What could be causing my pelvic pain after sex?

Post-Coital Pelvic Pain: Evaluation and Management

You need an urgent pelvic examination to identify the source of your pain, with sexually transmitted infections, pelvic inflammatory disease, ovarian pathology, and trauma being the most critical considerations requiring immediate evaluation. 1

Immediate Diagnostic Priorities

Essential Clinical Assessment

A complete pelvic examination is mandatory when evaluating lower abdominal pain following sexual activity, as this allows direct identification of cervical motion tenderness, adnexal masses, uterine abnormalities, and signs of trauma. 1 The examination should specifically assess for:

• Cervical motion tenderness indicating possible pelvic inflammatory disease (PID), which accounts for 20% of acute pelvic pain cases and includes tubo-ovarian abscess, oophoritis, salpingitis, endometritis, or cervicitis. 1
• Adnexal tenderness or masses suggesting ovarian cysts (the most common gynecologic cause, representing one-third of cases), ovarian torsion, or ovarian neoplasm (8% of cases). 1, 2
• Vaginal or vulvar trauma from intercourse itself. 1
• Uterine tenderness potentially indicating endometritis or fibroid-related complications. 1

Critical Laboratory Testing

Obtain testing for gonorrhea and chlamydia immediately using nucleic acid amplification tests (NAATs), as approximately 15% of untreated chlamydia infections progress to PID, and early treatment prevents serious complications. 1, 3 Testing can be performed on:

• Urine samples (non-clean catch acceptable for NAATs). 1
• Cervical or vaginal specimens during pelvic examination (may be more sensitive depending on the specific test used). 1

Perform a urine pregnancy test to exclude ectopic pregnancy, as approximately 40% of ectopic pregnancies are misdiagnosed at initial presentation. 3

Imaging Strategy

First-Line Imaging

Transvaginal ultrasound is the initial imaging modality of choice for suspected gynecologic causes due to superior sensitivity for ovarian pathology and absence of radiation exposure. 4 This should be obtained when:

• Physical examination reveals adnexal masses or tenderness. 1
• Clinical suspicion exists for ovarian cyst, torsion, or other adnexal pathology. 4
• PID is suspected and imaging is needed to identify tubo-ovarian abscess or pyosalpinx. 4

Second-Line Imaging

CT abdomen and pelvis with IV contrast should be obtained when ultrasound is nondiagnostic or when the differential includes non-gynecologic causes, as CT demonstrates 89% sensitivity versus 70% for ultrasound in urgent diagnoses. 1 CT is particularly useful for:

• Identifying appendicitis (95% sensitivity, 94% specificity), which must always be excluded in right-sided pain. 4
• Detecting ovarian torsion findings (enlarged, hypoenhancing ovary with vascular pedicle swirling). 1
• Evaluating for diverticulitis, which accounts for 8% of right lower quadrant pain. 4

Most Likely Diagnoses Based on Sexual Activity

Infectious Etiologies (Highest Priority)

Pelvic inflammatory disease represents the most critical diagnosis to identify and treat immediately, as the majority of PID cases are related to sexual activity. 1 Treatment should be initiated as soon as possible after diagnosis:

• Recommended regimen: Azithromycin 1 g orally single dose OR Doxycycline 100 mg orally twice daily for 7 days. 1
• Abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen. 1
• All sex partners within the preceding 60 days should receive empiric treatment effective against chlamydia. 1

Mechanical/Traumatic Causes

Ovarian cyst rupture or hemorrhage can occur with intercourse and presents with acute onset pain. 1, 2

Pelvic congestion syndrome may manifest as post-coital pain due to engorged periuterine and periovarian veins (≥8 mm diameter) with retrograde flow, particularly in reproductive-age women with estrogen stimulation. 5

Direct vaginal or cervical trauma from intercourse should be identified on speculum examination. 1

Less Common but Serious Causes

Ovarian torsion can present with acute severe pain and requires urgent surgical intervention, though it can occur despite normal Doppler flow on ultrasound. 6 High clinical suspicion may necessitate exploratory laparotomy even with normal imaging. 6

Ectopic pregnancy must be excluded in all reproductive-age women before proceeding with other diagnostic considerations. 3

Critical Red Flags Requiring Urgent Intervention

• Acute severe pain with hemodynamic instability suggests ruptured cyst, torsion, or other surgical emergency. 2
• Fever with pelvic pain indicates possible tubo-ovarian abscess requiring hospitalization and IV antibiotics. 1
• Persistent symptoms after treatment without objective signs of inflammation should prompt evaluation for chronic conditions rather than empiric retreatment. 1

Common Diagnostic Pitfalls

Do not assume gynecologic origin without systematic evaluation of gastrointestinal (appendicitis, diverticulitis), urologic (cystitis, pyelonephritis), and musculoskeletal systems, as this leads to missed diagnoses. 2, 3

Do not overlook pelvic inflammatory disease even when initial testing is negative, as recent instrumentation or cervical stenosis can cause isolated endometritis. 1, 2

Do not dismiss pain as normal post-coital discomfort without proper workup, as this may miss serious pathology including ovarian torsion or ectopic pregnancy. 2, 3

Follow-Up Considerations

Repeat testing at 3-6 months is recommended for all patients diagnosed with chlamydia or gonorrhea, as reinfection rates are high within 6 months after treatment regardless of partner treatment status. 1

Return for evaluation if symptoms persist or recur after completing therapy, though symptoms alone without objective signs are insufficient basis for retreatment. 1