alcohol intake force
disease, followed
6/19/22, 5:27 PM 5473
by thigh and Rest pain occurs rotat

buttock pain in approximately abdu
two-thirds of
patients, and
night pain occurs
in one-third
Ehlers-Danlos Vulvodynia Joint Chronic Pelvic

syndrome (joint Generalized pelvic hypermobility widespread dysfu
hypermobility pain Skin pain Beigh
syndromes) hyperextensibility Fatigue hype
Mitral valve Mood score
prolapse disorders
(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

inflammatory deep in the stiffness, and restricted to a for m
arthritis anterior groin but restricted few joints warm
may involve the movement
anteromedial or
upper lateral thigh
and occasionally
the buttocks
Fibromyalgia Widespread Symptoms Pain is often Tend

musculoskeletal suggestive of IBS chronic and soft-t
pain Pelvic pain and associated with anato
bladder numbness, locat
symptoms of tingling, and
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frequency and other

urgency abnormal
suggestive of the sensations
interstitial Fatigue and
cystitis/painful poor sleep
bladder Cognitive and
syndrome psychiatric
(formerly female symptoms
urethral
Headache
syndrome)
Vascular
Ovarian vein Pain localizes to Acutely ill, with Nausea, ileus, Pelvis
thrombophlebitis the side of the fever and and other palpa
affected vein abdominal pain gastrointestinal some
(usually the right) within 1 week symptoms may may
but can be felt in after delivery or occur but are tende
the flank or back pelvic surgery usually mild mass
exam
exten
from
the u
abdo
Septic pelvic Intermittent or With fever in the Recent vaginal Tend

thrombophlebitis mild early postpartum or cesarean palpa
abdominopelvic or postoperative delivery or typica
pain period (usually pelvic surgery
within 3 to 5 Patients may
days, but onset present
may be delayed following
to up to 3 weeks vaginal or
following cesarean
delivery) delivery or
pelvic surgery
with persistent
fever despite
antibiotic
therapy for
presumed
endometritis
and no other
apparent cause
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Vulvar varicosities Vulvar discomfort, Aggravated by Chronic pelvic Perin

swelling, and menses discomfort exam
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.
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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 abdo
6/19/22, 5:27 PM 5473
Δ The minimal rapid assessment typically includes a focused history, limited physical examination, rapid ass
ultrasound, and emergency CBC and type and crossmatch.
◊ For women whose pelvic pain persists after initial diagnosis and treatment, we reassess for emergency di
atypical presentations of common diagnoses and evaluate for rare conditions. More information can be fou
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 w
positive pregnancy test.
6/19/22, 5:27 PM 5473
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.
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Checklist used to assess the possibility of pregnancy
The provider can be reasonably certain that the patient is not pregnant if the patient has
no symptoms or signs of pregnancy and meets ANY of the following criteria:
The patient has not had intercourse since last normal menses.
The patient has been correctly and consistently using a reliable method of contraception.
The patient is within 7 days from the first day of menstrual bleeding.
The patient is within 4 weeks postpartum (for nonlactating patients).
The patient is within the first 7 days postabortion or miscarriage.
The patient 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:
1. Tepper NK, Marchbanks PA, Curtis KM. Use of a checklist to rule out pregnancy: A systematic review. Contraception
2013; 87:661.
2. Curtis KM, Tepper NK, Jatlaoui TC, et al. United States Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR
Recomm Rep 2016; 65:1.
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Evaluation for intrauterine pregnancy versus ectopic pregnancy in a hemodyna
TVUS: transvaginal ultrasound;

hCG: human chorionic gonadotropin;
mIU: milli-international unit;
IUP: intra
* Ectopic pregnancy can be life threatening; patients who are hemodynamically unstable or in whom a rupt
be evaluated in the emergency department.
¶ Patients with an undesired pregnancy may be able to forgo follow-up testing with TVUS and serum hCG an
aspiration [with laparoscopy if an adnexal mass is present], methotrexate).
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Δ Nondiagnostic findings on ultrasound include no findings in the uterus or adnexa, a potential gestational
adnexal mass with no yolk sac or embryo.
◊ We use a discriminatory zone of 3510 mIU/mL as the level above which a gestational sac should be visual
§ Rare etiologies of elevated hCG include heterotopic pregnancy and gestational trophoblastic tumors (hCG
¥ TVUS will show an intrauterine gestational sac with a yolk sac or embryo.
‡ Findings suspicious for ectopic pregnancy include a complex inhomogenous extraovarian adnexal mass or
(sometimes referred to as a "tubal ring"). Findings diagnostic of an ectopic pregnancy include a gestational
uterine cavity.
† Patients with clinical suspicion for ectopic pregnancy (eg, patients with risk factors for ectopic pregnancy)
and should be managed with surgery or methotrexate.
** In rare cases, an ectopic pregnancy can be present alongside an IUP; this is known as a heterotopic pregn
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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

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DKA: diabetic ketoacidosis.
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Less common causes of abdominal pain
Abdominal aortic aneurysm
Abdominal compartment syndrome
Abdominal migraine
Acute hepatic porphyrias (eg, 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
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Contributor Disclosures
Pamela Stratton, MD Grant/Research/Clinical Trial Support: Allergan [Pelvic pain from endometriosis].
Consultant/Advisory Boards: Abbvie [Pelvic Floor Muscle Spasm as part of Chronic Pelvic Pain].
All of the
relevant financial relationships listed have been mitigated. Howard T Sharp, MD No relevant financial
relationship(s) with ineligible companies to disclose. Kristen Eckler, MD, FACOG No relevant financial
relationship(s) with ineligible companies 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

Evaluation of Acute Pelvic Pain in Nonpregnant Adult Women

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Evaluation of Acute Pelvic Pain in Nonpregnant Adult Women

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Evaluation of acute pelvic pain in nonpregnant adult

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

● (See "Approach to acute abdominal/pelvic pain in pregnant and postpartum patients".)

● (See "Chronic pelvic pain in adult females: Evaluation".)

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".)

● (See "Evaluation and management of female lower genital tract trauma".)

● (See "Female sexual pain: Differential diagnosis".)

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

Life-threatening — Common processes that are potentially life-threatening must be quickly

● Gynecologic – Common gynecologic conditions include ruptured ectopic pregnancy,

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

• (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".)

EXCLUDE LIFE-THREATENING DISORDERS

Rapid preliminary assessment — The goal of the preliminary assessment is to identify

We take the following approach:

● Assess hemodynamic status – We obtain vital signs, including temperature and

● Perform abbreviated physical examination – We perform an abdominal examination to

● Perform rapid assessment ultrasound – A Focused Assessment with Sonography for

• (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation,

Management — Women diagnosed with, or suspected of having, a life-threatening condition (

INITIAL EVALUATION FOR COMMON CONDITIONS

● Timing of pain onset

• Gradual onset – Gradual-onset pain is more common with inflammatory or infectious

● Last menstrual period and possibility of pregnancy – Unless the patient is

General — The general physical examination includes evaluation of vital signs, a general

● External genitalia – Vesicles can be caused by herpes simplex infection, vulvar, or

● Speculum examination of vagina and cervix

• Abnormal vaginal or cervical discharge may be seen in various conditions including

● Bimanual examination of the uterus and bilateral adnexa

• Cervical motion tenderness commonly reflects peritonitis of the reproductive tract,

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

• Painful unilateral adnexal masses may indicate ectopic pregnancy, tubo-ovarian

• Cervical motion tenderness, uterine tenderness, and adnexal tenderness together

• 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

● Blood cultures are performed in women suspected of having disseminated infection,

● Free intraabdominal or pelvic fluid observed on ultrasound is presumed to be blood and

• If a definite intrauterine pregnancy is seen by ultrasound imaging, ectopic pregnancy is

• Ectopic pregnancy is probable if a complex adnexal mass, extrauterine yolk sac or

TREAT INITIAL DIAGNOSES AND REASSESS

PURSUE LESS COMMON DIAGNOSES IF SYMPTOMS PERSIST

● Consider whether the presentation may be an atypical presentation of a common

• Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS), which

• Familial Mediterranean fever (see "Clinical manifestations and diagnosis of familial

• Porphyria (see "Porphyrias: An overview")