Acute pelvic pain (APP), defined as lower abdominal or pelvic discomfort lasting less than three months, is a common and diagnostically complex gynecological issue [1]. It affects 15-30% of women of reproductive age, accounting for a significant proportion of gynecological consultations globally [2, 3]. The etiological spectrum includes gynecological conditions like pelvic inflammatory disease (PID), ovarian cysts, endometriosis, and non-gynecological mimics such as appendicitis or urinary tract infections [4]. Overlapping symptoms complicate diagnosis, and untreated severe conditions like ectopic pregnancy or ovarian torsion can lead to infertility, sepsis, or death [5]. Risk factors include young age, early menarche, multiple sexual partners, history of STIs, and psychosocial factors like stress or low socioeconomic status [6, 7]. Transvaginal ultrasonography (TVS) is the cornerstone of diagnosis due to its accuracy and accessibility [8]. Despite guidelines from ACOG and RCOG [1, 9], region-specific data on APP prevalence and etiology are limited, particularly in low- and middle-income countries. This study aims to determine the hospital-based prevalence, etiological distribution, and risk factors of APP in women of reproductive age in India to guide clinical practice and public health strategies.

Study Design and Setting: A prospective, cross-sectional study was conducted from February to July 2025 in the Gynecology Department of Government General Hospital, Kurnool, a tertiary care centre in India. Participants: We enrolled 200 consecutive women aged 15-45 years with APP of less than three months, excluding pregnant women, those with chronic pelvic pain, or non-gynecological causes (e.g., appendicitis). Sample size was calculated assuming a 15% prevalence, 95% confidence level, and 5% margin of error [2]. Data Collection: A pre-validated questionnaire collected socio-demographic data (age, marital status, education, socioeconomic status via modified Kuppuswamy scale [10]), reproductive history (menarche, parity, contraception), sexual history, and pain characteristics (onset, duration, severity via Visual Analog Scale). All participants underwent urine pregnancy tests, pelvic ultrasonography (transvaginal/transabdominal), and selective tests (complete blood count, C-reactive protein, endocervical swabs). Diagnoses followed ACOG/RCOG criteria [1, 9]. Statistical Analysis: Data were analyzed using SPSS. Prevalence was reported with 95% CI. Univariate (Chi-square/Fisher’s exact tests) and multivariate logistic regression identified risk factors (p<0.05 significant). Ethical consideration: The Institutional Ethics Committee of Kurnool Medical College approved the study. Informed consent was obtained, with assent for minors (<18 years).

Socio-demographic Characteristics: Mean age was 30.4 ± 6.8 years; 51.5% (n=103) were 25-34 years, 72% (n=144) were married, 40% (n=80) were illiterate, and 55% (n=110) were from lower socioeconomic strata (Table 1). Table 1: Socio-demographic Characteristics (N=200) Variable Category Frequency (n) Percentage (%) Age Group (years) 15-24 34 17.0 25-34 103 51.5 35-45 63 31.5 Marital Status Married 144 72.0 Unmarried 56 28.0 Education Level Illiterate 80 40.0 Primary/Secondary 90 45.0 Graduate & Above 30 15.0 Socioeconomic Status Lower 110 55.0 Middle 75 37.5 Upper 15 7.5 Prevalence and Clinical Features: Among 965 gynecology visits, APP prevalence was 20.71% (95% CI: 18.2-23.5%). Sudden onset occurred in 62% (n=124), with 56% (n=112) reporting pain for 1-3 days. Lower abdominal pain was predominant (81%, n=162). Common associated symptoms were vaginal discharge (56%, n=112), fever (30%, n=60), and nausea/vomiting (24%, n=48) (Table 2). Table 2: Clinical Characteristics of Pain (N=200) Characteristic Category Frequency (n) Percentage (%) Onset of Pain Sudden 124 62.0 Gradual 76 38.0 Duration of Pain <24 hours 88 44.0 1-3 days 112 56.0 Site of Pain Lower Abdomen 162 81.0 Generalized Pelvic 26 13.0 Unilateral 12 6.0 Associated Symptoms Vaginal Discharge 112 56.0 Fever 60 30.0 Nausea/Vomiting 48 24.0 Etiology: PID accounted for 51% (n=102) of cases, followed by dysmenorrhea (17.5%, n=35), ovarian cysts (14%, n=28), ruptured cysts (6%, n=12), and endometriosis (5%, n=10)(Table 3). Table 3: Etiological Diagnosis (N=200) Etiological Diagnosis Frequency (n) Percentage (%) Pelvic Inflammatory Disease (PID) 102 51.0 Dysmenorrhea 35 17.5 Ovarian Cyst (unruptured) 28 14.0 Ruptured Ovarian Cyst 12 6.0 Endometriosis 10 5.0 Others (e.g., fibroids, abscess) 13 6.5 Risk Factors: Significant associations were found with early menarche (p=0.02), multiple sexual partners (p=0.001), and history of PID/STIs (p<0.01). Low BMI and smoking were not significant (Table 4). Table 4: Risk Factor Analysis Risk Factor Present (n) APP Cases (n) p-value Significance Early Menarche (<12 yrs) 58 42 0.02 Significant Multiple Sexual Partners (≥2) 44 38 0.001 Significant History of PID/STIs 68 58 <0.01 Significant Low BMI (<18.5 kg/m²) 32 20 0.09 Not Significant History of Smoking 18 10 0.25 Not Significant Diagnosis and Management: Ultrasonography confirmed diagnoses in 100% of cases, identifying ovarian cysts, torsion, and abscesses. Conservative management (antibiotics, analgesics, NSAIDs) succeeded in 80.5% (n=161), with 13% (n=26) requiring laparoscopy for ruptured cysts or complicated PID. Hospitalization was needed for 25% (n=50).

This prospective cross-sectional study provides critical insights into the epidemiology, etiology, and risk factors of acute pelvic pain (APP) among women of reproductive age in a tertiary care hospital in India. The observed prevalence of 20.71% (95% CI: 18.2-23.5%) aligns closely with prior hospital-based studies, such as Sharma R, Kapoor R, Vaidya S (18.5% in North India) and Iwuoha CG, Uche-Nwachi EO, Nwankwo TO (22% in Nigeria) [8, 11]. This consistency underscores APP as a significant global gynecological challenge, consuming substantial healthcare resources in both outpatient and emergency settings. The high prevalence highlights the need for standardized diagnostic protocols to streamline evaluation and management, reducing the burden on healthcare systems [1].The predominance of pelvic inflammatory disease (PID) as the leading etiology (51%, n=102) is a key finding. This proportion exceeds rates typically reported in high-income countries (20-35%) [12] but is consistent with studies from other low- and middle-income countries (LMICs) [11, 13]. The elevated PID prevalence likely reflects regional challenges, including limited access to sexual health education, inadequate STI screening, and delayed healthcare-seeking due to socioeconomic barriers or stigma. The high frequency of associated symptoms, such as vaginal discharge (56%) and fever (30%), further supports the infectious nature of APP in this cohort. PID’s dominance has significant implications for long-term reproductive health, as untreated or recurrent PID is a major risk factor for tubal factor infertility, ectopic pregnancy, and chronic pelvic pain [4, 14]. These findings emphasize the urgent need for public health interventions focused on STI prevention, barrier contraception promotion, and early symptom recognition in resource-constrained settings.Significant risk factors identified—history of PID/STIs (OR: 4.12, p<0.01), multiple sexual partners (OR: 3.58, p=0.001), and early menarche (OR: 2.21, p=0.02)—are consistent with existing literature [6, 15]. A history of PID/STIs and multiple sexual partners strongly correlate with ascending genital tract infections, reflecting high-risk sexual behaviors [6]. Early menarche extends the duration of exposure to ovulatory cycles and sexual activity, potentially increasing the risk of gynecological conditions like endometriosis or functional ovarian cysts [16]. Notably, low BMI and smoking were not significant in this cohort, unlike some Western studies [17]. This may reflect the lower prevalence of these factors in our population or the overwhelming influence of infectious etiologies, particularly PID, which may overshadow other risk factors.Pelvic ultrasonography’s role as a diagnostic cornerstone was unequivocally demonstrated, confirming diagnoses in 100% of cases. Its ability to visualize uterine and adnexal structures makes it indispensable for differentiating medical from surgical emergencies, such as ovarian torsion or ruptured cysts [1, 8]. This finding supports ACOG and RCOG guidelines advocating ultrasonography as the first-line imaging modality for APP due to its non-invasiveness, accessibility, and lack of ionizing radiation [1, 9]. The high diagnostic yield underscores the importance of ensuring ultrasonography availability in tertiary and primary care settings to facilitate timely and accurate diagnoses.The success of conservative management in 80.5% of cases is encouraging, indicating that most APP cases can be effectively treated with antibiotics, analgesics, and NSAIDs, minimizing healthcare costs and surgical risks. However, the need for surgical intervention in 13% (e.g., laparoscopy for ruptured cysts or complicated PID) and hospitalization in 25% highlights a significant subset of patients with severe or complicated disease. This subgroup requires prompt access to specialized gynecological care and advanced facilities, emphasizing the importance of well-equipped tertiary centres in managing complex cases. Limitations: The single-center design may limit generalizability to primary care or other regional settings. The cross-sectional nature precludes establishing causality between risk factors and APP. Self-reported data on sensitive topics like sexual history may introduce recall or social desirability bias. Conditions like endometriosis, which often require laparoscopy for definitive diagnosis, may be underdiagnosed. Strengths: The prospective design, standardized diagnostic approach, and robust sample size enhance the study’s reliability. The comprehensive use of ultrasonography and adherence to international diagnostic criteria ensure diagnostic accuracy.

Our study highlights PID as the predominant cause of APP in this population, driven by modifiable risk factors related to sexual and reproductive health. Public health strategies should prioritize sexual health education, accessible STI screening, and early intervention to mitigate APP’s burden. Ultrasonography’s critical role and the high success of conservative management provide actionable insights for optimizing clinical pathways in resource-limited settings.

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