Acute Pelvic Pain

This is nearly always seen in women rather than men. In its mildest form it is experienced universally at some time or other associated with periods, ovulation or sexual intercourse. In its severest form it is the commonest reason for urgent laparoscopic examination in the UK.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Acute Pelvic Inflammatory Disease (PID)
  • Urinary Tract Infection (UTI)
  • Miscarriage
  • Ectopic Pregnancy
  • Ovarian Cysts: Torsion, Rupture

Occasional Diagnoses

  • Pelvic Abscess (Appendix, PID)
  • Endometriosis
  • Pelvic Congestion (Exacerbation of Pelvic Pain Syndrome)
  • Prostatitis (Men)
  • Functional (Psychosexual origin)

Rare Diagnoses

  • Misplaced IUCD (Perforated Uterus)
  • Referred (e.g. Spinal Tumour, Bowel Spasm)
  • Proctitis
  • Invasive Carcinoma of Ovaries or Cervix
  • Fibroid Degeneration
  • Strangulated Femoral or Inguinal Hernia

Ready reckoner

Key distinguishing features of the most common diagnoses

PIDUTIMiscarriage EctopicOvarian Cyst
Abnormal Vaginal Bleeding PossibleNoYes PossibleNo
Purulent Discharge PVYesNoNoNoNo
Palpable MassNoNo PossibleNo Possible
Tender Uterus PVYesNo PossibleNoNo

Possible investigations

Likely: HVS, cervical swab, urinalysis, MSU.

Possible: FBC, ESR/CRP, pregnancy test, ultrasound, laparoscopy (all usually arranged by hospital admitting team).

Small Print: None.

  • Urinalysis: Look for nitrites and pus cells to make diagnosis of UTI
  • MSU will confirm UTI and guide antibiotic treatment.
  • HVS for bacteria including gonococcus and endocervical swab for Chlamydia if purulent discharge present
  • ESR/CRP: Elevated in PID.
  • Pregnancy test: Positive in ectopic and miscarriage
  • FBC: Raised WCC helps confirm PID and UTI if not being admitted. Also elevated in pelvic abscess
  • Urgent ultrasound helpful if miscarriage or ectopic pregnancy suspected.
  • Cases referred to hospital are likely to undergo laparoscopy.

Top Tips

  • In miscarriage, pain follows bleeding. In ectopic pregnancy, the sequence is usually reversed.
  • Remember that there may be no bleeding with an ectopic pregnancy – or that the vaginal loss may be a light, blackish discharge.
  • PV bleeding will cause haematuria on urinalysis. Only diagnose UTI if the symptoms are suggestive and urinalysis also shows nitrites and pus cells.

Red Flags

  • Severe unilateral pain in very early pregnancy suggests ectopic pregnancy, even with no bleeding. Admit urgently.
  • If PID does not settle within 48 hours of appropriate antibiotic treatment, consider abscess formation.
  • Don’t forget to check femoral and inguinal canals for a possible strangulated hernia.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.