Abdominal and Pelvic Pain
CAPT Mike Hughey, MC, USNR
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 1
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.”
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 2
The Point is:
“In gynecology, the
diagnosis is often
obscure.”
“You must frequently
treat the patient before
you know the correct
diagnosis.”
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 3
The Other Point is:
“More important than
knowing the correct
diagnosis is doing the right
thing for the patient.”
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 4
Pain of Unknown Cause
Bedrest for a few days is
never the wrong thing to
do.
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 5
Pain and Fever
•Give antibiotics to cover
PID
•Mild symptoms respond to
PO drugs.
•Severe symptoms respond
to IVs.
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 6
Chronic Pelvic Pain
• Doxycycline
• OCPs
• Refer to GYN if
pain persists
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 7
Pregnancy Test
Every patient complaining
of lower abdominal pain
should have a pregnancy
test.
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 8
BCPs and Pain
•
Most with chronic pain
benefit from BCPs
-dysmenorrhea
-ovarian cysts
-endometriosis
-adenomyosis
•
Monophasic better
•
Cyclic vs. Continuous
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 9
Dysmenorrhea
• Painful Periods
– Back ache
– Pelvic cramps
• NSAIDs
• BCPs
• If persistent and
severe, laparoscopy to
rule out endometriosis
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 10
Mittelschmerz
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SAT
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P
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Mid-cycle pain
Unilateral
NSAIDs
BCPs
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 11
IUDs and Pain
ALWAYS, remove the IUD
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 12
IUDs and Pain
•5% become infected
•Pain, tenderness, fever
•Remove IUD and begin ABx
•Oral or IV, depending on
high fever or severe symptoms.
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 13
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
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 14
Ovarian Cysts
• May be normal (<4 cm)
• 95% disappear within
1-2 months
• May cause problems:
-delay menstruation
-Rupture
-Torsion
-Pain
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 15
Ovarian Cyst: Ruptured
•
May go unnoticed
•
May cause abdominal
or shoulder pain
•
Usually resolves with
rest alone
•
Sometimes requires
surgery (bleeding)
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 16
Ovarian Cyst: Unruptured
•
May go unnoticed
•
May cause pain
•
Usually resolve spontaneously
•
Sometimes requires surgery
(pain)
•
Ultrasound scan of persistent
cysts
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 17
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
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 18
Pelvic Inflammatory Disease (PID)
• Bacterial inflammation of
cervix, uterus, tubes and ovaries
• Bilateral disease
• 1st infection single agent
• Repeat:multiple agents
• Two categories:
– Mild
– Moderate to Severe
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 19
PID: Mild
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No fever
Bilateral pelvic pain
Cervical motion tenderness
WBC near normal
Doxy 100 BID #28, plus
– Cefoxitin/Probenecid
– Ceftriaxone
– Ceftizoxime
– Cefotaxime
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 20
PID: Moderate to Severe
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Fever > 100.4
Bilateral pelvic pain
Cervical motion tenderness
WBC elevated
IV antibiotics
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 21
PID Treatment : Moderate to Severe
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Clinda/Gent
Ofloxacin/Flagyl
Amp/Sulbactam/Doxy
Cipro/Doxy/Flagyl
Doxy/Cefoxitin/Cefotetan
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 22
Endometriosis
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Progressive pelvic pain
Deep Dysparunia
Dysmenorrhea
Tender nodules in cul-dusac
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 23
Endometriosis: Treatment
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Conservative Surgery
Radical Surgery
Danazol, Lupron
Continuous BCPs
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 24
Degenerating Fibroid
• Bulky, irregular, tender
uterus
• 40% of women >40 have
them
• Supportive treatment
• Symptoms gradually
resolve over ~3 weeks
• Surgery for anemia,
chronic pain, size >12
weeks
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 25
Cystitis
•
Urgency, frequency, dysuria
•
Always treat
•
Push fluids (citric acid)
•
Any broad-spectrum ABx
-Ampicillin (Amox)
-Keflex
-Bactrim DS
-Doxycycline
•
Pyridium helps symptoms
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 26
Pyelonephritis
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Urgency, frequency, dysuria
•
Fever, flank
pain/tenderness, chills
•
Push fluids (citric acid)
•
Any broad-spectrum Abx
•
Probably will need IV
antibiotics
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 27
Gastroenteritis
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Diffuse, cramping pain
Nausea, vomiting, diarrhea
Fever, chills, distension
Pain moves from place to
place
Supportive therapy
• IV’s
• Antibiotics
• Cultures
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 28
Functional Bowel Syndrome
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Intermittent pain
Diarrhea/Constipation
Stress related
Moves from place to place
Supportive Rx:
• Antispasmotics
• No narcotics
• No psychoactives
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 29
Appendicitis
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Progressive RLQ pain
Nausea/Anorexia
Guarding/Rigidity
Rebound
WBC variable
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 30
Appendicitis: Treatment
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Surgery
NPO/IVs
Antibiotics
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Mefoxin/Gent
Flagyl/Gent
Amp/Sulbactam/Doxy
Clinda/Gent
Oflaxacin/Flagyl
Cipro/Doxy/Flagyl
Doxy/Cefoxitin/Cefotetan
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 31
Bowel Obstruction
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Cramping pain and
distension
Hx: abdominal surgery
X-ray: distended loop
Most are partial
obstructions
IV fluids
Decompression
Surgery
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 32
Diverticular Disease
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Variable presentation
(mild to severe)
Cramping pain and
distension
Blood streaked stool
Fever, WBC
IV fluids
Antibiotics
Sometimes Surgery
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 33
Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000
Slide 34