What could be causing painful left lower abdominal pain during orgasm?

Painful Left Lower Abdomen with Orgasm

The most likely causes are pelvic floor muscle spasm, endometriosis, or ovarian pathology, and you should obtain a transvaginal pelvic ultrasound as the initial imaging study if gynecologic pathology is suspected. 1, 2

Understanding the Clinical Context

This symptom pattern—pain specifically triggered by orgasm in the left lower abdomen—suggests a gynecologic or pelvic floor origin rather than gastrointestinal pathology. While diverticulitis is the most common cause of left lower quadrant pain overall in adults 1, 3, pain specifically associated with orgasm points toward structures affected by pelvic muscle contraction and increased pelvic blood flow during sexual activity.

Most Likely Diagnoses to Consider

Gynecologic Causes

• Endometriosis: Can cause deep dyspareunia and pain with orgasm due to pelvic muscle contraction affecting endometrial implants 4
• Ovarian pathology: Ovarian cysts, particularly functional cysts or endometriomas on the left side, can cause pain with orgasm due to increased pelvic pressure 1
• Fibroids: Can cause chronic pelvic pain and pressure that worsens with orgasm, especially if degenerating 1
• Pelvic inflammatory disease or adhesions: Chronic inflammation can make orgasmic contractions painful 4

Urologic Causes

• Interstitial cystitis: Often misdiagnosed as gynecologic pain, presents with chronic pelvic pain that can worsen with orgasm due to bladder pressure changes 4
• Detrusor overactivity: Women with coital incontinence at orgasm have more severe bladder dysfunction and may experience pain 5

Musculoskeletal Causes

• Pelvic floor myofascial pain: Trigger points in pelvic floor muscles can cause localized left-sided pain with muscle contraction during orgasm 6

Diagnostic Approach

Initial Imaging Based on Age and Presentation

For women of reproductive age:

• Order transvaginal pelvic ultrasound as the first-line imaging study when gynecologic pathology is suspected 1, 2
• This has high sensitivity and specificity for detecting ovarian cysts, endometriomas, and fibroids 2

For perimenopausal or postmenopausal women:

• Fibroids become significantly more important as a pain cause in this age group 1
• Transvaginal ultrasound combined with transabdominal approach is the initial study of choice 1
• Maintain high suspicion for ovarian pathology, as ovarian cysts are the most common gynecologic cause of postmenopausal pelvic pain 1

When to Escalate to CT

Order CT abdomen and pelvis with IV contrast if:

• Ultrasound is equivocal or negative but symptoms persist 7, 2
• There are systemic symptoms (fever, elevated white blood cell count) suggesting infection or abscess 3
• You need to exclude gastrointestinal causes like diverticulitis or bowel pathology 7, 2
• The patient has acute severe pain rather than pain only with orgasm 2

CT has 98% diagnostic accuracy for abdominal pathology and can detect complications requiring different management 3

Physical Examination Pearls

Key Findings to Assess

• Carnett's sign: If tenderness increases when abdominal muscles are tensed, the abdominal wall itself may be the pain source 6
• Pelvic examination: Check for adnexal masses, cervical motion tenderness, and pelvic floor muscle trigger points 4
• Localized trigger points: A specific tender point that reproduces the pain suggests myofascial origin 6

Common Pitfalls to Avoid

Don't Assume Diverticulitis

While diverticulitis is the most common cause of left lower quadrant pain overall 1, 3, pain specifically with orgasm is not a typical presentation. The classic triad of fever, left-sided pain, and leukocytosis is only present in 25% of diverticulitis cases anyway 3

Don't Overlook the Bladder

Interstitial cystitis frequently masquerades as gynecologic pain and is often missed because clinicians don't consider the bladder as a pelvic pain source 4. Ask specifically about urinary urgency, frequency, and nocturia.

Don't Forget Endometriosis Can Coexist

Endometriosis can coexist with other causes of pelvic pain, particularly interstitial cystitis 4. Finding one diagnosis doesn't exclude another.

Treatment Considerations

If Imaging is Negative

• Consider pelvic floor physical therapy for myofascial pain 6
• Trial of local anesthetic injection into trigger points can be both diagnostic and therapeutic 6
• Refer to gynecology for possible laparoscopy if endometriosis is strongly suspected despite negative imaging 4

Red Flags Requiring Emergency Evaluation

• Fever with left-sided pain and elevated WBC (possible diverticulitis with complications) 3
• Acute severe pain rather than pain only with orgasm 2
• Signs of peritonitis on examination 3