Evidence‑Based Differential Diagnosis of Pelvic Pain

Acute Pelvic Pain in Reproductive‑Age Women

Spontaneous abortion (miscarriage) should be considered in patients with acute pelvic pain and a positive pregnancy test 1
Complications of an intra‑uterine pregnancy (e.g., threatened abortion, placental abruption) are important differential diagnoses in pregnant patients presenting with acute pelvic pain 1
Adnexal torsion is identified by an asymmetrically enlarged ovary with a twisted pedicle on imaging and must be ruled out promptly 1
Tubo‑ovarian abscess should be included in the work‑up of acute pelvic pain when infection is suspected 1

Ovarian cysts account for roughly one‑third of gynecologic causes of acute pelvic pain in peri‑ and postmenopausal patients 4, 2, 3
Uterine fibroids are the second most common gynecologic cause; they are more frequent in this age group because of torsion of pedunculated fibroids, prolapse of submucosal fibroids, or acute infarction/hemorrhage in degenerating fibroids 4, 2, 3
Pelvic infection (≈20 % of cases) includes tubo‑ovarian abscess, oophoritis, salpingitis, endometritis, cervicitis, or peritonitis and is often related to recent sexual activity or iatrogenic instrumentation 4, 2, 3
Ovarian neoplasm represents about 8 % of acute pelvic pain cases in this population and should be prioritized because of malignancy risk 4, 2, 3
Rare etiologies such as ovarian torsion, retained intra‑uterine device, and reactivated endometriosis (in patients on hormone therapy) may also present 4, 2, 3
Non‑gynecologic urinary system pathology (e.g., obstructive uropathy, infection) is a relevant differential 4, 2, 3
Gastrointestinal disorders (e.g., diverticulitis, bowel obstruction) should be considered 4, 2, 3
Vascular conditions (e.g., abdominal aortic aneurysm, venous thrombosis) are additional possible causes 4, 2, 3

When vaginal bleeding or a suspected adnexal mass is present, evaluation for endometrial and ovarian malignancy must take precedence 5, 6
Pelvic venous disorders (pelvic congestion syndrome) are a recognized cause of deep pelvic pain 5, 6
Intraperitoneal adhesions can produce chronic deep pelvic discomfort 5, 6
Hydrosalpinx is an important gynecologic source of persistent deep pelvic pain 5, 6
Chronic inflammatory disease (e.g., chronic PID) may underlie deep pelvic pain 5, 6
Cervical stenosis is another possible contributor to deep pelvic pain 5, 6
Vaginal atrophy is a common cause of perineal, vulvar, or vaginal pain in this group 5, 7
Vaginismus should be considered when pain is associated with attempted vaginal penetration 5, 7
Vaginal or vulvar cysts can produce localized pain 5, 7
Vulvodynia is a recognized chronic pain condition affecting the vulvar region 5, 7
Pelvic myofascial pain contributes to chronic pelvic discomfort 5, 7

Male chronic pelvic pain syndrome is a diagnosis of exclusion with multifactorial etiology involving cardiovascular, psychological, immunologic, neurologic, musculoskeletal, and endocrine factors 8
Urinary tract infection must be ruled out using standard microbiologic methods 8
Urogenital malignancy should be excluded 8
Prior pelvic radiation or chemotherapy effects need consideration 8
Urethral stricture is a potential reversible cause 8
Neurologic diseases affecting bladder function must be excluded 8
Bladder outlet obstruction should be evaluated 8
Overactive bladder is distinguished by urgency/frequency without pain 8
Pelvic floor muscle dysfunction is present in approximately 70 % of men with chronic pelvic pain 8
Chronic overlapping pain conditions are common: irritable bowel syndrome (≈34 %), migraine (≈24 %), fibromyalgia (≈13 %), chronic fatigue syndrome (≈5 %) 8
Bladder symptoms (pain on filling and painful urge to void) occur in up to 75 % of affected men 8
Widespread pain outside the pelvis is reported by about 70 % of patients 8

Strict research definitions should not replace clinical judgment; patients with symptom duration < 3 months may still require evaluation based on pain severity alone 8
Non‑gynecologic causes should not be overlooked; roughly 15 % of women presenting with acute pelvic pain are postmenopausal, making urinary, gastrointestinal, and vascular etiologies more prominent 2, 3