Pelvic Pain: Causes, Diagnosis and When to Worry

Acute vs chronic pelvic pain

• Acute pelvic pain starts suddenly, over hours or days. It is more likely to have a single cause that needs urgent treatment, such as an ectopic pregnancy, ovarian torsion, infection or appendicitis.
• Chronic pelvic pain lasts 6 months or more. It often has several contributing causes, such as endometriosis, bladder pain, irritable bowel syndrome and pelvic floor muscle tension, with changes in how the nerves process pain.

Pelvic pain in women: causes

Menstrual and ovulation-related

• Period pain (dysmenorrhea): cramping that starts with bleeding and lasts 1 to 3 days. See painful periods.
• Ovulation pain (mittelschmerz): a one-sided ache or twinge midway through the cycle, lasting minutes to 2 days.
• Endometriosis: tissue similar to the uterine lining grows outside the uterus. It causes severe period pain, pain during sex, pain with bowel movements or urination during periods, and sometimes infertility. Diagnosis takes an average of several years, so persistent symptoms deserve investigation.
• Adenomyosis: endometrial tissue grows into the uterine muscle, causing heavy, painful periods and an enlarged uterus.

Ovaries and fallopian tubes

• Ovarian cysts: most cause no symptoms, but larger cysts cause a dull one-sided ache or pressure. A ruptured cyst causes sudden sharp pain.
• Ovarian torsion: twisting of the ovary cuts off its blood supply, causing sudden severe pain and vomiting. It needs emergency surgery.
• Ectopic pregnancy: a pregnancy growing outside the uterus, usually in a tube, causing one-sided pain and spotting around 6 to 8 weeks. Rupture causes internal bleeding.

Infection

Pelvic inflammatory disease is infection of the uterus, tubes and ovaries, often from chlamydia or gonorrhea. It causes lower belly pain, pain during sex, abnormal discharge, bleeding between periods and sometimes fever. Prompt antibiotics reduce the risk of infertility and chronic pain.

Uterus

• Uterine fibroids: benign growths causing heavy periods, pressure, and sometimes pain.
• Pelvic organ prolapse: a dragging sensation or bulge in the vagina, worse at the end of the day.

Pregnancy

Early pregnancy commonly causes mild cramping. Round ligament pain causes sharp groin pain with movement in the second trimester. Pelvic girdle pain affects the joints of the pelvis. Pain with bleeding needs assessment for miscarriage or ectopic pregnancy, and later in pregnancy for preterm labor or placental abruption.

Pelvic pain in men

• Prostatitis: bacterial infection of the prostate causes fever, pelvic pain and urinary symptoms. Chronic prostatitis/chronic pelvic pain syndrome causes long-term pain in the perineum, testicles, penis or lower belly, often with urinary symptoms and pain after ejaculation, usually without infection.
• Inguinal hernia: a groin bulge that aches with straining.
• Testicular problems that cause pain felt in the lower belly.

Causes in anyone

Accompanying symptoms and what they suggest

• Missed period or positive pregnancy test: ectopic pregnancy or miscarriage until proven otherwise.
• Fever and abnormal discharge: PID.
• Pain with sex: endometriosis, PID, pelvic floor dysfunction, vaginal dryness. See pain during intercourse.
• Urinary symptoms: UTI, bladder pain syndrome, stones.
• Bowel symptoms: IBS, constipation, endometriosis on the bowel, diverticulitis.

How doctors find the cause

A clinician will ask about the pain's timing and pattern, the menstrual cycle, the chance of pregnancy, sexual history, urinary and bowel symptoms, and previous surgery. Examination includes the abdomen and, for women, often a pelvic exam.

Common tests:

• Pregnancy test for anyone who could be pregnant
• Urine test for infection and blood
• Swabs for chlamydia and gonorrhea
• Blood tests for infection, anemia and inflammation
• Pelvic ultrasound, usually transvaginal, to look at the uterus and ovaries
• CT or MRI in selected cases
• Laparoscopy: keyhole surgery to diagnose and treat endometriosis and adhesions

Treatment and relief

Treatment depends on the cause. General measures for pelvic pain:

• Heat: a heating pad or warm bath.
• Pain relief: ibuprofen or naproxen, started at the first sign of period pain, at the label dose, or acetaminophen (paracetamol). Avoid NSAIDs with stomach ulcers or kidney disease.
• Hormonal treatments: combined pills, progestin-only methods or hormonal IUDs reduce period pain and endometriosis pain.
• Antibiotics: for PID, UTIs and bacterial prostatitis.
• Surgery: for ectopic pregnancy, torsion, appendicitis, endometriosis and some fibroids.
• Pelvic floor physical therapy: for muscle-related pain in women and men.
• Chronic pelvic pain: a combined approach with pain medicines that target nerves, physical therapy, psychological support such as CBT, and treatment of each contributing condition.

Frequently asked questions

What causes pelvic pain in women?

Common causes include period pain, ovulation pain, ovarian cysts, endometriosis, pelvic inflammatory disease, fibroids and pregnancy-related problems. Urinary infections, constipation, IBS and pelvic floor muscle problems also cause pelvic pain. Sudden severe pain, especially with a possible pregnancy, needs urgent care.

When should I worry about pelvic pain?

Get emergency care for sudden severe pain, pain with a positive pregnancy test or missed period, fainting, heavy bleeding, fever with a rigid belly, or one-sided pain with vomiting. See a doctor soon for pain with fever, unusual discharge, urinary symptoms or pain that keeps returning.

What is chronic pelvic pain?

Chronic pelvic pain is pain in the pelvis lasting 6 months or more. It often has several causes at once, such as endometriosis, bladder pain syndrome, IBS and pelvic floor muscle tension, and the nervous system can become more sensitive to pain. Treatment combines several approaches.

Can men have pelvic pain?

Yes. Men can have pelvic pain from prostatitis, chronic pelvic pain syndrome, urinary tract infections, kidney stones, hernias, bowel problems and pelvic floor muscle tension. Chronic pelvic pain syndrome causes long-term pain in the perineum, lower belly or genitals and often responds to physical therapy.

What does endometriosis pelvic pain feel like?

Endometriosis typically causes severe cramping period pain that may start before bleeding, deep pain during sex, and pain with bowel movements or urination during periods. Some people have pelvic pain throughout the month. Pain that worsens over time or does not respond to usual pain relief should be investigated.