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Acute pelvic pain


Acute pelvic pain in females is a common presentation. Whilst it often seems to drive terror into the hearts of clinicians, patients are often a lot more straightforward to assess than you think they will be.  In fact, the whole of non-specialist gynae is a topic that lends itself well to Bayesian decision modelling. Your patient is either “pregnant” or “not pregnant” and that she might have pain, bleeding, discharge or a combination of these things. Today, I want to focus on acute pelvic pain as the primary presenting symptom.

Alina is 15. She presents to A&E in significant pain and is tearful.  She describes a 2-3 day history of intermittent lower abdominal pain, which doesn’t appear to localize to any particular side but is possibly slightly worse on the left.

She’s been taking 1g paracetamol four times a day for the last 48 hours, as well as maximum doses of ibuprofen. They seem to dent the pain a bit, but when they wear off, she is left crying with pain and unable to cope.

She describes it as “like the worst period pain I’ve ever had” but is adamant it isn’t her period as “that was 2 weeks ago”. It is a lot worse today, and she has been vomiting with the pain.  

Alina is struggling to stand as she sobs her way through triage leaning on her mum.

At this point, it is probably worth having a list of possible differential diagnoses in your head to help to tailor your assessment to come to a diagnosis and, most importantly, to rule out the life-threatening “never miss” causes of severe pelvic pain. 

Possible differentials for acute pelvic pain in the adolescent:

  • Ectopic pregnancy
  • Pelvic Inflammatory Disease
  • Miscarriage
  • Dysmenorrhoea
  • Ruptured or torted ovarian cyst
  • Torted ovary
  • Mittelschmerz
  • Endometriosis
  • Appendicitis
  • UTI
  • Sickle cell crisis
  • Porphyria
  • Haematocolpos
  • Unexplained

Ectopic pregnancy

Top of your list of things to look for and rule out in a case of acute pelvic pain in a female of childbearing age has got to be an ectopic pregnancy.  A negative urine pregnancy test, especially in the context of a young person with a reliable menstrual history AND with a LARC method of contraception on board AND/OR a sexual history of not being sexually active, is a good way to rule out pregnancy rapidly.  There would be little justification for not doing a urinary pregnancy test in this presentation. In many A&E departments, a pregnancy test is a standard triage investigation, and a urine dip is performed for blood/protein/WBC and nitrite before a clinician starts their assessment. If the pregnancy test is positive, she needs a comprehensive assessment to exclude other causes of acute pain. But until an ectopic has been fully excluded, it must remain the working diagnosis of the moment, with anything else coming second. 

The 2019 NICE guidelines provide an extremely useful and user-friendly guide to managing ectopic/early miscarriage.  NICE reminds us that PV bleeding and pain, whilst common symptoms of an ectopic, are not always present.  In order not to miss it, we need to have a low threshold for doing a urinary pregnancy test in any female of reproductive age. This table from the guidelines is a helpful summary of other less common presenting symptoms in which a pregnancy test may well be indicated.

Table of some of the potential presenting complaints of a ruptured ectopic including abdominal or pelvic pain, a missed period or vagianl bleeding,
Presenting complaints of a ruptured ectopic pregnancy

Advice around examining patients with a suspected ectopic pregnancy seems to vary from department to department, and, interestingly, NICE does not comment on this. In primary care, the traditional teaching is not to do a bimanual examination in case the pressure of the physical examination on the adnexal mass ruptures the ectopic. In a hospital setting, with resus and surgical facilities, a bimanual looking for cervical excitation and guarding may help make the diagnosis.  If they are stable an expectant approach looking for B-hCG doubling (for a normal pregnancy) or falling (for a failed pregnancy) may be adopted. If medical management with methotrexate is chosen, a baseline B-hCG is vital.

A patient with a probable ectopic needs to have bloods taken for FBC, crossmatch and B-hCG and should be referred on the on call Gynae service promptly.

Alina’s pregnancy test is negative, and she shows you the Nexplanon contraceptive implant she has in her left arm. You start to relax. An ectopic pregnancy is highly unlikely, and this almost certainly isn’t a threatened miscarriage.

Pelvic inflammatory disease

The next one down in the serious/scary things to rule in or out urgently is Pelvic Inflammatory Disease.  The British Association for the Study of Sexual Health (BASSH) recommend that acute pelvic pain in a non-pregnant woman aged <25 is PID until proven otherwise.  1 in 60 primary care consultations in women aged under 45 is for PID.  Youth is a major risk factor especially if associated with multiple or new sexual partners.  Taking a sensitive but full sexual history is vital. Asking direct questions such as “When was the last time you had sex?”, “Who was it with?”, “Did you use a condom?”, “How many other people have you had sex with in the last 3 months?” are likely to yield clearer answers. 

In teenagers, try and avoid the phrase “Are you sexually active?”. Most won’t understand the nuance of the question, and the number of teenagers who answer “no” but later turn out to be “sexually active” is high.  You may well need to ask these questions more than once, ideally without the parent present. Acknowledging that they are having sex, especially with multiple partners, may well not be anything they want their parents to know.  In the UK and the USA, the incidence of chlamydia in the 14-24 age group is quoted as 1 in 20 women.

Table showing signs and symptoms of PID
Signs and symptoms suggestive of PID. Abnormal bleeding may manifest as post-coital bleeding, menorrhagia or secondary dysmenorrhoea

The Commonest pathogens in PID are chlamydia (4-35%), gonorrhoea (2-3%), mycoplasma genitalium.  Pathogen-negative PID is not uncommon (but is a diagnosis of exclusion).  BASSH advice is that “A diagnosis of PID should be considered, and usually empirical antibiotic treatment offered, in any sexually active woman who has recent onset, lower abdominal pain associated with local tenderness on bimanual vaginal examination, in whom pregnancy has been excluded and no other cause for the pain has been identified

Any patient with suspected PID needs cervical and HVS “triple swabs” taken for chlamydia, gonorrhoea, trichomonas and M. genitalium.  The treatment of choice in PID is IM ceftriaxone 1g stat.  If M. genitalium is found the treatment is moxifloxacin 400mg daily for 14 days.  M genitalium is difficult to isolate and culture and is best seen urgently on NAAT swabs.  All patients with PID need to be referred to the local GUM clinic for ongoing treatment and contact tracing.  Complications of PID include sepsis, pelvic abscess, chronic pain, infertility as well as ectopic pregnancy so it is crucial to suspect, identify and treat to prevent disability or serious illness.

When to admit in PID:

  • Pyrexia >38⁰C.
  • Signs of tubo-ovarian abscess (e.g. fluctuant mass in adnexa).
  • Signs of pelvic peritonitis (rebound, guarding, cervical motion tenderness).
  • No response to oral treatment.
  • Pregnancy


This is an easily missed diagnosis and a common cause of pelvic pain. Ectopic deposits of endometrial tissue appear in locations outside the uterine cavity, typically on the ovaries, fallopian tubes, and in the peritoneum.  These deposits respond to hormonal changes during the menstrual cycle and menstruation, and they bleed, causing irritation and pain. The pain, classically, is cyclical and at its worst in the day or two before menstruation. As the condition progresses and becomes more chronic, adhesions can form, and the pain can become more severe and constant.  It is worth knowing that laparoscopy findings do not always correlate well with symptoms. Some women can have severe symptoms with what appears visually to be small/minimal deposits, and another woman can have minimal symptoms with quite “severe disease”.  It can take six years from the first presentation to make a diagnosis.  Management is usually symptomatic with the combined contraceptive pill, analgesia and sometimes surgery.


This is a rare condition worth bearing in mind, even though it may well be a once-in-a-career diagnosis presentation. Menstrual blood builds up in the vagina and uterus due to the presence of a thick complete vaginal membrane – an “imperforate hymen”. Classically, the adolescent presents with cyclical pelvic pain and primary amenorrhoea.  An ultrasound will show a grossly distended uterus filled with old blood, and treatment involves surgical division of the vaginal membrane under a general anaesthetic.


Translated literally from German as “middle pain”, Mittelschmerz is cyclical pain occurring mid-cycle at the point of ovulation. It is uncommon. It will not occur in someone on an anovulant contraception, and whilst painful, is unlikely to render someone unwell enough to present to ED.

Alina’s abdominal examination reveals tenderness globally over the lower abdomen but worst in the left iliac fossa with some guarding.  She tells you she has not had sex for 3-4 months and has no PV bleeding or discharge.  

You attempt a bimanual and speculum examination with verbal consent and the support of her mum and a nurse, but she is crying in severe pain, and you have to stop. She is tachycardic with a HR of 122, but her other observations are normal. Her FBC, CRP and urine dip are normal, as was the urinary pregnancy test. 

You suspect ovarian pathology, either a ruptured or torted cyst or an ovarian torsion and arrange an ultrasound scan.

Ovarian cyst

Ovarian cysts occur in around 10% of pre-menopausal women and are often an incidental finding on an ultrasound scan done for an unconnected reason. The vast majority are benign, asymptomatic and require no treatment.  The RCOG Green Top guideline 63 from 2011 advises that most asymptomatic incidental cysts should be managed conservatively, reassuring us that “the overall incidence of a symptomatic ovarian cyst in a premenopausal female being malignant is approximately 1:1000”.

Most of us remember ovarian teratoma from our embryology and pathology lectures as undergraduates. Ovarian teratomas are almost always benign, though scary looking if well differentiated, and contain teeth or hair. This is in contrast to testicular teratomas with a high risk of malignancy.

An ovarian cyst can rupture or twist on its pedicle – leading to torsion of an ovarian cyst. Both can result in acute pelvic pain associated with peritonism and vomiting.  Diagnosis is usually made through an ultrasound scan, though occasionally, diagnostic laparoscopy is the only way to identify the situation. Management of a ruptured or torted cyst will usually be surgical, though a small ruptured cyst in a haemodynamically stable patient may be managed conservatively with observation.

Ovarian torsion

Ovarian torsion occurs when an ovary twists on its ligamentous supports, compromising the blood supply and presenting acute pain. This is often associated with peritonism and vomiting. A rapid diagnosis is important in to save the ovary and conserve future fertility.  The twisted pedicle may be visualized on ultrasound scanning or only on diagnostic laparoscopy.  Treatment is always surgical, and the ovary may not always be salvageable.

An urgent ultrasound scan reveals an enlarged left ovary, dopplers with minimal venous flow but preservation of arterial flow, and a twisted vascular pedicle called the whirlpool sign; there is free fluid in the Pouch of Douglas. 

Alina consents to laparoscopy, which includes an attempt to untwist and fix the ovary, but with consent to perform an oophorectomy if this is unsuccessful. Unfortunately, the surgeon is unable to save the ovary, and an oophorectomy is required. Alina made a good recovery and was discharged home 36 hours postoperatively.

Selected references

NICE NG126 April 2019 – Ectopic Pregnancy and Miscarriage, initial presentation and management 

RCOG Green Top Guidelines on ectopic pregnancy 2016 

BASSH 2019 guideline update on PID


  • Dr Tara George. MBChB (Hons) Sheffield 2002, FRCGP, DCH, DRCOG, DFSRH, PGCertMedEd Salaried GP and GP Trainer, Wingerworth Surgery, Wingerworth, Derbyshire. GP Training Programme Director, Chesterfield and the Derbyshire Dales GP Speciality Training Programme. Out of Hours GP and supervisor, Derbyshire Health United. Early Years Tutor, Phase 1, Sheffield University Medical School. Mentor, GP-s peer mentoring service and Derbyshire GPTF new to practice scheme. External Advisor RCGP. Host Bedside Reading podcast. Pronouns: she/her When she's not doing doctory things Tara loves to bake, to read novels, run and take out some of that pent up angst in Rockbox classes.

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1 thought on “Acute pelvic pain”

  1. My daughter is a 10 year old (not yet experienced her first cycle) that presented in September 2022 with sever left side pain and vomiting. Patient was triaged at the hospital and the diagnosis after X-ray was kidney stone ( though nothing was seen on X-ray) that had passed as pain and vomiting stopped after 2 hours. Fast forward to November 2022 and the left side pain is back with vomiting. Left side pain is worse than before. Urgent care doctors proceed with a CT scan and see possible torsion of the left ovary and a large cyst like mass. Ultrasound confirms torsion and we are sent to the children’s hospital. Patient undergoes second ultrasound that confirms a left ovarian torsion and large cyst. Laparoscopic surgery is performed to untwist the ovary. At time do surgery the cyst measures 10cm. Patient is discharged next day with strict physical restrictions and a second surgery schedule for 2 weeks in the future. What can cause this to happen in a 10 year old that has not yet had their first menstral cycle?