Background: Acute Abdominal Pain (AAP) is a common reason for calling the Emergency Medical Services (EMS). Despite the importance of prehospital pain management being widely acknowledged, existing studies on AAP patients indicate room for improvement in pain assessment and treatment. However, studies on the subject are sparse, especially in rural conditions, despite indications that the duration of prehospital care may be a factor in prehospital pain management. Methods: The aim was to illuminate 1) room for improvement of prehospital pain management in AAP patients who call for EMS in a rural area and 2) if and how sex, age, ambulance clinician competence and duration of prehospital care affect the prehospital pain management of those patients. A single-center, retrospective observational study was performed, where 816 patient records were manually reviewed. Results: Pain was assessed in 55% of all cases. Median initial pain intensity was eight units on the Numerical Rating Scale (NRS), with 70% of the patients experiencing severe pain. Pharmacological treatment was given in 39% of all cases, and in 62% of the cases with moderate or severe pain. Pain was re-assessed in 50% of the cases receiving treatment, with a median pain reduction of four NRS units. Lower age, prehospital emergency nurse (PEN) competence and longer duration of prehospital care were associated with more assessment and treatment. Conclusions: The study found significant room for improvement in the prehospital management of patients with acute abdominal pain. Lower age, PEN competence and longer duration of prehospital care were all associated with more assessment and treatment of pain. Competence stood out as the only clearly affectable factor, suggesting that PEN competence could be considered as a way for EMS organizations of improving the prehospital pain management.