Physiological pelvic pain with menstruation or childbirth is almost universal, but many women will present with pelvic pain for other reasons. This is most commonly acute pelvic pain, for example with appendicitis, a miscarriage or an ectopic pregnancy, but the pain may also be chronic, lasting for many months or years.

With acute pain, there is usually a well-defined pathological cause, which either resolves spontaneously or can be effectively treated. Chronic pelvic pain (CPP) is a symptom, not a diagnosis. CPP presents in primary care as frequently as does migraine or low back pain. Aiming for accurate diagnosis and effective management from the first presentation may help to reduce the disruption of the woman’s life and may avoid a seemingly endless succession of referrals, investigations and operations.

Pelvic pain is considered under the two headings of ‘acute’ and ‘chronic’, although it is important to note that there is significant overlap. Although focusing on the gynaecological causes of pelvic pain, the non-gynaecological causes are also important and it is for this reason that a multidisciplinary approach, particularly for those women with CPP, is important.

Pain is a subjective phenomenon. Many of the factors affecting pain are centrally mediated, such that pelvic pain is often made worse by psychological, psychiatric or social distress. Unlike external organs such as the skin, which contains pain sensors, the organs within the peritoneal cavity (the viscera) are sensitive to inflammation, chemicals and stretching or distortion caused by specific stimuli, for example adhesions or gaseous distension. The sensitivity of different organs to varying stimuli is an important factor influencing pelvic pain: the cervix and uterus are relatively insensitive, for example, whereas the fallopian tubes are exquisitely sensitive. Crushing of the bowel is associated with minimal discomfort, whereas stretching and distension cause severe pain. Unlike cutaneous painful stimuli, localization of visceral pain is often very difficult.

The history is arguably the most important factor in determining how quickly the diagnosis is reached and appropriate treatment instigated. Particular attention should be given to the time of onset of the pain, the characteristics, radiation, duration, severity, exacerbating and relieving factors, cyclicity and analgesic requirements. Associated symptoms of gastrointestinal, urological or musculoskeletal origin should be sought. It is also important to take a detailed menstrual history, in particular the frequency and character of vaginal bleeding, any intermenstrual bleeding or vaginal discharge, and their relationship to the pain. Ectopic pregnancy can occur without recognizable amenorrhoea.

A sexual history may be of help, particularly details of any superficial or deep dyspareunia, contraception and sexually transmitted infections (STIs). There may be a family history of gynaecological disorders, for example endometriosis. A cervical cytology history should be recorded.

With chronic pain, there is often value in detailing a family and social history, including marital or relationship problems, pressure at work, financial worries and childhood or adolescent problems, such as sexual abuse. Listening is a centrally important facet of the history-taking, which may in itself be therapeutic for some women. It is useful to ask some open-ended questions such as: ‘What do you think the cause of your pain might be?’ and ‘How is the pain affecting your life?’ to give the woman an opportunity to tell you about aspects of the problem which might not be apparent from a more systematic history.

If the history suggests there is a non-gynaecological component to the pain, referral to the relevant healthcare professional, such as gastroenterologist, urologist, genitourinary medicine physician, physiotherapist, psychologist or psychosexual counsellor, should be considered.

The examination is most usefully undertaken when there is time to explore the woman’s fears and anxieties. The examiner should be prepared for new information to be revealed at this point. Observation of the woman’s general demeanour is important when assessing the severity of pain. Eye-witness accounts from other health professionals and friends or family may also be helpful. The temperature, pulse and blood pressure should be recorded.

Abdominal examination should include inspection for distension or masses, palpation for tenderness, rebound and guarding, and abdominal auscultation if gastrointestinal obstruction or ileus is suspected. Inspection of the vulva and vagina at speculum examination may reveal abnormal discharge (suggestive of infection) or bleeding. Permission should then be sought to perform a vaginal and rectal examination.

A bimanual examination may reveal uterine or adnexal enlargement suggestive of a pelvic mass, fibroids or an ovarian cyst. Cervical excitation (pain associated with digital displacement of the cervix) is associated with ectopic pregnancy and pelvic infection. Tenderness or pain elicited by bimanual palpation of the pelvic organs themselves is suggestive of an ongoing inflammatory process, which may be infective (e.g. chlamydia) or non-infective (e.g. endometriosis). A fixed immobile uterus suggests multiple adhesions from whatever cause, and nodularity within the uterosacral ligaments (sometimes palpable only by combined rectovaginal examination) can be a feature of endometriosis.