There are a number of possible causes for pelvic pain, and pinpointing the source may be difficult. As a result, identifying the cause of pelvic pain can be a long process.

Physicians will typically begin an evaluation by taking the patient’s medical history. Patients should be prepared to answer a number of questions about pain, such as:

• When did the pain begin?
  
  
• Where is the pain located?
  
  
• How strong is the pain?
  
  
• How does the pain feel (e.g., dull, sharp, steady, cramping)?
  
  
• When does the pain occur (e.g., during urination, menstruation or defecation)? Is there sexual pain?
  
  
• How often does the pain occur?
  
  
• Has the pain spread beyond its original location?
  
  
• How long does the pain last?
  
  
• Does the pain vary based on the time of day or time of week?
  
  
• Is the pain linked with abnormal skin sensations, muscle pain, joint pain, back pain or abdominal pain?
  
  
• Is the pain interfering with daily activities?
  
  
• Is there anything that relieves the pain or makes it worse?
  
  
• Does the pain affect sleep?
  
  
• Has there been an infection?
  
  
• Has there been constipation, diarrhea or other bowel disorders?
  
  
• Has there been surgery in the pelvic area?
  
  
• Is there a family history of pelvic conditions?
  
  
• What medications are being taken?

Female patients may also be asked about their menstrual history, gynecologic history and obstetric history. Questions regarding sexual history, sexual abuse, domestic violence and substance abuse may be posed to patients of either sex. Patients may be asked to complete a pain assessment form.

A physical examination will focus on the lower abdomen. The physician will look for signs of tenderness and distention. The abdomen and pelvis may then be examined for trigger points. In a process known as pain mapping, the physician prods areas of the abdomen in a grid–like pattern. The patient alerts the physician when experiencing pain. The areas that cause pain are noted or mapped.

For women, a pelvic examination (examination of the uterus, cervix and other pelvic organs) may be performed. This exam enables physicians to check the area for tenderness and changes in skin sensations. The test may also reveal abnormal growths, signs of infection or tense pelvic floor muscles. A rectovaginal examination, in which one finger is placed in the vagina while another is placed in the rectum, may also be performed.

Men may undergo a digital rectal exam (DRE) if a prostate problem such as benign prostatic hyperplasia is indicated or an examination of the scrotum and testicles if a condition such as testicular cancer is suspected.

A number of tests are usually required to determine the cause of pelvic pain. This allows physicians to eliminate a number of causes and close in on an exact source. Information provided in the medical history and factors revealed in the physical examination are used to help physicians determine which tests to order. These may include:

• Cultures. These tests require samples to be taken from the urethra, vagina or cervix. They may reveal an infection, including sexually transmitted disease or prostatitis.
  
  
• Blood tests. These tests can reveal infections.
  
  
• Urine tests. Urine may be examined for signs of bladder or kidney disorders.
  
  
• Pregnancy test. Female patients may undergo a pregnancy test to determine if an ectopic pregnancy may be causing the pain.
  
  
• Cystoscopy. A physician inserts a thin, camera-tipped tube through the urethra to inspect the inside of the bladder.
  
  
• Colonoscopy. This is a procedure where a camera can be introduced through rectum and lower colon can be visually examined. It is used to find cancer or polyps in the same area.
  
  
• Laparoscopy. A small incision is made above or below the naval. A thin lighted tube (laparoscope) is then inserted into the abdomen. This enables physicians to view the pelvic organs. This procedure may reveal abnormal tissue or signs of infection. In some cases, the tissues are probed and pulled with surgical instruments during the procedure. Then the patient describes the severity and nature of the pain (laparoscopic pain mapping).
  
  
• Biopsy. A sample of tissue may be taken for laboratory analysis if a condition such as prostate cancer, bladder cancer or ovarian cancer is suspected.

A number of imaging studies may also be ordered to detect abnormal masses including ovarian cysts, uterine fibroids and prostate growths. Possible imaging studies include:

• An x-ray is a painless test in which an image is created of part of the body. It uses low doses of electromagnetic radiation that are reflected on film or fluorescent screens. The physician may order a specialized x-ray such as an intravenous pyelogram (IVP), in which a contrast dye injected into a vein in the arm highlights the urinary tract.
  
  
• Pelvic, bladder, transvaginal or transrectal ultrasound. This procedure uses high–frequency sound waves to create images of organs and other body structures.
  
  
• CAT scan (computed axial tomography). Also known as a CT scan, this test allows for multiple x–rays to be taken from different angles around the patient. A computer analyzes the cross–sectional images. Frequently after the first set of images is taken, the patient receives an intravenous (I.V.) injection of a contrast agent (dye) to better outline body parts. Then a second set of images is taken.
  
  
• MRI (magnetic resonance imaging). MRIs use a powerful magnetic field to create images of structure and organs within the body allowing a computer to produce clear cross–sectional or three–dimensional images.

Sometimes in spite of all the testing, it may not be possible to find out the source of the pain. When the cause is not clear, physicians may ask their patients to maintain a journal of their symptoms. This may help the physicians narrow down the list of possible causes and help them determine what additional tests should be performed.