Pelvic Pain — সংজ্ঞা
Pelvic pain হলো নাভির নিচ থেকে genital/perineal area পর্যন্ত pelvic অঞ্চলের ব্যথা। এটি নিজে একটি রোগ নয়, বরং অনেক disease-এর symptom। ব্যথা acute হলে সাধারণত <3 মাস, আর chronic pelvic pain হলে সাধারণত ≥6 মাস স্থায়ী বা recurrent হয়। Reproductive-age female-এর pelvic pain হলে pregnancy test বাধ্যতামূলক, কারণ ectopic pregnancy missed হলে life-threatening bleeding হতে পারে।
Emergency Red Flags — এখনই hospital/ER
নিচের যেকোনোটি থাকলে ঘরে treatment নয়:
- Pregnancy test positive + pelvic pain / vaginal bleeding / dizziness / shoulder-tip pain
- Severe sudden unilateral pain + vomiting → ovarian torsion/ruptured cyst সন্দেহ
- Fever, toxic look, hypotension, tachycardia, severe lower abdominal tenderness
- Peritonitis: guarding, rebound tenderness
- Fainting, pallor, shock
- Acute urinary retention, gross hematuria with severe flank pain
- Male patient with fever + perineal pain + urinary retention → acute prostatitis/sepsis risk
NICE ectopic guideline অনুযায়ী reproductive-age woman-এ pain/bleeding থাকলে ectopic pregnancy exclude করতে হবে, এবং haemodynamic instability বা significant pain/bleeding থাকলে direct emergency referral লাগে।
Causes — কারণগুলো point আকারে details
A. Female gynecological causes
1) Pelvic Inflammatory Disease — PID
- Cervix/uterus/tube/ovary পর্যন্ত ascending infection।
- Common organism: Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes, BV-associated flora।
- Risk: unprotected sex, multiple partner, previous STI/PID, young age, recent uterine procedure, IUD insertion-এর প্রথম 3 সপ্তাহ।
- PID-তে endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis হতে পারে। CDC PID-কে upper female genital tract inflammatory disorder হিসেবে define করে।
2) Ectopic pregnancy
- Fertilized ovum uterus-এর বাইরে, সাধারণত fallopian tube-এ implant করে।
- Classic: missed period + lower abdominal/pelvic pain + vaginal bleeding।
- Rupture হলে massive intra-abdominal bleeding ও shock হতে পারে। NICE guideline ectopic pregnancy-তে pelvic pain, amenorrhoea, vaginal bleeding, dizziness/syncope, shoulder-tip pain উল্লেখ করেছে।
3) Ovarian torsion
- Ovary/adnexa twist হয়ে blood supply কমে যায়।
- Sudden severe unilateral pelvic pain, nausea/vomiting।
- Surgical emergency; delay হলে ovary necrosis হতে পারে।
4) Ruptured/hemorrhagic ovarian cyst
- Sudden lower abdominal pain, often unilateral।
- যদি bleeding বেশি হয়: dizziness, hypotension, peritonism।
5) Endometriosis
- Uterus-এর lining-এর মতো tissue uterus-এর বাইরে থাকে।
- Estrogen-driven inflammation → dysmenorrhea, chronic pelvic pain, dyspareunia, bowel/bladder symptoms, infertility।
- CMAJ review অনুযায়ী endometriosis pelvic pain ও infertility-এর common cause এবং disease cure নেই; management symptom control, hormonal suppression, surgery, multidisciplinary care।
6) Dysmenorrhea
- Primary: prostaglandin-mediated uterine cramps; pelvic pathology নেই।
- Secondary: endometriosis, adenomyosis, fibroid, PID, IUCD, cervical stenosis।
7) Adenomyosis / Fibroid
- Heavy menstrual bleeding, dysmenorrhea, pressure symptoms, infertility/subfertility।
- Enlarged tender uterus হতে পারে।
B. Pregnancy-related causes
- Ectopic pregnancy
- Miscarriage / threatened abortion
- Degenerating fibroid in pregnancy
- Round ligament pain — benign but diagnosis of exclusion
- Placental causes later pregnancy
C. Urinary causes
1) UTI / cystitis
- Suprapubic pain, dysuria, frequency, urgency।
- Fever/flank pain থাকলে pyelonephritis consider করতে হবে।
2) Ureteric stone
- Severe colicky flank-to-groin pain, hematuria, nausea/vomiting।
- Obstruction + infection হলে emergency.
3) Interstitial cystitis / bladder pain syndrome
- Chronic pelvic/bladder pain, frequency/urgency, urine culture negative।
D. Gastrointestinal causes
- Appendicitis — right iliac fossa pain, fever, anorexia, vomiting
- IBS — chronic abdominal/pelvic discomfort + bowel habit change
- Constipation
- Diverticulitis
- IBD
- Hernia
Acute pelvic pain evaluation-এ life-threatening এবং fertility-threatening causes—ectopic pregnancy, appendicitis, ruptured ovarian cyst, PID, torsion—প্রথমে exclude করতে হয়।
E. Musculoskeletal / neuropathic causes
- Pelvic floor myalgia/spasm
- Pudendal neuralgia
- Sacroiliac joint pain
- Herniated disc/radiculopathy
- Post-surgical adhesion
EAU chronic pelvic pain guideline chronic pain management-এ biopsychosocial model, pelvic floor physiotherapy, pain education, psychological support, এবং selected pharmacotherapy emphasise করে।
Cause Explain in Bangla :-
Pelvic Pain-এর কারণগুলো — বিস্তারিত
1. Pregnancy-related কারণ
1) Ectopic pregnancy — জরুরি কারণ
- মানে: Pregnancy uterus-এর ভিতরে না হয়ে fallopian tube বা অন্য কোথাও develop করে।
- কেন pain হয়: Tube stretch হয়, পরে rupture হলে abdomen-এর ভিতরে bleeding হয়।
- কারা risk-এ: Previous ectopic pregnancy, PID history, tubal surgery, infertility treatment, IUD with pregnancy, smoking.
- Clinical clue: Missed period + pelvic/lower abdominal pain + vaginal bleeding। Dizziness, fainting, shoulder-tip pain হলে rupture/bleeding সন্দেহ।
- Danger: Life-threatening internal bleeding হতে পারে। NICE ectopic pregnancy-এর common symptoms হিসেবে pelvic/abdominal pain, missed period, vaginal bleeding উল্লেখ করেছে।
2) Miscarriage / threatened abortion
- মানে: Early pregnancy-তে uterus থেকে pregnancy tissue বের হতে শুরু করা বা bleeding হওয়া।
- কেন pain হয়: Uterus contraction করে pregnancy tissue expel করতে চায়।
- Clinical clue: Pregnancy positive + lower abdominal cramp + vaginal bleeding/clots।
- Danger: Excessive bleeding, incomplete abortion, infection হতে পারে।
2. Female gynecological কারণ
2.1 Pelvic Inflammatory Disease — PID
- মানে: Cervix থেকে infection উপরে উঠে uterus, fallopian tube, ovary পর্যন্ত চলে যায়।
- মূল organism: Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes, BV-associated bacteria.
- কেন pain হয়: Tube/uterus/ovary inflamed হয়, pus বা abscess হতে পারে।
- Risk factor: Unprotected sex, multiple sexual partner, previous STI/PID, young age, recent uterine procedure, IUD insertion-এর প্রথম কয়েক সপ্তাহ।
- Clinical clue: Lower abdominal/pelvic pain + vaginal discharge + fever + painful intercourse + cervical motion tenderness।
- Danger: Infertility, ectopic pregnancy, chronic pelvic pain, tubo-ovarian abscess। CDC বলছে chlamydia/gonorrhea screening ও treatment PID risk কমাতে সাহায্য করে।
2.2 Ovarian torsion
- মানে: Ovary নিজের axis-এ twist করে blood supply বন্ধ/কমে যায়।
- কেন pain হয়: Ovary ischemic হয়, অর্থাৎ blood না পেয়ে tissue damage শুরু হয়।
- Risk factor: Ovarian cyst, enlarged ovary, pregnancy, fertility treatment.
- Clinical clue: হঠাৎ এক পাশে severe pelvic pain + nausea/vomiting।
- Danger: Delay হলে ovary necrosis হয়ে ovary lose হতে পারে।
- Important: এটা surgical emergency.
2.3 Ruptured ovarian cyst / hemorrhagic cyst
- মানে: Ovary-এর cyst ফেটে যায় বা cyst-এর ভিতরে bleeding হয়।
- কেন pain হয়: Cyst rupture হলে fluid/blood pelvic cavity-তে পড়ে irritation করে।
- Clinical clue: হঠাৎ এক পাশে sharp pain, period-এর mid-cycle বা luteal phase-এ হতে পারে।
- Danger: বেশি bleeding হলে hypotension, dizziness, shock হতে পারে।
2.4 Endometriosis
- মানে: Uterus-এর lining-এর মতো tissue uterus-এর বাইরে থাকে—ovary, tube, pelvic wall, bowel/bladder-এর উপর।
- কেন pain হয়: প্রতিমাসে hormone-এর প্রভাবে ওই tissue inflamed হয়, bleeding-like reaction করে, adhesion/scar তৈরি করে।
- Clinical clue: Period-এর সময় severe pain, chronic pelvic pain, deep dyspareunia, painful defecation/urination during period, infertility.
- Danger: Chronic pain, adhesion, infertility, poor quality of life। NICE endometriosis guideline অনুযায়ী pelvic pain, painful period, subfertility endometriosis-এর typical features।
2.5 Primary dysmenorrhea
- মানে: Period pain, কিন্তু pelvic organ-এ কোনো structural disease থাকে না।
- কেন pain হয়: Uterus থেকে prostaglandin বেশি release হয় → uterus বেশি contraction করে → crampy pain।
- Clinical clue: Period শুরু হওয়ার কয়েক ঘণ্টা আগে/শুরুর দিন crampy lower abdominal pain, কোমরে বা thigh-এ ছড়াতে পারে।
- Usually: Teenager/young female-এ common.
- Danger: সাধারণত dangerous নয়, কিন্তু severe হলে daily activity disturb করে।
2.6 Secondary dysmenorrhea
- মানে: Period pain-এর পেছনে কোনো disease থাকে।
- Common cause: Endometriosis, adenomyosis, fibroid, PID, cervical stenosis, IUCD-related cramp.
- Clinical clue: আগে pain ছিল না, পরে progressively pain বাড়ছে; heavy bleeding, infertility, dyspareunia থাকতে পারে।
- Important: New-onset severe dysmenorrhea সবসময় evaluate করতে হবে।
2.7 Adenomyosis
- মানে: Uterine lining-এর gland uterus muscle layer-এর ভিতরে ঢুকে যায়।
- কেন pain হয়: Uterus bulky ও inflamed হয়, period-এ uterine contraction বেশি হয়।
- Clinical clue: Heavy menstrual bleeding + severe dysmenorrhea + enlarged tender uterus.
- Common: 35–50 বছর বয়সে বেশি, কিন্তু young female-এও হতে পারে।
- Danger: Anemia, chronic pelvic pain, fertility problem.
2.8 Fibroid / uterine leiomyoma
- মানে: Uterus-এর benign smooth muscle tumor.
- কেন pain হয়: Large fibroid pressure দেয়, degeneration হলে acute pain হয়, submucosal fibroid uterine cramp বাড়ায়।
- Clinical clue: Heavy period, prolonged bleeding, pelvic pressure, urinary frequency, constipation, infertility.
- Danger: Anemia, pregnancy complication, subfertility.
2.9 Tubo-ovarian abscess
- মানে: PID severe হয়ে fallopian tube/ovary-তে pus collection হয়।
- কেন pain হয়: Abscess pressure + infection + inflammation।
- Clinical clue: Severe pelvic pain + high fever + adnexal mass/tenderness + toxic appearance.
- Danger: Abscess rupture হলে peritonitis/sepsis হতে পারে।
- Management: Usually admission, IV antibiotic ± drainage/surgery.
3. Urinary system কারণ
3.1 Urinary tract infection / cystitis
- মানে: Bladder infection.
- কেন pelvic pain হয়: Inflamed bladder suprapubic area-তে pain করে।
- Clinical clue: Burning urination, frequency, urgency, suprapubic pain, cloudy urine.
- Danger: Infection kidney-তে গেলে pyelonephritis; pregnancy বা male UTI complicated ধরা হয়।
3.2 Pyelonephritis
- মানে: Kidney infection.
- কেন pain হয়: Kidney inflamed হয়, flank pain হয়; pelvic discomfortও থাকতে পারে।
- Clinical clue: Fever, chills, flank pain, vomiting, dysuria.
- Danger: Sepsis, renal abscess, pregnancy complication.
3.3 Ureteric stone
- মানে: Kidney/ureter-এ stone আটকে যায়।
- কেন pain হয়: Ureter obstruction + spasm → severe colicky pain.
- Clinical clue: Flank থেকে groin/pelvis-এ pain ছড়ায়, hematuria, nausea/vomiting.
- Danger: Stone + fever = infected obstructed kidney, emergency.
3.4 Interstitial cystitis / bladder pain syndrome
- মানে: Chronic bladder pain, কিন্তু urine culture সাধারণত negative.
- কেন pain হয়: Bladder wall sensitivity/inflammation-like pain mechanism.
- Clinical clue: Bladder full হলে pain বাড়ে, urine করলে কিছুটা কমে; frequency/urgency থাকে।
- Duration: Chronic/recurrent pelvic pain-এর cause.
4. Gastrointestinal কারণ
4.1 Appendicitis
- মানে: Appendix inflammation.
- কেন pelvic pain হয়: Appendix pelvic position-এ থাকলে pain lower abdomen/pelvis-এ feel হতে পারে।
- Clinical clue: Initially central abdominal pain, পরে right lower abdomen pain; fever, anorexia, nausea/vomiting.
- Danger: Perforation, peritonitis, abscess, sepsis.
- Important: Female pelvic pain-এ appendicitis PID/ovarian cyst-এর মতো mimic করতে পারে।
4.2 Irritable bowel syndrome — IBS
- মানে: Functional bowel disorder; structural disease থাকে না।
- কেন pain হয়: Gut hypersensitivity + bowel motility change.
- Clinical clue: Pain with bloating, constipation/diarrhea, stool করার পর pain কমে।
- Danger: Life-threatening না, কিন্তু chronic discomfort ও anxiety বাড়ায়।
- Red flag: Weight loss, blood in stool, nocturnal diarrhea, anemia থাকলে IBS ধরে নেওয়া যাবে না।
4.3 Constipation
- মানে: Stool জমে colon/rectum distend হয়।
- কেন pelvic pain হয়: Rectum/pelvis-এ pressure পড়ে।
- Clinical clue: Hard stool, straining, incomplete evacuation, lower abdominal heaviness.
- Common: Low fiber diet, dehydration, hypothyroidism, opioid/iron/calcium channel blocker use.
4.4 Diverticulitis
- মানে: Colon-এর diverticula inflamed/infected হয়।
- কেন pain হয়: Colon wall inflammation.
- Clinical clue: Usually left lower abdominal/pelvic pain, fever, bowel habit change.
- Danger: Abscess, perforation, fistula.
4.5 Inflammatory bowel disease — IBD
- মানে: Crohn’s disease/ulcerative colitis.
- কেন pelvic pain হয়: Chronic bowel inflammation, ulceration, fistula/abscess.
- Clinical clue: Chronic diarrhea, blood/mucus stool, weight loss, anemia, fever, perianal disease.
5. Musculoskeletal ও nerve-related কারণ
5.1 Pelvic floor muscle spasm / pelvic floor myalgia
- মানে: Pelvic floor muscle tight/spasm হয়ে pain তৈরি করে।
- কেন pain হয়: Muscle overactivity, trigger point, poor relaxation.
- Clinical clue: Sitting-এ pain বাড়ে, sex painful, urinary urgency, constipation-like symptoms।
- Common with: Chronic pelvic pain, anxiety, post-delivery trauma, endometriosis, recurrent infection history.
- EAU chronic pelvic pain guideline chronic pelvic pain-এ pelvic floor ও multidisciplinary approach গুরুত্ব দেয়।
5.2 Pudendal neuralgia
- মানে: Pudendal nerve irritation/compression.
- কেন pain হয়: Nerve pain pelvis/perineum/genital area-তে burning/shooting pain দেয়।
- Clinical clue: Sitting করলে pain বাড়ে, standing/lying করলে কমে; genital/perineal burning pain.
- Cause: Cycling, pelvic surgery, childbirth trauma, pelvic floor spasm.
5.3 Sacroiliac joint / lumbar spine problem
- মানে: Back/pelvic joint বা nerve root problem pelvic pain হিসেবে feel হতে পারে।
- Clinical clue: Low back pain, buttock pain, movement-এ pain বাড়ে, leg radiation থাকতে পারে।
- Cause: Disc prolapse, sacroiliitis, posture, trauma.
6. Male-specific pelvic pain causes
6.1 Acute prostatitis
- মানে: Prostate gland infection/inflammation.
- কেন pain হয়: Prostate swollen/inflamed হয়ে pelvic/perineal pain দেয়।
- Clinical clue: Fever, chills, dysuria, urinary frequency, perineal pain, painful ejaculation, urinary retention.
- Danger: Sepsis, prostatic abscess.
- Important: Acute prostatitis suspected হলে vigorous prostate massage করা যাবে না।
6.2 Chronic prostatitis / chronic pelvic pain syndrome
- মানে: ≥3 মাস pelvic/perineal/genital pain; culture positive নাও হতে পারে।
- Clinical clue: Perineal pain, testicular/penile pain, urinary symptoms, sexual dysfunction, anxiety/stress association.
- Cause mechanism: Infection, inflammation, pelvic floor dysfunction, nerve hypersensitivity—mixed mechanism.
6.3 Epididymitis / orchitis
- মানে: Epididymis/testis inflammation/infection.
- কেন pelvic pain হয়: Scrotal infection pain groin/pelvis-এ refer করতে পারে।
- Clinical clue: Scrotal pain/swelling, dysuria, urethral discharge, fever.
- DDx: Testicular torsion must exclude if sudden severe testicular pain.
7. Other important causes
7.1 Pelvic adhesion
- মানে: Previous surgery/infection/endometriosis-এর পর scar tissue তৈরি হয়।
- কেন pain হয়: Organs pull/tether করে chronic pain হতে পারে।
- Clinical clue: Previous C-section/appendectomy/pelvic surgery/PID/endometriosis history.
7.2 Hernia
- মানে: Inguinal/femoral hernia pelvis/groin pain করতে পারে।
- Clinical clue: Groin swelling, cough/standing-এ বাড়ে, lying-এ কমে।
- Danger: Irreducible painful hernia → strangulation emergency.
7.3 Malignancy
- Female: Ovarian, cervical, uterine cancer.
- Male: Prostate/bladder/colorectal malignancy.
- Clinical clue: Persistent pain, weight loss, abnormal bleeding, bloating, early satiety, hematuria, anemia.
- Important: Chronic unexplained pelvic pain + red flags হলে malignancy exclude করতে হবে।
Pain pattern দিয়ে cause ধরার shortcut
| Pain pattern | সম্ভাব্য cause |
| Missed period + pain + bleeding | Ectopic pregnancy / miscarriage |
| Sudden one-sided severe pain + vomiting | Ovarian torsion / ruptured cyst |
| Fever + discharge + lower abdominal pain | PID / cervicitis |
| Burning urine + suprapubic pain | UTI / cystitis |
| Flank থেকে groin-এ severe colicky pain | Ureteric stone |
| Period-এর সময় severe cyclic pain | Dysmenorrhea / endometriosis / adenomyosis |
| Deep sex pain + infertility | Endometriosis / PID sequelae |
| Right lower abdomen pain + fever/anorexia | Appendicitis |
| Stool problem + bloating + pain relief after stool | IBS / constipation |
| Sitting করলে perineal pain বাড়ে | Pudendal neuralgia / pelvic floor pain |
| Male fever + perineal pain + urinary symptoms | Acute prostatitis |
Overview / Summary
Pelvic pain-এর cause বোঝার সবচেয়ে ভালো পদ্ধতি হলো pregnancy-related, gynecological, urinary, gastrointestinal, musculoskeletal/nerve, male urological—এই ৬ ভাগে চিন্তা করা। Acute pelvic pain-এ প্রথমে ectopic pregnancy, ovarian torsion, ruptured cyst, appendicitis, severe PID exclude করতে হবে, কারণ এগুলো delay হলে life-threatening বা fertility-threatening হতে পারে।
Actionable Plan / Steps
- Female reproductive age হলে আগে urine pregnancy test।
- Fever/discharge/CMT থাকলে PID/STI evaluation।
- Sudden severe unilateral pain হলে USG/TVS urgently — torsion/cyst/ectopic exclude।
- Dysuria থাকলে urine R/M/E + culture।
- Bowel symptom থাকলে appendicitis/IBS/constipation/IBD consider।
- Chronic pain হলে endometriosis + pelvic floor + bladder pain syndrome evaluate।
2. Symptoms — লক্ষণগুলো details
Common pelvic pain symptoms
- নাভির নিচে dull/aching/sharp/cramping pain
- এক পাশে বেশি ব্যথা → ovarian cyst/torsion/stone/ectopic ভাবতে হবে
- Period-এর আগে/সময় severe pain → dysmenorrhea/endometriosis
- Sex-এর সময় pain — deep dyspareunia → endometriosis/PID/pelvic floor disorder
- Vaginal discharge, bad smell, postcoital bleeding → cervicitis/PID
- Fever/chills → PID, UTI, appendicitis, pyelonephritis
- Dysuria, frequency, urgency → UTI/interstitial cystitis
- Nausea/vomiting → torsion, appendicitis, stone
- Bowel symptom: constipation, diarrhea, painful defecation → IBS/endometriosis/GI disease
- Heavy menstrual bleeding → fibroid/adenomyosis/AUB
- Missed period + pain + bleeding → ectopic until proven otherwise
PID-specific symptoms
- Lower abdominal/pelvic pain
- Cervical motion tenderness, uterine tenderness, adnexal tenderness
- Abnormal mucopurulent discharge/cervical friability
- Fever, elevated ESR/CRP, WBC in vaginal wet prep
CDC অনুযায়ী PID diagnosis difficult; low threshold দরকার, কারণ diagnosis/treatment delay হলে reproductive sequelae হয়।
Symptopms Explain in Bangla :-
Pelvic Pain-এর Symptoms — বিস্তারিত
1. ব্যথার ধরন অনুযায়ী symptoms
1) Cramping pain / মোচড়ানো ব্যথা
- তলপেট বা pelvis-এ চাপ/মোচড়ের মতো ব্যথা।
- সাধারণত period pain / dysmenorrhea, miscarriage, uterine contraction, adenomyosis, fibroid-এর ক্ষেত্রে হয়।
- Period শুরু হওয়ার আগে বা period চলাকালীন বাড়তে পারে।
- কোমর বা উরুতে ছড়িয়ে যেতে পারে।
2) Sharp pain / ছুরির মতো তীব্র ব্যথা
- হঠাৎ শুরু হওয়া এক পাশে তীব্র ব্যথা।
- Ovarian torsion, ruptured ovarian cyst, ectopic pregnancy rupture, stone—এসব ভাবতে হবে।
- Pain খুব বেশি হলে patient হাঁটতে/সোজা হয়ে দাঁড়াতে পারে না।
- Vomiting, sweating, dizziness থাকলে emergency.
3) Dull aching pain / ভারী বা টান টান ব্যথা
- দীর্ঘদিন ধরে নিচের পেটে ভারী ভাব বা dull pain।
- Endometriosis, chronic PID, pelvic adhesion, fibroid, adenomyosis, pelvic floor muscle pain-এ হতে পারে।
- কাজ করলে, দীর্ঘক্ষণ দাঁড়ালে বা sex-এর পর বাড়তে পারে।
4) Colicky pain / ঢেউয়ের মতো ব্যথা
- ব্যথা একবার বাড়ে, আবার কমে।
- Ureteric stone, bowel colic, intestinal spasm, constipation-এর ক্ষেত্রে বেশি হয়।
- Stone হলে flank থেকে groin/pelvis-এ pain ছড়াতে পারে।
2. Location অনুযায়ী symptoms
1) এক পাশে pelvic pain
- Right বা left lower abdomen-এ pain।
- সম্ভাব্য cause:
- Ovarian cyst
- Ovarian torsion
- Ectopic pregnancy
- Ureteric stone
- Appendicitis, যদি right side হয়
- যদি এক পাশে sudden severe pain + vomiting থাকে, torsion বা ruptured cyst emergency হিসেবে ভাবতে হবে।
2) মাঝখানে suprapubic pain
- নাভির নিচে bladder/uterus area-তে pain।
- সম্ভাব্য cause:
- UTI/cystitis
- Dysmenorrhea
- PID
- Bladder pain syndrome
- Burning urination থাকলে urinary cause বেশি likely.
3) কোমর/পিঠে ছড়ানো pain
- Period pain, endometriosis, adenomyosis, stone বা kidney infection-এর সাথে হতে পারে।
- Fever + flank pain থাকলে pyelonephritis ভাবতে হবে।
3. Menstrual / Period-related symptoms
1) Period-এর সময় বেশি ব্যথা
- Period শুরু হওয়ার আগে বা প্রথম ১–২ দিনে pain বেশি।
- Primary dysmenorrhea হলে সাধারণত teenage/young age থেকে থাকে।
- Pain crampy হয়, lower abdomen থেকে back/thigh-এ যেতে পারে।
2) Period pain ধীরে ধীরে বাড়ছে
- আগে pain কম ছিল, এখন প্রতি মাসে বাড়ছে।
- Endometriosis, adenomyosis, fibroid, PID sequelae ভাবতে হবে।
- NICE guideline অনুযায়ী endometriosis সন্দেহ করতে হবে যদি chronic pelvic pain, daily activity affect করা period pain, deep sex pain, cyclical bowel/urinary symptoms থাকে।
3) Heavy menstrual bleeding
- বেশি রক্ত যাওয়া, clot পড়া, prolonged period।
- Fibroid, adenomyosis, hormonal problem, endometrial pathology হতে পারে।
- দীর্ঘদিন হলে anemia হতে পারে: weakness, dizziness, palpitation.
4) Irregular bleeding / spotting
- Period-এর মাঝখানে bleeding।
- PID, cervicitis, pregnancy complication, ectopic pregnancy, hormonal imbalance, cervical pathology হতে পারে।
- Pelvic pain + missed period + spotting হলে ectopic pregnancy exclude করতে হবে।
4. Pregnancy-related warning symptoms
1) Missed period + pelvic pain
- Pregnancy possibility থাকলে প্রথমেই urine pregnancy test করতে হবে।
- Pain এক পাশে হলে ectopic pregnancy risk বেশি ভাবতে হবে।
2) Vaginal bleeding with pain
- Early pregnancy-তে bleeding + pelvic pain হলে:
- Ectopic pregnancy
- Miscarriage
- Threatened abortion
- NICE ectopic pregnancy suspicion-এর symptom হিসেবে pelvic/abdominal pain, missed period, vaginal bleeding উল্লেখ করেছে।
3) Shoulder tip pain
- কাঁধের আগায় অদ্ভুত pain।
- Ectopic rupture হয়ে internal bleeding হলে diaphragm irritation থেকে shoulder tip pain হতে পারে।
- এটা dangerous sign.
4) Dizziness / fainting / collapse
- Internal bleeding বা shock-এর লক্ষণ হতে পারে।
- Pregnancy positive হলে emergency.
5. Infection-related symptoms
1) Fever / জ্বর
- Pelvic pain-এর সাথে fever থাকলে infection বা acute surgical condition ভাবতে হবে।
- Possible causes:
- PID
- Tubo-ovarian abscess
- UTI/pyelonephritis
- Appendicitis
- Diverticulitis
2) Vaginal discharge
- Yellow/green/pus-like discharge, bad smell, itching বা burning থাকতে পারে।
- PID, cervicitis, bacterial vaginosis, trichomoniasis, gonorrhea/chlamydia হতে পারে।
- CDC PID guideline অনুযায়ী abnormal cervical mucopurulent discharge/cervical friability PID support করে।
3) Lower abdominal pain + cervical motion tenderness
- Pelvic exam-এ cervix নাড়ালে pain হলে PID-এর important clinical sign।
- CDC অনুযায়ী pelvic/lower abdominal pain-এর সাথে cervical motion tenderness, uterine tenderness বা adnexal tenderness থাকলে PID-এর presumptive treatment consider করা হয়।
4) Pain during sex / dyspareunia
- Sex-এর সময় deep pelvic pain।
- Possible causes:
- Endometriosis
- PID
- Pelvic adhesion
- Pelvic floor muscle spasm
- Ovarian pathology
- Endometriosis-এ deep pain during or after intercourse common symptom হিসেবে ধরা হয়।
6. Urinary symptoms
1) Burning urination / প্রস্রাবে জ্বালা
- UTI/cystitis-এর common symptom।
- Pelvic pain suprapubic area-তে বেশি থাকে।
- সাথে frequency, urgency থাকতে পারে।
2) Frequency / বারবার প্রস্রাব
- অল্প অল্প করে বারবার প্রস্রাব।
- UTI, bladder pain syndrome, pregnancy, pelvic mass pressure-এর কারণে হতে পারে।
3) Urgency / প্রস্রাব ধরে রাখতে না পারা
- প্রস্রাবের বেগ হঠাৎ আসে।
- UTI, bladder irritation, interstitial cystitis-এ দেখা যায়।
4) Blood in urine / hematuria
- Ureteric stone, UTI, bladder pathology হতে পারে।
- Flank-to-groin severe pain + hematuria হলে stone likely.
5) Pain worse when bladder full
- Bladder full হলে pain বাড়ে, urine করার পর কিছুটা কমে।
- Interstitial cystitis/bladder pain syndrome-এর clue.
7. Bowel-related symptoms
1) Pain with constipation
- Stool আটকে থাকলে pelvic pressure ও lower abdominal pain হতে পারে।
- Hard stool, straining, incomplete evacuation থাকে।
2) Diarrhea বা bowel habit change
- IBS, gastroenteritis, IBD, appendicitis, diverticulitis হতে পারে।
- Pelvic pain + fever + vomiting থাকলে simple IBS ধরে নেওয়া যাবে না।
3) Painful defecation during period
- Period-এর সময় stool করার সময় pain হলে endometriosis suspect করতে হবে।
- NICE endometriosis symptom হিসেবে cyclical GI symptoms, বিশেষ করে painful bowel movement উল্লেখ করেছে।
4) Blood/mucus in stool
- IBD, infection, colorectal pathology, severe endometriosis bowel involvement হতে পারে।
- Weight loss/anemia থাকলে urgent evaluation দরকার।
8. Nausea-vomiting related symptoms
1) Pelvic pain + vomiting
- Ovarian torsion, appendicitis, ureteric stone, severe infection, ectopic rupture হতে পারে।
- Sudden unilateral pain + vomiting = torsion strongly consider।
- AAFP notes ovarian torsion suspicion থাকতে পারে nausea/vomiting এবং risk factor যেমন adnexal mass/pregnancy থাকলে—even Doppler normal হলেও torsion বাদ যায় না।
2) Anorexia / খাবারে অরুচি
- Appendicitis-এ common।
- Right lower abdominal pain + anorexia + fever + vomiting হলে appendicitis consider.
9. Chronic pelvic pain-এর symptoms
1) ৩–৬ মাস বা তার বেশি pain
- Chronic pelvic pain সাধারণত long-term/recurrent হয়।
- Causes:
- Endometriosis
- Bladder pain syndrome
- IBS
- Pelvic floor myalgia
- Chronic PID sequelae
- Neuropathic pain
2) Sitting করলে pain বাড়া
- Pudendal neuralgia বা pelvic floor muscle spasm হতে পারে।
- Pain perineum/genital/rectal area-তে burning বা pressure-like হতে পারে।
3) Sex, stool, urine, period—সবকিছুর সাথে pain relation
- Chronic pelvic pain-এ একাধিক system involve থাকতে পারে।
- Pain diary diagnosis-এ helpful.
10. Male pelvic pain symptoms
1) Perineal pain
- অণ্ডকোষ ও পায়ুপথের মাঝামাঝি জায়গায় pain।
- Acute prostatitis বা chronic prostatitis/chronic pelvic pain syndrome হতে পারে।
2) Fever + urinary symptoms
- Fever, chills, dysuria, urinary frequency, weak stream।
- Acute bacterial prostatitis হতে পারে।
- Urinary retention হলে emergency.
3) Painful ejaculation
- Prostatitis/chronic pelvic pain syndrome-এ দেখা যায়।
- Sexual dysfunction বা discomfort থাকতে পারে।
4) Scrotal pain/swelling
- Epididymitis/orchitis বা testicular torsion।
- Sudden severe testicular pain হলে torsion emergency.
11. Red flag symptoms — এগুলো থাকলে জরুরি
- Pregnancy positive বা missed period + pelvic pain
- Vaginal bleeding + dizziness/fainting
- Sudden severe one-sided pelvic pain
- Shoulder tip pain
- Fever >38°C with severe pelvic pain
- Repeated vomiting
- Severe pain with abdominal guarding/rebound tenderness
- Heavy vaginal bleeding
- Foul-smelling discharge + fever
- Pain + low BP/fast pulse/sweating
- Blood in urine + severe flank-to-groin pain
- Postmenopausal bleeding + pelvic pain
- Unexplained weight loss, appetite loss, anemia
12. Symptom pattern দিয়ে diagnosis shortcut
| Symptom pattern | সম্ভাব্য diagnosis |
| Missed period + one-sided pain + spotting | Ectopic pregnancy |
| Sudden severe unilateral pain + vomiting | Ovarian torsion |
| Sudden pain after cyst history | Ruptured ovarian cyst |
| Fever + discharge + cervical motion tenderness | PID |
| Period-related severe pain + dyspareunia | Endometriosis |
| Heavy period + enlarged/tender uterus | Adenomyosis/fibroid |
| Burning urine + suprapubic pain | UTI/cystitis |
| Flank-to-groin colicky pain + hematuria | Ureteric stone |
| Right lower abdominal pain + fever/anorexia | Appendicitis |
| Pain relieved after stool + bloating | IBS |
| Sitting করলে perineal burning pain | Pudendal neuralgia |
| Male fever + perineal pain + urinary retention | Acute prostatitis |
Overview / Summary
Pelvic pain-এর symptom analysis করতে হবে pain-এর ধরন, location, period relation, pregnancy relation, vaginal discharge/bleeding, urinary symptoms, bowel symptoms, fever, vomiting, sex-related pain—এই clue দেখে। Reproductive-age female হলে pregnancy test first priority, কারণ ectopic pregnancy missed হলে rupture ও life-threatening bleeding হতে পারে। PID-এর symptoms অনেক সময় subtle হয়; CDC বলছে mild বা nonspecific symptoms হলেও delay করলে infertility/chronic pain হতে পারে।
Actionable Plan / Steps
- Pain sudden/severe হলে urgent evaluation করুন।
- Female reproductive age হলে urine pregnancy test করুন।
- Fever/discharge/sex pain থাকলে PID/STI evaluation করুন।
- Burning urine থাকলে urine R/M/E + culture করুন।
- Period-related chronic pain হলে endometriosis/adenomyosis/fibroid evaluate করুন।
- Vomiting + one-sided pain হলে torsion/cyst/ectopic exclude করতে USG/TVS জরুরি।
3. Clinical Diagnosis — clinically কীভাবে approach করবেন
Short-cut clinical algorithm
Step 1 — Stability
- BP, pulse, temperature, SpO₂
- Shock/peritonitis/sepsis? → ER, IV access, CBC, group & crossmatch, urgent USG/CT/surgical/OBGYN consult.
Step 2 — Pregnancy status
- Reproductive-age female হলে urine β-hCG or serum β-hCG always।
- Positive হলে: ectopic pregnancy exclude না করা পর্যন্ত safe নয়।
Step 3 — Pain pattern
- Sudden severe unilateral → torsion/cyst rupture/stone
- Cyclic menstrual → dysmenorrhea/endometriosis/adenomyosis
- Discharge + CMT → PID/cervicitis
- Dysuria/frequency → UTI
- RIF pain + fever/anorexia → appendicitis
Step 4 — Focused examination
- Abdomen: guarding, rebound, mass, hernia
- Pelvic exam: discharge, cervical motion tenderness, uterine/adnexal tenderness, adnexal mass
- Speculum exam: cervicitis, bleeding, discharge
- Male: abdominal, genital, DRE if prostatitis suspected; acute prostatitis-এ vigorous prostate massage করা যাবে না.
4. Investigations — specific list
First-line tests
- Urine pregnancy test / serum β-hCG — reproductive-age female
- CBC — leukocytosis, anemia
- CRP/ESR — infection/inflammation support
- Urine R/M/E + urine culture — UTI/hematuria/stone
- High vaginal/endocervical swab or NAAT for Chlamydia/Gonorrhea ± Trichomonas/Mycoplasma depending setting
- Wet mount/pH/whiff test — BV/trichomoniasis support
- Transvaginal USG ± transabdominal USG — ectopic, ovarian cyst, torsion, TOA, fibroid, adenomyosis
- Serum creatinine/eGFR, LFT — before NSAID/antibiotic/hormonal/surgical decisions
- HIV, VDRL/RPR, HBsAg, anti-HCV — STI-risk/PID context
MSD Manual recommends acute pelvic pain evaluation with vital signs, physical examination, pregnancy test, CBC, urinalysis, and pelvic imaging.
When needed
- CT abdomen/pelvis — appendicitis, diverticulitis, stone, unclear acute abdomen
- MRI pelvis — deep endometriosis/adenomyosis mapping
- Diagnostic laparoscopy — torsion, ectopic, endometriosis, unclear severe pain
- Serum CA-125 — not routine pain test; adnexal mass/endometriosis suspicionে selected use
- Urine culture sensitivity — recurrent/complicated UTI, pregnancy, male UTI, treatment failure
5. Differential Diagnosis — core list
| Presentation | Likely DDx |
| Missed period + pain + bleeding | Ectopic pregnancy, miscarriage |
| Sudden unilateral severe pain + vomiting | Ovarian torsion, ruptured cyst, ureteric stone |
| Fever + discharge + CMT | PID, cervicitis |
| RIF pain + fever/anorexia | Appendicitis |
| Dysuria + suprapubic pain | UTI/cystitis |
| Cyclic pain + dyspareunia | Endometriosis, adenomyosis |
| Chronic pelvic pain + negative tests | Pelvic floor myalgia, bladder pain syndrome, IBS, neuropathic pain |
6. Complications — রোগভেদে
- PID: infertility, ectopic pregnancy, chronic pelvic pain, tubo-ovarian abscess, recurrent PID। CDC PID complication prevention-এর জন্য early antimicrobial therapy emphasise করে।
- Ectopic pregnancy: tubal rupture, intraperitoneal hemorrhage, shock, maternal death।
- Ovarian torsion: ovarian ischemia/necrosis, loss of ovary, infertility risk।
- Endometriosis: chronic pain, dyspareunia, infertility/subfertility, adhesions, bowel/bladder involvement, reduced quality of life।
- UTI: pyelonephritis, sepsis, recurrent UTI; pregnancy হলে preterm labour risk।
- Appendicitis: perforation, peritonitis, abscess, sepsis।
- Chronic pelvic pain: anxiety/depression, sexual dysfunction, sleep disturbance, reduced work productivity; multidisciplinary approach দরকার।
7. Treatment Management — cause-based
General non-pharmacological management
- Vitals unstable হলে resuscitation + urgent referral
- Pregnancy status জানা না থাকলে NSAID/hormonal/antibiotic blind use avoid
- Heat pad, rest, hydration
- Pelvic floor pain হলে pelvic floor physiotherapy
- Chronic pain হলে pain diary: relation with period, urine, bowel, sex, food, stress
- STI suspected হলে partner evaluation/treatment and abstinence until treatment complete
- Recurrent or chronic pain হলে OBGYN/urology/GI referral
8. Pharmacological Treatment — Generic, dose, duration, purpose, side effect, interaction, Bangladesh brands
Important: Antibiotic, hormonal drug, and injectable treatment registered physician-এর prescription ছাড়া ব্যবহার করা উচিত নয়। Brand availability বদলাতে পারে; নিচেরগুলো Bangladesh commonly listed examples.
1) Generic name: Paracetamol / Acetaminophen
Therapeutic category: Analgesic, antipyretic
Pharmacological class: Non-opioid analgesic
কেন used হয়: Mild–moderate pelvic pain, dysmenorrhea, fever-associated painে supportive analgesia।
Dose: Adult 500–1000 mg PO every 6–8 hours PRN; max usually 4 g/day; liver disease/alcohol use/low body weight হলে lower max.
Duration: 1–3 days initially; persistent pain হলে diagnosis review.
Side effects: Usually safe; overdoseে hepatotoxicity.
Interactions: Alcohol, warfarin long-term high dose, enzyme-inducing drugs.
Bangladesh available brand examples: Napa 500 mg, Napa One 1000 mg, Napa Extend 665 mg, Feva Rapid 500 mg, Neopara 500 mg. MedEx lists these paracetamol brands/strengths.
2) Generic name: Ibuprofen
Therapeutic category: Analgesic, anti-inflammatory
Pharmacological class: NSAID; non-selective COX inhibitor
কেন used হয়: Primary dysmenorrhea, inflammatory pelvic pain, mild musculoskeletal pelvic pain।
Dose: 400 mg PO 2–3 times daily after food; use lowest effective dose.
Duration: 2–5 days for dysmenorrhea/acute pain.
Side effects: Gastritis, dyspepsia, GI bleeding, renal impairment, BP rise, bronchospasm in aspirin-sensitive asthma.
Interactions: Warfarin/DOAC/antiplatelet, steroid, SSRI, ACEI/ARB + diuretic, lithium, methotrexate.
Avoid/caution: Peptic ulcer, CKD, uncontrolled HTN, anticoagulant use, aspirin-sensitive asthma. Pregnancy ≥20 weeksে NSAID fetal renal dysfunction/oligohydramnios risk; FDA warns against NSAID use around 20 weeks or later unless clinically necessary.
Bangladesh available brand examples: Profen 400 mg, Flamex 400 mg, Iburex 400 mg, Inflam 400 mg, G-Ibuprofen 400 mg.
3) Generic name: Naproxen sodium
Therapeutic category: Analgesic, anti-inflammatory
Pharmacological class: NSAID
কেন used হয়: Dysmenorrhea, endometriosis-associated pain supportive, musculoskeletal pelvic pain।
Dose: 250–500 mg PO twice daily after food.
Duration: 2–5 days during painful period; chronic use avoid unless supervised.
Side effects/interactions: Ibuprofen-এর মতো NSAID adverse effects/interactions.
Bangladesh available brand examples: Naprox 500 mg, Naprosyn 250/500 mg, Napryn 500 mg, Napsod 275/550 mg, Naproxin 500 mg.
4) Generic name: Mefenamic acid
Therapeutic category: Analgesic for menstrual pain
Pharmacological class: NSAID, fenamate group
কেন used হয়: Primary dysmenorrhea, menorrhagia-associated cramp pain.
Dose: 500 mg PO up to three times daily with meals; often start at onset of menses. MedEx lists adult dose 500 mg up to three times daily with meals.
Duration: Usually 2–3 days; avoid >7 days without review.
Side effects: GI upset, diarrhea, ulcer/bleeding, renal risk, rash.
Interactions: Anticoagulant, antiplatelet, steroid, SSRI, ACEI/ARB/diuretic, lithium, methotrexate.
Avoid: PUD, IBD, CKD, severe liver disease, NSAID allergy, pregnancy later stages.
Bangladesh available brand examples: Dysmen 500 mg, Amifen 500 mg, Flamic 500 mg, Fenaton 500 mg, Myfocin 500 mg, Mefalgin 500 mg.
5) Generic name: Hyoscine butylbromide
Therapeutic category: Antispasmodic
Pharmacological class: Anticholinergic/antimuscarinic
কেন used হয়: Colicky pelvic/abdominal spasm, GI/GU smooth muscle spasm, spasmodic dysmenorrhea supportive.
Dose: 10–20 mg PO 3 times daily PRN; severe colicে injection only clinical setting.
Duration: 1–3 days; persistent severe pain হলে surgical cause exclude.
Side effects: Dry mouth, blurred vision, tachycardia, constipation, urinary retention.
Interactions: Other anticholinergics, antihistamines, TCA; caution glaucoma/BPH/urinary retention.
Bangladesh available brand examples: Colipan 10/20 mg, Hysomide 10/20 mg, Hysin 10 mg, Lopan 10 mg, Hybucin 10 mg.
6) Generic name: Dicycloverine / Dicyclomine HCl
Therapeutic category: Antispasmodic
Pharmacological class: Anticholinergic smooth muscle relaxant
কেন used হয়: IBS-like crampy lower abdominal/pelvic pain, intestinal spasm.
Dose: 10–20 mg PO 2–3 times daily before meals PRN.
Duration: Short course; chronic IBS হলে full evaluation.
Side effects: Dry mouth, dizziness, constipation, blurred vision, urinary retention.
Interactions: Anticholinergics, TCA, antihistamines; caution glaucoma, BPH, elderly.
Bangladesh available brand examples: Colicon 10 mg, Cyclopan 10 mg, Abdorin 10 mg, Robentyl 10 mg, Loverin 10 mg.
7) Generic name: Ceftriaxone
Therapeutic category: Antibiotic
Pharmacological class: 3rd-generation cephalosporin
কেন used হয়: PID/gonorrhea coverage; severe pelvic infectionে parenteral therapy.
PID outpatient CDC dose: Ceftriaxone 500 mg IM single dose + doxycycline + metronidazole. >150 kg with documented gonorrhea হলে 1 g.
PID inpatient CDC dose: Ceftriaxone 1 g IV every 24 hours + doxycycline + metronidazole; improve হলে oral step-down to complete 14 days.
Side effects: Injection pain, diarrhea, rash, allergy, biliary sludge, rare C. difficile.
Interactions: IV calcium-containing solutions in neonates; warfarin effect may increase; severe beta-lactam allergy caution.
Bangladesh available brand examples: Ceftron 250/500 mg/1 g/2 g vial, Ceftriaid 500 mg/1 g/2 g, Exephin 500 mg/1 g/2 g, Traxon 500 mg/1 g/2 g, Dicephin 500 mg/1 g/2 g.
8) Generic name: Doxycycline
Therapeutic category: Antibiotic
Pharmacological class: Tetracycline antibiotic
কেন used হয়: PID-তে Chlamydia coverage; cervicitis/urethritis/chlamydial infection.
PID dose: 100 mg PO twice daily for 14 days with ceftriaxone + metronidazole.
Chlamydia/cervicitis dose: 100 mg PO twice daily for 7 days per CDC STI guidance.
Side effects: Nausea, esophagitis, photosensitivity, diarrhea, vaginal candidiasis.
Interactions: Antacid/iron/calcium/zinc/dairy reduce absorption; warfarin effect may increase; avoid isotretinoin combination.
Avoid: Pregnancy, breastfeeding caution, children <8 years unless special indication.
Bangladesh available brand examples: Doxin 100 mg, Doxy-A 100 mg, Doxycin 100 mg, Doxylin 100 mg, Doxysina 100 mg.
9) Generic name: Metronidazole
Therapeutic category: Antibiotic/antiprotozoal
Pharmacological class: Nitroimidazole; anaerobic antibacterial
কেন used হয়: PID-তে anaerobic coverage এবং BV/trichomonas coverage; CDC PID regimen-এ metronidazole add করা হয় anaerobe coverage-এর জন্য।
PID guideline dose: 500 mg PO twice daily for 14 days with ceftriaxone + doxycycline.
Local practical note: Bangladesh-এ common tablet 400 mg; dose adjustment prescriber করবেন.
Side effects: Metallic taste, nausea, abdominal discomfort, dark urine, headache, peripheral neuropathy with prolonged use.
Interactions: Alcohol disulfiram-like reaction—treatment চলাকালীন ও শেষের 48–72 h alcohol avoid; warfarin effect increase; lithium toxicity risk.
Bangladesh available brand examples: Flagyl 400 mg, Amodis 400 mg, G-Metronidazole 400 mg, Jetrazole 400 mg, Kemet 400 mg.
10) Generic name: Nitrofurantoin
Therapeutic category: Urinary antibiotic
Pharmacological class: Nitrofurans
কেন used হয়: Uncomplicated lower UTI/cystitis with suprapubic pelvic pain, dysuria, frequency.
Dose: Nitrofurantoin monohydrate/macrocrystals 100 mg PO twice daily for 5 days is IDSA-recommended for uncomplicated cystitis.
Bangladesh SR product note: Some local SR formulations list 100 mg twice daily for 7 days; culture/eGFR/pregnancy status অনুযায়ী prescriber adjust করবেন।
Side effects: Nausea, headache, brown urine, rare pulmonary/hepatic toxicity, neuropathy.
Interactions/caution: Avoid significant renal impairment; antacids with magnesium reduce absorption; caution G6PD deficiency and near-term pregnancy.
Bangladesh available brand examples: Nintoin SR 100 mg, Nintoin 50 mg, Nitrofur SR 100 mg.
11) Generic name: Fosfomycin trometamol
Therapeutic category: Urinary antibiotic
Pharmacological class: Phosphonic acid derivative antibiotic
কেন used হয়: Acute uncomplicated cystitis; single-dose option.
Dose: 3 g sachet PO single dose. IDSA lists fosfomycin trometamol 3 g single dose as an option where available.
Side effects: Diarrhea, nausea, headache, vaginitis.
Interactions: Metoclopramide may reduce urinary concentration; avoid using for pyelonephritis/systemic infection.
Bangladesh available brand examples: Fosfomax 3 g sachet, Fosfocin 3 g sachet, Fosamin 3 g sachet, Monuril 3 g sachet, Utifos 3 g sachet.
12) Generic name: Tranexamic acid
Therapeutic category: Antifibrinolytic
Pharmacological class: Lysine analogue; plasminogen activation inhibitor
কেন used হয়: Heavy menstrual bleeding associated pelvic cramp/AUB; painkiller নয়, bleeding কমাতে used হয়।
Dose: 1 g PO three times daily during heavy bleeding days, usually up to 4–5 days per cycle; local 500 mg capsule/tablet হলে 2 tab/cap per dose.
Side effects: Nausea, vomiting, diarrhea, headache; rare thrombosis.
Interactions/avoid: Combined oral contraceptive-এর সাথে thrombosis risk বাড়তে পারে; history of DVT/PE/stroke/active clotting disorder হলে avoid.
Bangladesh available brand examples: Tracid 500 mg, Tranexil 500 mg, Frabex 500 mg, Hemostat 500 mg, Xamic 500 mg/650 mg CR.
13) Generic name: Ethinyl estradiol + Levonorgestrel
Therapeutic category: Hormonal therapy/contraceptive
Pharmacological class: Combined oral contraceptive pill — estrogen + progestin
কেন used হয়: Primary dysmenorrhea, endometriosis-related cyclic pain, cycle regulation, contraception—contraindication না থাকলে। NICE endometriosis guidance hormonal treatment such as combined oral contraceptive or progestogen offer করতে বলে।
Dose: 1 tablet daily as 21/7 or 28-day pack; continuous regimen endometriosis painে specialist adviceে দেওয়া যায়।
Duration: 3–6 months trial, then review.
Side effects: Nausea, breast tenderness, breakthrough bleeding, headache, mood change; rare VTE/stroke.
Interactions: Rifampicin/rifabutin, phenytoin, carbamazepine, phenobarbital, topiramate high dose, St John’s wort reduce efficacy.
Avoid: Migraine with aura, VTE history, uncontrolled HTN, smoker >35 years, breast cancer, severe liver disease, pregnancy.
Bangladesh available brand examples: Femipil 0.03 mg + 0.15 mg + ferrous fumarate 75 mg, Nordette 28 same strength, Lyta 28, Mayapill, Mini 28.
14) Generic name: Dienogest
Therapeutic category: Hormonal therapy for endometriosis
Pharmacological class: Progestin
কেন used হয়: Confirmed/suspected endometriosis pain; estrogen effect reduce করে endometriotic lesion activity কমায়। MedEx lists dienogest as indicated for endometriosis and pelvic pain reduction.
Dose: 2 mg PO once daily continuously, same time daily.
Duration: Usually ≥3–6 months; longer use specialist follow-up.
Side effects: Irregular bleeding, amenorrhea, headache, breast discomfort, acne, mood change, reduced libido.
Interactions: CYP3A4 inducer—rifampicin, carbamazepine, phenytoin, St John’s wort reduce effect; CYP3A4 inhibitor may increase level.
Avoid: Pregnancy, active VTE, severe liver disease, hormone-dependent malignancy.
Bangladesh available brand examples: Dinosen 2 mg, Dinogest 2 mg, Daizy 2 mg, Endosis 2 mg, Metrinor 2 mg, Neogest 2 mg.
15) Generic name: Norethisterone acetate
Therapeutic category: Progestin hormonal therapy
Pharmacological class: Synthetic progestogen
কেন used হয়: AUB/menstrual disorder-associated pelvic pain, endometriosis-related symptoms selected caseে; OBGYN supervision দরকার।
Dose: Commonly 5 mg PO 2–3 times daily depending indication/cycle protocol; exact regimen diagnosis-based.
Duration: Short cyclic course or specialist-directed.
Side effects: Irregular bleeding, breast tenderness, bloating, mood change, acne, headache.
Interactions/avoid: Enzyme-inducing drugs reduce effect; caution VTE history, liver disease, hormone-sensitive cancer.
Bangladesh available brand examples: Menoral 5 mg, Norestin 5 mg, Normens 5 mg, Noteron 5 mg, Remens 5 mg.
16) Generic name: Esomeprazole
Therapeutic category: Gastroprotection/acid suppression
Pharmacological class: Proton pump inhibitor
কেন used হয়: Pelvic pain-এর direct drug নয়; NSAID ব্যবহার করলে ulcer-risk patient-এ gastric protection.
Dose: 20 mg PO once daily before breakfast while NSAID needed; high-risk হলে clinician-directed.
Side effects: Headache, diarrhea/constipation, abdominal pain; long-termে B12/Mg deficiency, fracture/C. difficile risk.
Interactions: Clopidogrel interaction concern less than omeprazole but still review; warfarin/phenytoin monitoring.
Bangladesh available brand examples: Maxpro MUPS 20 mg, EZ-20 20 mg, Exor 20/40 mg.
9. PID Standard Regimen — shortcut
Mild–moderate PID outpatient, pregnancy excluded, surgical emergency unlikely:
- Ceftriaxone 500 mg IM single dose
- Doxycycline 100 mg PO twice daily × 14 days
- Metronidazole 500 mg PO twice daily × 14 days
CDC recommends this regimen; no improvement within 72 hours হলে hospital evaluation/IV therapy/alternative diagnosis consider করতে হবে।
Hospitalize if: pregnancy, tubo-ovarian abscess, severe illness/vomiting/high fever, surgical emergency cannot be excluded, oral regimen intolerance, or no response to oral therapy.
10. Prevention — কীভাবে prevent করবেন
- Safe sex: condom, mutual monogamy, STI screening
- Chlamydia/gonorrhea suspected/confirmed হলে partner treatment
- PID treatment complete না হওয়া পর্যন্ত sexual intercourse avoid
- Recurrent UTI হলে hydration, post-coital voiding, unnecessary antibiotic avoid, culture-based treatment
- Menstrual hygiene maintain
- Unnecessary vaginal douching avoid
- Chronic dysmenorrhea/endometriosis symptoms ignore না করে early OBGYN evaluation
- IUD insertion aseptic technique; STI risk screening
- Pregnancy suspected হলে early test + pain/bleeding থাকলে urgent scan
- NSAID overuse avoid; CKD/PUD/anticoagulant/pregnancy থাকলে doctor advice ছাড়া নয়
- Vaccination: HPV vaccine cervical disease preventionে important, though pelvic pain-এর direct prevention নয়
11. Real clinical examples
Example 1 — PID likely
24-year female, lower abdominal pain + foul discharge + fever + cervical motion tenderness।
Immediate: Urine β-hCG, CBC/CRP, urine R/M/E, NAAT for GC/CT, TVS if mass/severe pain।
Treatment if ectopic/surgical cause excluded: Ceftriaxone + doxycycline + metronidazole, partner treatment, follow-up within 72 h.
Example 2 — Ectopic pregnancy until proven otherwise
28-year female, missed period 6 weeks + one-sided pelvic pain + spotting + dizziness।
Immediate: ER, vitals, β-hCG, TVS, blood group/crossmatch, OBGYN consult. Painkiller-only treatment unsafe.
Example 3 — Endometriosis pattern
30-year female, severe dysmenorrhea, deep dyspareunia, pain with defecation during period, infertility concern।
Investigations: Pelvic exam, TVS ± MRI.
Management: NSAID short course + hormonal therapy such as COC/progestin/dienogest if no contraindication; infertility/severe symptoms হলে specialist referral.
Overview / Summary
Pelvic pain একটি symptom, একক disease নয়। সবচেয়ে জরুরি হলো pregnancy/ectopic, ovarian torsion, appendicitis, severe PID, ruptured cyst, UTI/stone complications exclude করা। Reproductive-age female-এ pregnancy test mandatory। PID suspected হলে treatment delay করলে infertility, ectopic pregnancy, chronic pelvic pain হতে পারে, তাই CDC guideline অনুযায়ী low threshold এবং early broad-spectrum therapy দরকার। Chronic pelvic pain হলে endometriosis, pelvic floor dysfunction, bladder pain syndrome, IBS, neuropathic pain—সব বিবেচনা করে multidisciplinary care প্রয়োজন।
Actionable Plan / Steps
- Vitals + red flags check করুন। Shock, fever, peritonitis, pregnancy pain/bleeding → emergency referral.
- Urine β-hCG করুন — reproductive-age female হলে always.
- Urine R/M/E + culture, CBC, CRP, STI NAAT, pelvic exam করুন based on presentation.
- TVS/USG pelvis first-line imaging; appendicitis/stone/unclear acute abdomenে CT consider.
- Pain control: Paracetamol ± NSAID if no contraindication and pregnancy status clear.
- PID suspected: Ceftriaxone + doxycycline + metronidazole regimen; partner treatment and 72-hour review.
- Chronic/cyclic pain: Endometriosis/adenomyosis/fibroid evaluate; hormonal therapy or referral.
- Persistent, recurrent, severe, or unexplained pain: OBGYN/urology/GI/pain specialist referral.
Reference List
Textbooks
- Berek JS. Berek & Novak’s Gynecology. 16th/17th ed. Chapters: pelvic pain, endometriosis, PID, adnexal masses.
- Hoffman BL, Schorge JO, et al. Williams Gynecology. 4th ed. Chapters: pelvic pain, endometriosis, benign gynecologic disorders.
- Jameson JL, Fauci AS, et al. Harrison’s Principles of Internal Medicine. 21st ed. Sections: abdominal pain, UTI, sexually transmitted infections.
- Ralston SH, Penman ID, et al. Davidson’s Principles and Practice of Medicine. 24th ed. Sections: abdominal pain, urinary tract infection, reproductive medicine overview.
Guidelines
- CDC. Sexually Transmitted Infections Treatment Guidelines, 2021 — Pelvic Inflammatory Disease regimen and partner management.
- NICE NG126. Ectopic pregnancy and miscarriage: diagnosis and initial management; updated recommendations.
- NICE NG73. Endometriosis: diagnosis and management; last reviewed 2025.
- EAU. Guidelines on Chronic Pelvic Pain — multidisciplinary/biopsychosocial approach.
- IDSA/ESCMID. Acute uncomplicated cystitis and pyelonephritis guideline.
Peer-reviewed journals with DOI
- Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1–187. DOI: 10.15585/mmwr.rr7004a1.
- Wiesenfeld HC, Meyn LA, Darville T, Macio IS, Hillier SL. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for acute PID. Clinical Infectious Diseases. 2021;72(7):1181–1189. DOI: 10.1093/cid/ciaa101.
- Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for acute uncomplicated cystitis and pyelonephritis. Clinical Infectious Diseases. 2011;52(5):e103–e120. DOI: 10.1093/cid/ciq257.
- Allaire C, Bedaiwy MA, Yong PJ. Diagnosis and management of endometriosis. CMAJ. 2023;195(10):E363–E371. DOI: 10.1503/cmaj.220637
Md.Rafiqul Islam Lipu.Date:-25-05-2026 Monday Time:-11-47-55 Am