Abdominal and Pelvic Pain

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Abdominal and Pelvic Pain
CAPT Mike Hughey, MC, USNR
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Uncertainty of Diagnosis
When I see a woman with abdominal or pelvic
pain, I often haven't a clue as to what the
problem is, even using ultrasound, a full lab,
and countless consultants. All I know is that
the patient is sick with something.
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The Point is
In gynecology, the diagnosis is often obscure.
You must frequently treat the patient before
you know the correct diagnosis.
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The Other Point is
More important than knowing the correct
diagnosis is doing the right thing for the
patient.
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Pain of Unknown Cause
Bedrest for a few days is never the wrong thing
to do.
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Pain and Fever

• Give antibiotics to cover PID
• Mild symptoms respond to PO drugs.
• Severe symptoms respond to IVs.

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Chronic Pelvic Pain

• Doxycycline
• OCPs
• Refer to GYN if pain persists

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Pregnancy Test
Every patient complaining of lower abdominal pain
should have a pregnancy test.
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BCPs and Pain

• Most with chronic pain benefit from BCPs
  -dysmenorrhea -ovarian cysts
  -endometriosis -adenomyosis
• Monophasic better
• Cyclic vs. Continuous

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Dysmenorrhea

• Painful Periods
• Back ache
• Pelvic cramps
• NSAIDs
• BCPs
• If persistent and severe, laparoscopy to rule out
  endometriosis

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Mittelschmerz

• Mid-cycle pain
• Unilateral
• NSAIDs
• BCPs

P
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IUDs and Pain
ALWAYS, remove the IUD
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IUDs and Pain
5 become infectedPain, tenderness,
feverRemove IUD and begin ABxOral or IV,
depending on high fever or severe symptoms.
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IUDs and Pain

• Never push an IUD back in place if it is partway
  expelled.
• Always remove an IUD if the patient complains
  of -pelvic pain -tenderness
  -abnormal bleeding

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Ovarian Cysts

• May be normal (lt4 cm)
• 95 disappear within 1-2 months
• May cause problems -delay menstruation
  -Rupture -Torsion -Pain

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Ovarian Cyst Ruptured

• May go unnoticed
• May cause abdominal or shoulder pain
• Usually resolves with rest alone
• Sometimes requires surgery (bleeding)

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Ovarian Cyst Unruptured

• May go unnoticed
• May cause pain
• Usually resolve spontaneously
• Sometimes requires surgery (pain)
• Ultrasound scan of persistent cysts

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Ovarian Cyst Torsioned

• Severe unilateral pain
• Marked rebound and rigidity
• Surgery indicated within 24 hours
• If surgery unavailable -IVs, NPO, bedrest
  -Metabolic acidosis -20-50 Mortality

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Pelvic Inflammatory Disease (PID)

• Bacterial inflammation of cervix, uterus, tubes
  and ovaries
• Bilateral disease
• 1st infection single agent
• Repeatmultiple agents
• Two categories
• Mild
• Moderate to Severe

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PID Mild

• No fever
• Bilateral pelvic pain
• Cervical motion tenderness
• WBC near normal
• Doxy 100 BID 28, plus
• Cefoxitin/Probenecid
• Ceftriaxone
• Ceftizoxime
• Cefotaxime

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PID Moderate to Severe

• Fever gt 100.4
• Bilateral pelvic pain
• Cervical motion tenderness
• WBC elevated
• IV antibiotics

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PID Treatment Moderate to Severe

• Clinda/Gent
• Ofloxacin/Flagyl
• Amp/Sulbactam/Doxy
• Cipro/Doxy/Flagyl
• Doxy/Cefoxitin/Cefotetan

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Endometriosis

• Progressive pelvic pain
• Deep Dysparunia
• Dysmenorrhea
• Tender nodules in cul-du-sac

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Endometriosis Treatment

• Conservative Surgery
• Radical Surgery
• Danazol, Lupron
• Continuous BCPs

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Degenerating Fibroid

• Bulky, irregular, tender uterus
• 40 of women gt40 have them
• Supportive treatment
• Symptoms gradually resolve over 3 weeks
• Surgery for anemia, chronic pain, size gt12 weeks

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Cystitis

• Urgency, frequency, dysuria
• Always treat
• Push fluids (citric acid)
• Any broad-spectrum ABx -Ampicillin (Amox)
  -Keflex -Bactrim DS -Doxycycline
• Pyridium helps symptoms

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Pyelonephritis

• Urgency, frequency, dysuria
• Fever, flank pain/tenderness, chills
• Push fluids (citric acid)
• Any broad-spectrum Abx
• Probably will need IV antibiotics

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Gastroenteritis

• Diffuse, cramping pain
• Nausea, vomiting, diarrhea
• Fever, chills, distension
• Pain moves from place to place
• Supportive therapy
• IVs
• Antibiotics
• Cultures

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Functional Bowel Syndrome

• Intermittent pain
• Diarrhea/Constipation
• Stress related
• Moves from place to place
• Supportive Rx
• Antispasmotics
• No narcotics
• No psychoactives

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Appendicitis

• Progressive RLQ pain
• Nausea/Anorexia
• Guarding/Rigidity
• Rebound
• WBC variable

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Appendicitis Treatment

• Surgery
• NPO/IVs
• Antibiotics
• Mefoxin/Gent
• Flagyl/Gent
• Amp/Sulbactam/Doxy
• Clinda/Gent
• Oflaxacin/Flagyl
• Cipro/Doxy/Flagyl
• Doxy/Cefoxitin/Cefotetan

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Bowel Obstruction

• Cramping pain and distension
• Hx abdominal surgery
• X-ray distended loop
• Most are partial obstructions
• IV fluids
• Decompression
• Surgery

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Diverticular Disease

• Variable presentation (mild to severe)
• Cramping pain and distension
• Blood streaked stool
• Fever, WBC
• IV fluids
• Antibiotics
• Sometimes Surgery

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