**4. Severe pelvic pain**

Based on the history pelvic pain could either be cyclical or non-cyclical. Cyclical pain is commonly as a result of pre-menstrual syndrome, pelvic endometriosis, primary dysmenor‐ rhoea and ovulation pain (Mittelschmerz). For non-cyclical pain the common causes include pelvic inflammatory disease (PID), severe endometriosis, pelvic tumours, pelvic congestion syndrome and surgical causes like appendicitis and diverticulitis. A good history is required to make a possible diagnosis. The nature of the pain, whether cyclical or non-cyclical, acute or chronic (if present for 6 months or more), severity and exacerbating and relieving factors should be noted. Other associations to be noted include the parity, vaginal discharge, abnormal vaginal bleeding, dyspareunia, urinary symptoms, gastrointestinal symptoms, loss of appetite, weight loss and cervical smear.

Examination of the patient would involve general and systemic examinations, most especially the abdomen, pelvis and vagina. Pallor, wasting, abdominal distension, masses in the abdomen and pelvis, and abnormal growth in the lower genital tract should be sought for.

For the investigations, ultrasonography of the abdomen and the pelvis plays a key role. A growth in the lower genital tract may require a biopsy, and tumour marker screen for cancer antigen 125 (CA-125), carcino-embryonic antigen (CEA) and alpha feto-protein (AFP) may be required for pelvic tumours. A complete blood count, C-reactive protein and urine culture are often required. Diagnostic laparoscopy, when available, is a positive addition in the manage‐ ment of chronic pelvic pain when there is diagnostic difficulty, but not forgetting idiopathic pain.
