Pleviner pain is a discomfort in the pelvis, which often occurs in women. He is separated from perineal pain that occurs in the external genital area and the perineal skin. Etiology Plevine pain can from the internal reproductive organs (cervix, uterus, adnexa) or other organs out. Sometimes the cause is unclear. Some gynecological diseases gynecological diseases (see table: gynecologic causes of pelvic pain) cause cycle-dependent pain (ie pain that occur repeatedly in the same phase of the menstrual cycle..). In other cases, the pain occurs regardless of the menstrual cycle. The type of pain onset (sudden or gradual) helps to distinguish the two species. Among the most common gynecologic causes of pelvic pain include dysmenorrhea ovulation (central pain) endometriosis Nichtgynäkologische diseases These diseases (acute abdominal pain) are gastrointestinal disorders (eg. As gastroenteritis, inflammatory bowel disease, appendicitis, diverticulitis, tumors, constipation, ileus, perirectal abscess, irritable bowel syndrome) urinary tract (eg. as cystitis, interstitial cystitis, pyelonephritis, stones) musculoskeletal disorders (z. B. symphysis pubis diastasis due to injuries in previous vaginal births, overuse of the abdominal muscles) psychogenic problems (eg. as somatization, impact of physical, psychological or sexual abuse) It is difficult to name the most common cause. Gynecologic causes of pelvic pain caused Suspicious findings Diagnostic procedure * With respect to menstrual dysmenorrhea Stinging or cramping pain a few days before or at the beginning of the menstrual period, often with headache, nausea, constipation, diarrhea or urinary frequency usually symptoms for 24 hours, occasionally persist it for 2-3 days after onset of menstruation Clinical examination Endometrios e Stinging or cramping pain before and during the early menstrual period, often with dysmenorrhea, dyspareunia, or painful bowel movements can cause pain not related to the menstrual cycle results in advanced stages sometimes retroversion of the uterus, pain, decreased mobility Occasionally during bimanual vaginal and rectovaginal examination, a solid pelvic resistance (possibly an endometriosis tumor) or painful nodules found Clinical examination Occasionally laparoscopy Mittelschmerz Sudden, severe, stabbing pain, most intense at the beginning and decay over 1-2 days Often accompanied by bright spot-shaped vaginal bleeding occurs at midcycle on (during ovulation), Part a low-grade, short-lasting Peritonealreizung due to a ruptured follicle Clinical examination diagnosis of exclusion Without respect for menstrual pelvic inflammatory disease (pelvic inflammatory disease [PID]) Gradually developing pelvic pain, mucopurulent cervical discharge Occasionally fever, dysuria, dyspareunia Typically pronounced cervical motion pain and tenderness adnexal rare resistance in the adnexal region (eg. B. abscess) Clinical examination Zervixkultur Occasionally sonography of the pelvis (for suspected abscess) Ruptured ovarian cyst Sudden pain, usually at the beginning and most often quick easing within a few hours occasionally slight vaginal bleeding, nausea, vomiting and Peritonealzeichen Clinical examination Occasionally ultrasonography pelvis rupture sudden onset with ectopic pregnancy, localized, consistent (no spasmodic) pain, often with vaginal bleeding abdominal muscle and occasionally occasionally acute with syncope or hemorrhagic shock Closed cervix inale bloating or painful resistance in the adnexal region Quantitative ?-hCG determination sonography of the pelvis occasionally laparoscopy or laparotomy Acute degeneration of uterine fibroids sudden onset of pain, vaginal bleeding usually during the first 12 weeks of pregnancy or after birth or after Schwangerschaftsbbruch sonography of the pelvis adnexal torsion sudden onset, strong, unilateral pain, sometimes colic (due to intermittent torsion) often accompanied by nausea, vomiting, Peritonealzeichen and cervical motion pain presence of risk factors (eg. B. pregnancy, ovulation, ovarian enlargement> 4 cm) color Doppler sonography of the pelvis Occasionally laparoscopy or laparotomy uterine or ovarian cancer Gradual onset of pain, vaginal discharge (the bleeding precedes), abnormal vaginal bleeding (eg. As postmenopausal bleeding, premenopausal recurrent metrorrhagia ) Rarely palpable pelvic ultrasound pelvic adhesions biopsy Gradual onset of pelvic pain (often chronically becoming), or dyspareunia in patients with vorausgegangenem surgery on the abdomen or with occasional pelvic infections K any vaginal bleeding or discharge occasionally nausea and vomiting (indication of bowel obstruction) Clinical examination diagnosis of exclusion Occasionally abdominal plain (in horizontal and vertical position) spontaneous abortion vaginal bleeding with cramping pain in the abdomen or back pain during early pregnancy, accompanied by other features of early pregnancy, such as sensitivity of breasts, nausea and a missed menstrual period Clinical examination pregnancy test ultrasound of the pelvis to assess the viability of the fetus * pelvic exam, urinalysis and urine o serum pregnancy test should be performed. For most patients with acute or serious, recurrent symptoms, a pelvic ultrasound is required. ?-hCG = ? chain of human chorionic gonadotropin. Clarification The clarification must be done quickly, as some causes of pelvic pain (particularly ectopic pregnancy or adnexal torsion) require immediate treatment. Pregnancy should be ruled independently in women of childbearing age of the recorded history. History The history of the current disease should include a gynecological survey (pregnancies, parity, menstrual disorders, sexually transmitted diseases) and the onset, duration, location and nature of the pain. The severity of the pain and its relationship to the menstrual cycle are noted. Important associated symptoms include vaginal bleeding or discharge and signs of hemodynamic instability (eg. As dizziness, drowsiness, syncope or syncope). Clues to the possible causes are to be found on the review of organ systems; it includes morning sickness, swelling and tenderness of the breasts, missed menstrual period (pregnancy), fever and chills (infection), abdominal pain, nausea, vomiting or altered bowel properties (gastrointestinal diseases) as well as urinary urgency and increased urination or dysuria (urinary tract). The history should include infertility, ectopic pregnancy, pelvic inflammatory disease, urolithiasis, diverticulitis and all gastrointestinal and genitourinary tumors. Earlier surgery on the abdomen or in the pelvic area should noted werden.Körperliche Investigation On physical examination, the vital signs are first signs of instability checked (eg. As fever, hypotension) and then examined the abdomen and pelvic area. The abdomen is scanned for tenderness, masses and Peritonealzeichen. Rectal exam is taken on tenderness, masses and occult blood. The localization of pain and accompanying findings may give clues to the cause (see table: Notes the diagnosis of pelvic pain). The examination of the pelvis comprises an inspection of the external genitals, a speculum and bimanual palpation. The cervix is ??examined for discharge, uterine prolapse and cervical stenosis or lesions of. Bimanual palpation should the cervical motion pain, adnexal tumors or tenderness of the adnexa and magnification and sensitivity of the uterus umfassen.Warnzeichen The following findings are of particular importance: syncope or hemorrhagic shock (e.g., tachycardia, hypotension.) Peritonealzeichen (rebound tenderness, guarding, posture ) Postmenopausal vaginal bleeding fever or chills sudden onset of severe pain with nausea, vomiting, sweating or agitation interpretation of the findings, the sharpness and intensity of pain and its relation to the cycle provide important clues to the cause (see table: Gynecological causes of pelvic pain). The pain quality and localization capability and accompanying findings may also lead to the goal (see table: Notes the diagnosis of pelvic pain). However, the findings may be nonspecific. For example, endometriosis can lead to a variety of reports. Notes the diagnosis of pelvic pain finding Possible diagnostic syncope or hemorrhagic shock Ruptured ectopic pregnancy may a ruptured ovarian cyst Vaginal discharge, fever, bilateral pain, tenderness pelvic inflammatory disease (PID) Strong, intermittent, colicky pain (sometimes with nausea), which within seconds develop or minutes and reach a peak intensity can adnexal torsion Renal nausea, then loss of appetite, fever, and right-sided abdominal pain appendicitis constipation, diarrhea and a loss or worsening of pain after defecation gastrointestinal disease pain in the left lower abdomen in women> 40 years diverticulitis tenderness of the whole abdomen or signs of Peritonealreizung peritonitis (eg. B. due to appendicitis, diverticulitis, other gastrointestinal disease, pelvic inflammatory disease [PID], adnexal torsion or rupture of an ovarian cyst, or ectopic pregnancy) tenderness of the anterior vaginal wall lower urinary tract disease (pain of the bladder or urethra caused) immobility of the uterus in bimanual palpation adhesions endometriosis Advanced carcinoma pressure Painful cervical or Adnexresistenz motion pain Ectopic pregnancy pelvic inflammatory disease (PID) or ovarian cell carcinoma adnexal torsion Tenderness in the pubic area in women who have given birth, especially if the pain when walking occurs symphysis pubis diastasis Acute painful defecation plus finding of a localized, pressure-sensitive, fluctuating resistance in the internal or external examination of the rectum, with or without fever perirectal abscess visible or microscopic firmly posed blood in the rectum gastrointestinal disease chronic, painful defecation plus detection of a localized, wood-like resistance in the inner n or external examination of the rectum without fever Severe endometriosis Advanced cervical cancer tests should All patients urinalysis urine pregnancy test Is a patient be performed pregnant, ectopic pregnancy is so long believed to them through ultrasound or, when it is uncertain sonographic findings by other can be excluded studies (lower abdominal pain in early pregnancy). A serum pregnancy test should be performed when it is assumed that the patient is in the <5th week of pregnancy; a urine pregnancy test may not be sensitive enough to rule out an early stage of pregnancy. Any further clarification depends on the clinical diagnosis. If the patient can not be adequately studied (z. B. because of pain or lack of ability to cooperate) is suspected or a tumor, pelvic sonography is required. Is the cause of severe or persistent pain unclear laparoscopy is attached. The pelvic ultrasound with a vaginal probe may be a useful addition to pelvic examination; (1 week d. E., After a missed period) to space requirements can better define or pregnancy after the fifth week of pregnancy find her. So an ectopic pregnancy by free pelvic fluid and positive pregnancy test and the absence of evidence of an intrauterine pregnancy can be confirmed. Treatment If possible, the underlying disease is treated. In pain you are first oral NSAIDs (nonsteroidal anti-inflammatory or anti-inflammatory drugs =). Speaks a patient not respond to an NSAID, can not be excluded that another perhaps works better. Should not be sufficient NSAIDs, can try other analgesics or hypnosis. Muscle and bone pain often respond to rest, warmth, physiotherapy or - on trigger point injections with 0.5% bupivacaine or 1% lidocaine - in fibromyalgia. In patients with intractable pain due to dysmenorrhea or another disorder is a cut through the Uterosakralnerven or presacral neurectomy can be tried. If all measures fail, as a last resort, a hysterectomy, but they can also be ineffective or even lead to a worsening of pain. Geriatric aspects Pelvic pain in older women can be indefinite. A careful examination of the organ systems with consideration of bowel and bladder function is essential. A sexual history should be performed; Doctors are often unaware that many women remain sexually active throughout their lives. Before the survey on sexual activity was to determine whether the partner of a woman living still. In older women, vaginal irritation, itching, discomfort during urination or bleeding can occur as a result of sexual intercourse. Such problems often disappear after a few days of the conservation of the basin. Acute loss of appetite, weight loss, dyspepsia, or a sudden change in bowel properties can be a sign of ovarian or uterine cancer and require a thorough clinical examination. Summary Pelvic pain are common and can have a gynecological or nichtgynäkologische cause. Pregnancy should be excluded in women of childbearing age. The quality, sharpness, expression and localization of the pain and its relation to the cycle provide important clues to the cause. Dysmenorrhea is a common cause of pelvic pain, but is a diagnosis of exclusion.