Abdominopelvic pain in the non-pregnant female

HISTORY

GI symptoms – Nausea, vomiting, diarrhoea, anorexia – Non-specific and may be due to pelvic pathology

Gynae symptoms – PV bleeding, discharge, dyspareunia, postcoital bleeding, breast tenderness, LNMP

PMHx

PSHx

Gynae – PID, STI, procedures, IUD, PCOS, dysmenorrhoea

ObsHx – GxPxTxMx

Sexual Hx

Always interview adolescents without family present

Onset

• Sudden onset – Vascular or obstructive
• Semiacute – Inflammatory
• >1 week – Undifferentiated

Peak time of pain

• Night, after meals – Biliary, GORD
• Before bowels move – Gastroenteritis
• Upon waking – Lower back pain

Migration

• Ill-defined to localised – Appendicitis, cholecystitis
• Radiates to lower back – Cystitis
• Radiates to labia – Nephrolithiasis
• Back – AAA

Exacerbating factors

• Menses – Endometriosis
• Food – Gastric, biliary
• Certain positions – Musculoskeletal
• Dyspareunia – PID, tubo-ovarian abscess
• Belching – Gastric
• Jumping – Peritonitis

Relieving factors

• Antacids – Gastric
• Urination – Bladder spasm
• Laying still – Peritonitis

Similar previous episodes – Ulcer, biliary colic, mittelschmerz, endometriosis

EXAMINATION

There is a paucity of evidence that pelvic examination should be routinely performed for abdominal pain presentations

There is a lack of interexaminer reliability

INVESTIGATION

First step is to rule out pregnancy

Urinalysis if symptoms of UTI (careful of false positives from alternative diagnoses e.g. appendicitis)

FBC/UEC/LFT/Lipase/CRP

USS is the mainstay of investigation in the non-pregnant female with abdominal pain

CT has much higher sensitivity for appendicitis than USS

OVARIAN CYSTS

Symptoms may arise due to:

• Rupture with chemical peritonitis
• Torsion of enlarged ovary
• Mechanical pressure on adjacent structures

Sudden onset lateralising pain suggests rupture or torsion vs. gradual constant pain suggests mechanical pressure

• Right-sided pain is more common possibly owing to the rectosigmoid colon protecting the left ovary from abdominal trauma
• Often post-coital

Pelvic US is imaging modality of choice

Functional cysts

• Functional ovarian cysts (3 types)
  • Graafian follicles: May persist and grow if no ovulation. May cause Mittelschmerz pain or brief pain at ovulation/rupture
  • Corpus luteum: Graafian follicle after ovum released. Midcycle bleeding associated with ovum release. May cause pressure on adjacent structures, rupture with chemical peritonitis and predisposes to torsion if large/multiple
  • Haemorrhagic cyst: Rupture of blood vessel in cyst wall with contained bleeding and ultimately involutes. Can cause peritonism from blood and if large can cause pressure effect
• Functional cysts must be >2cm to be termed ‘cysts’ and usually involute within 2-3 months
• Those that persist may rupture or leak fluid and are treated conservatively unless severe pain or significant blood loss

Non-functional cysts

• Dermoid cysts: Contain hair, teeth, bone, cartilage. Account for 10-15% of cysts in premenopausal women. Rarely neoplastic. Adnexal torsion or cyst rupture with chemical peritonitis can occur
• Endometriomas: Filled with thick chocolate-type material. Hence ‘chocolate cysts’. Can rupture into pelvis producing peritonitis +/- adhesions
• Cystadenomas: Usually benign but can grow very large and cause pain
• Rupture at ovulation is mid-cycle vs. rupture of corpus luteum occurs between days 20-26
• Bleeding is usually minor but can be catastrophic

Complications

• Haemodynamic instability
• Ongoing or heavy blood loss
• Signs of an infective process
• Findings suggestive of malignancy (particularly post-menopausal women)

Uncomplicated cyst rupture

• Observation recommended
• Can be managed as outpatients if haemodynamically stable and no significant Hb drop
• Oral analgesia
• Will require ongoing surveillance until cyst resolves as per adnexal mass guidelines
  • Guidelines vary but usually physiological cysts resolve and undergo USS observation at 3-6 month intervals

Heavy or ongoing blood loss

• Surgery is indicated if doesn’t cease on its own while observed in hospital

ADNEXAL TORSION

Surgical emergency and prompt diagnosis is crucial to preserving ovarian function

Almost always associated with ovarian enlargement

Initial impairment of venous return leads to congestion then decreased arterial flow

Adnexal torsion (ovary + oviduct) is most common

>50% occur on right side

Classically present with sudden onset, severe, unilateral, lower abdominal pain possibly after exertion

Classically describes as ‘reverse renal colic’– radiates from groin to loin

Atypical presentations are common: Bilateral pain, mild vs. severe pain and intermittent pain

50% of patients are initially misdiagnosed

Risk factors: Pregnancy (enlarged corpus luteum), large ovarian cysts/tumors, chemical induction of ovulation ■ Doppler USS is the primary modality for diagnosis

ENDOMETRIOSIS

Pain is chronic, recurrent and cyclic

Most common symptom is dysmenorrhoea. Dyspareunia is also common

Non-specific pelvic tenderness is the most common diagnosis in ED

May palpate tender nodules in uterosacral ligaments or in posterior cul-de-sac

Adenomyosis may be indicated by enlarged or asymmetric uterine mass

USS is the primary diagnostic modality in ED with f/u for MRI +- laparoscopy

ED treatment consists of analgesia (NSAID’s) and arranging follow-up

FITZ-HUGH-CURTIS

Perihepatitis secondary to PID

1/3 have RUQ pain, 1/3 lower abdominal pain and 1/3 both

LFT normal

Chlamydia isolated from most patients

USS is only useful for ruling out cholecystitis

Abdominal CT shows perihepatic inflammation

Treat as for PID

LEIOMYOMAS

Benign, oestrogen-dependent, uterine smooth muscle tumors

Can lead to increased vaginal bleeding and pain

50% of women have them but only 50% of them are symptomatic

Can outgrow blood supply and degenerate with subsequent peritonitis

Those on pedicles can become torted

USS crucial for diagnosis

Management is pain control and referral unless SIRS due to degeneration or torsion warranting admission

CHRONIC PELVIC PAIN

Defined as that lasting >6mo, localised to the anatomic pelvis causing functional disability requiring medical or surgical treatment

Most common diagnoses are endometriosis and pelvic adhesions

60% of patients have no visible pathology on laparoscopy and 25% remain without a definitive diagnosis

Presentation to ED is usually due to acute-on-chronic exacerbation, unrelated acute cause of pelvic pain or inability to cope with their chronic condition

PELVIC ADHESIONS

Account for 33% of chronic pelvic pain

Associated with PID, endometriosis, abdominal surgery, perforated appendix and IBD

Adhesions contain their own nerve fibres and pain is thought to arise from tension through these structures

Pain often consistent in location and exacerbated by movement and intercourse

PELVIC CONGESTION SYNDROME

Dilatation, congestion and venous stasis of pelvic veins

Associated with multiparity, PCOS, tubal ligation and lower limb varicosities

Often present with chronic, lower pelvic and back pain with exacerbations of sharp stabbing pain

Dyspareunia (75%), DUB (54%) and mucoid vaginal discharge (47%)

Superficial vulval varices may be seen +- bluish tinge to engorged cervix

USS may demonstrate uterine enlargement and venous incompetence

Pelvic venography can confirm diagnosis

CYCLIC PELVIC PAIN

Mittelshmertz

Dysmenorrhoea

Endometriosis

Adenomyosis

Cervical stenosis

IUD

Leiomyoma

Pelvic congestion

ACYCLIC PELVIC PAIN

Chronic PID

Pelvic adhesions

Uterine prolapse

Chronic urethritis

Diverticulitis

IBS

Detrusor instability

Interstitial cystitis

Abdominal hernia

Depression

Last Updated on September 29, 2021 by Andrew Crofton