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Abdominal and Pelvic Pain in the Nonpregnant Female - Coggle Diagram
Abdominal and Pelvic Pain in the Nonpregnant Female
General Approach
History
Pain characteristics
Onset
Duration
Location
Quality
Radiation
Exacerbating factors
Alleviating factors
Review of systems
GI symptoms
Nausea
Vomiting
Diarrhea
Constipation
Urologic symptoms
Dysuria
Anuria
Hematuria
Frequency
Urgency
Gynecologic symptoms
Vaginal bleeding
Discharge
Dyspareunia
Menstrual history
Past medical and social history
Prior pregnancies and outcomes
Active lactation
Medication use
Birth control methods
Infertility treatments
Increases risk of ovarian torsion
Increases risk of cysts
Increases risk of ovarian hyperstimulation syndrome
Sexual history
Interview patient alone
Unprotected intercourse
Prior sexually transmitted infections
Multiple sexual partners
Safety at home
Assess for potential abusive situations
Physical and sexual abuse associated with chronic somatic pain
Personal habits
Tobacco use
Alcohol use
Drug use
Living situation
Occupation
Physical Examination
Vital signs
Abdominal exam
Determine quadrant location of pain
Palpate for tenderness
Palpate for masses
Evaluate for surgical scars
Evaluate for rashes
Evaluate for bruising
Evaluate for ascites
Peritoneal signs may be less obvious in elderly patients
Peritoneal signs may be less obvious in obese patients
Peritoneal signs may be less obvious in altered neurologic status
Digital rectal exam
Evaluate complaints of rectal pain
Evaluate complaints of rectal bleeding
Pelvic examination
Obtain lab specimens for sexually transmitted infections
Palpation for tenderness
Palpation for mass
Check for vaginal bleeding
Check for discharge
Check for foreign body
Laboratory Evaluation
Pregnancy test
Obtain in all women of childbearing age who still have uterus and ovaries
CBC
WBC count is not reliable to rule in or exclude serious disease
Urinalysis and urine culture
Obtain in pediatric patients
Obtain in pregnant women
Obtain in patients at risk for complicated urinary tract infections
Be cautious in making UTI sole cause of symptoms
Imaging
Ultrasound
Imaging modality of choice for genital tract pathology
Ovarian cyst
Ectopic pregnancy
Uterine or ovarian mass
Tubo-ovarian abscess
Ovarian torsion
Leiomyoma
Advantages
Ready availability
Relatively low cost
Lack of ionizing radiation
Drawbacks
Operator dependence
Technical limitations from body habitus
Technical limitations from bowel gas
Bedside ultrasound
Positive FAST exam identifies bleeding from ruptured ectopic pregnancy
Positive FAST exam identifies hemorrhage from ovarian cyst
Identifies normal intrauterine pregnancy
Technique
Pelvic US for suspected ovarian torsion must include Doppler flow
Transabdominal probe requires full bladder to aid visualization
Intravaginal probe requires empty bladder to aid visualization
Never delay US waiting for full bladder if torsion suspected
CT of abdomen and pelvis
Preferred when GI or GU pathology is highest in differential
Appendicitis
Diverticulitis
Bowel obstruction
Renal stones
Contrast usage
IV contrast alone is sufficiently sensitive for appendicitis
Oral contrast enhances accuracy if pelvic abscess suspected
Oral contrast enhances accuracy if patient weighs less than 70 kg
MRI
Accurate for many conditions
Use limited by cost and limited availability
Treatment Prioritization
Pain control
Nausea control
Fluid resuscitation
Opiate use
Titrate to control pain
Does not obscure abdominal exam findings
Does not negatively impact outcomes
Avoid excessive somnolence or respiratory depression
Antiemetics
Ondansetron
Metoclopramide
Promethazine
Prochlorperazine
Antibiotics
Give in ED for suspected severe intra-abdominal infection
Give in ED for suspected sepsis
Disposition and Follow-up
Early specialist consultation
Indicated when serious or surgical diagnosis is likely
General surgery
Urology
Obstetrics and gynecology
Admission or observation criteria
Persistent concern for serious pathology even if diagnosis unclear
Abnormal vitals
Poorly controlled pain
Vomiting
Significant comorbid conditions
Immunocompromised
Unstable medical problems
Inability to care for oneself at home
Discharge instructions
Appropriate to discharge as undifferentiated abdominal pain
Must include specific instructions for follow-up
Must include specific indications for return to ED
Acute pain with diagnostic uncertainty requires repeat exam in 12 to 24 hours
Chronic pain follow-up timed according to individual needs
Specific Gynecologic Conditions
Ovarian Cysts
Clinical features
Sudden-onset unilateral pain
More common on right side than left
Pain often starts during physical activity
Exercise
Sexual intercourse
Cervical motion tenderness sometimes present
Mild vaginal bleeding sometimes present
Types of cysts
Functional cysts
Fluid-filled sacs developing during normal menstrual cycle
Follicular cysts
Contain maturing ovum
Rupture at ovulation
Corpus luteum cysts
Present after ovum is released
Involutes if no conception occurs
Enlarges and secretes estrogen and progesterone if fertilization occurs
Dermoid cyst
Ovarian germ cell neoplasm
Multicystic mass containing fat, skin, hair, and teeth
Usually occurs between age 10 and 30 years
Benign in most cases
Malignancy risk factors include age over 45
Malignancy risk factors include diameter greater than 8 cm
Malignancy risk factors include rapid growth
Complications
Hemorrhage within cyst or rupture causes pelvic pain
Ruptured hemorrhagic cysts can cause significant hemoperitoneum
Complicated cyst rupture features abnormal vital signs and acute abdomen
Requires hospitalization or observation for serial exams and hematocrits
Surgery may be necessary to control hemorrhage
Mittelschmerz
Midcycle pain at time of ovulation
Caused by normal follicular enlargement prior to ovulation
Caused by follicular bleeding at ovulation
Mild pain lasting a few hours up to a few days
Management by size
Cysts less than 8 cm, unilocular, and unilateral
Generally observed
Typically resolve within two menstrual cycles
Cysts greater than 8 cm, solid, and multiloculated
Worrisome for neoplasm, dermoid cysts, or endometriomas
All patients require referral to gynecologist or primary care physician
Endometriomas
Chocolate cysts containing thick brown fluid
Pelvic mass caused by growth of ectopic endometrial tissue within ovary
Can rupture and present with peritoneal signs
Can present with pelvic pain, dysmenorrhea, and dyspareunia
Ovarian Neoplasm
Ovarian mass in postmenopausal woman is malignant until proven otherwise
Mean age at diagnosis is 50 to 60 years
Nonspecific and persistent symptoms
Anorexia
Dyspepsia
Early satiety
Constipation
Bloating
Abdominal discomfort
Ascites
Nearly half of women diagnosed at stage III or IV disease
Metastasis to ovaries and fallopian tubes can come from endometrium, breast, and GI tract
Ovarian Hyperstimulation Syndrome
Complication of ovulation induction treatments
Can occur 5 to 7 days after ovulation or later due to rising hCG levels
Initial symptom is abdominal bloating
Severe syndrome features
Massive transudation of albumin and fluid from vascular compartment
Fluid shifts into peritoneal cavity
Fluid shifts into pleural cavity
Fluid shifts into pericardial cavity
Complications
Venous and arterial thrombosis
Jugular vein thrombosis
Subclavian vein thrombosis
Retinal vein thrombosis
Extremity vein thrombosis
Cerebral venous thrombosis
Stroke
ST-segment elevation myocardial infarction
Sepsis
Adult respiratory distress syndrome
Pulmonary embolism
Endometriosis and Adenomyosis
Endometriosis
Endometrium-like tissue outside uterus inducing chronic inflammatory reaction
Adenomyosis
Endometrial tissue within the uterine wall
Clinical features
Chronic, recurrent, and cyclic pain
Dysmenorrhea
Dyspareunia
Ultrasound may show cystic or solid masses
Diagnosis and management
Laparoscopy is definitive method of diagnosis
Primary diagnosis usually not made in ED
ED management consists of pain control and outpatient referral
Foreign Body and Trauma
Vaginal foreign bodies like retained tampons cause pelvic pain
Can cause vaginal discharge or bleeding
Complications like abscess or perforation are rare
Ovarian Torsion
Surgical emergency to preserve ovarian function
Pathophysiology
Ischemic condition almost always associated with ovarian enlargement
Enlargetment usually due to ovarian cysts or masses
Ovary twists and creates fulcrum around which oviduct revolves
Venous return blockage causes congestion
Decreased distal arterial blood flow produces ischemia and necrosis
Adnexal torsion involving both ovary and oviduct is most common
Anatomic features
Nearly 70% of torsions occur on the right side
Right utero-ovarian ligament is longer than the left
Sigmoid colon on left limits space for movement
Risk factors
Pregnancy due to enlarged corpus luteum
Presence of large ovarian cysts or tumors
Polycystic ovaries
Chemical induction of ovulation
Tubal ligation
Clinical features
Classically sudden-onset, severe, unilateral, lower abdominal pain
Pain can develop after episodes of exertion
Atypical presentation in half of patients featuring gradual or intermittent pain
Nausea and vomiting present in 70% of cases
Tenderness and masses
Unilateral lower abdominal tenderness with guarding
Unilateral adnexal tenderness on bimanual exam
Presence of latero-uterine mass
Nearly 30% haveč¯ bilateral adnexal tenderness
Minority of patients have no tenderness at all
Fifty percent of patients are initially misdiagnosed
Diagnostic imaging
Transvaginal US with Doppler is primary modality
Ovary greater than 4 cm due to cyst, tumor, or edema is most common finding
Up to 26% of US studies reveal normal adnexa due to dynamic nature
Up to 60% missed on arterial Doppler alone as arterial flow disruption is late
Positive Doppler study has 100% positive predictive value
Venous Doppler flow may be only abnormality identified in early torsion
CT scan findings
Enlarged ovary greater than 4.0 cm
Abnormal ovarian enhancement with contrast
Adnexal mass
Thickening of fallopian tube
Displacement of ovary
Deviation of uterus to affected side
Clinical decision making
No radiologic or clinical finding rules out torsion with certainty
Involve gynecologic consultation if US is negative but clinical suspicion remains high
Special populations
Adolescents and premenarchal girls
Increased risk in first year of life, at menarche, and during pregnancy
Pediatric torsion is rare and difficult to diagnose
Torsion is more likely to occur in an otherwise normal ovary
Premenarchal girls have higher rates of fever compared to postmenarchal
Premenarchal girls have higher rates of restlessness compared to postmenarchal
Premenarchal girls have higher rates of palpable pelvic mass compared to postmenarchal
Associated with longer interval between symptom onset and presentation