Abdominal and Pelvic Pain
The diagnosis and management of abdominal and pelvic pain in women can be challenging. While some diagnoses are obvious or nearly so, others are elusive. While the diagnosis is most often made on the basis of clinical history, the relative certainty of diagnosis is often strengthened through the use of laboratory, imaging studies, and the physical examination.
I'm going to provide you with some general guidelines and a structure for evaluating patients with abdominal or pelvic pain, but I must caution you:
A structured approach usually works best for for those learning these skills, later, with more experience, you may skip over some parts of this process. The process involves asking a series of questions (history), examining the patient with an abdominal exam and pelvic exam (exam), obtaining a set of vital signs, and some basic laboratory tests. While learning these skills, you may find the Abdominal and Pelvic Pain Patient Evaluation Form useful as a teaching aid.
"Where is the pain?"
"Did the pain start suddenly (within a few minutes) or gradually (over hours or days)?"
How long has the pain lasted?
How intense is the pain?
Is the pain constant?
Is the pain getting worse?
Pain throughout the whole abdomen favors moderate to severe PID, ruptured ectopic pregnancy, gastroenteritis and functional bowel syndrome
Upper abdominal pain makes any gynecologic diagnosis unlikely, while lower abdominal pain makes a gynecologic diagnosis (PID, endometriosis, degenerating fibroids, etc.) more likely.
Right lower quadrant pain increases the likelihood of appendicitis, ectopic pregnancy, ovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.
Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.
Suprapubic pain favors cystitits, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.
Pain moving to different places at different times is characteristic of such GI problems as gastroenteritis and functional bowel syndrome, and is very uncharacteristic of any gynecologic problem.
Sudden onset of pain is typically seen in ruptured ectopic pregnancy, ruptured or torsioned ovarian cysts, mittelschmerz, renal colic, gastroenteritis and functional bowel syndrome.
If the pain has lasted for months, it is unlikely to be from appendicitis, ectopic pregnancy, gastroenteritis or renal colic.
Mild pain favors mild PID, threatened abortion, ovarian cyst, cystitis, mittelschmerz, dysmenorrhea, endometriosis, degenerating uterine fibroid, infected/rejected IUD, gastroenteritis and functional bowel syndrome. It makes renal colic unlikely.
Moderate pain (interferes with some activities) can be seen with all gynecologic diagnoses, appendicitis, functional bowel syndrome, gastroenteritis, and pyelonephritis.
Severe pain (unable to function without extreme effort) can be caused by moderate-severe PID, ruptured ectopic pregnancy, abortion, labor, torsioned ovarian cysts, pyelonephritis, renal stones, degenerating uterine fibroids, infected/rejected IUD, gastroenteritis, bowel obstruction, and diverticulitis. This degree of pain is not often seen in ruptured ovarian cysts, cystitis or endometriosis.
Cramping indicates the rhythmic contractions of smooth muscle, such as is found in bowel, uterus, and ureter. Appendicitis may be both cramping and constant, as is diverticulitis. PIDmay also cause constant pain (from stretching and inflammation of the peritoneum) and cramping (from local irritation of the bowel).
Progressive pain points towards more serious problems (appendicitis, ovarian torsion, moderate-severe PID, sepsis, etc.) and toward a deteriorating clinical condition. Pain that is steadily improving often requires no intervention at all.
How's your appetite?
Are you nauseated?
Have you vomited?
Nausea (feeling sick to your stomach)
and loss of appetite are characteristic of such GI problems as
appendicitis, bowel obstruction, diverticulitis,
and those other conditions that stimulate the peritoneum or
otherwise provoke a vagal stimulation. Among these are torsioned
ovarian cysts, ruptured
ectopic pregnancy and moderate-severe
Presence of a normal appetite or increased appetite are favorable signs that whatever has caused the pain is either of a mild nature or is resolving.
Vomiting is associated with appendicitis, gastroenteritis, and bowel obstruction.
How are your bowel movements?
Normal BMs speak against
functional bowel syndrome and
Constipation is seen in bowel obstruction, functional bowel syndrome, and not often seen in gastroenteritis or diverticulitis. There is a symptoms, tenesmus, in which the patient describes the sensation that if she could just have a good bowel movement, the pain would be relieved. Tenesmus can be seen in any acute process in the pelvis, but is characteristic of diverticulitis.
Diarrhea is associated with gastroenteritis, diverticulitis and functional bowel syndrome. Bloody and mucousy diarrhea is seen usually associated with diverticulitis, but can also be seen in functional bowel syndrome.
Is your urination normal?
The presence of urinary symptoms
directs your attention to such conditions as cystitis,
pyelonepritis and renal stones.
Cystitis usually provokes frequent, painful urination, and occasionally bloody urine. The absence of these symptoms makes cystitis very unlikely.
pyelonephritis can have the same symptoms as cystitis, but also kidney pain. Not all cases of pyelonepritis have these lower urinary tract symptoms, however.
With renal colic due to ureteral stones, the only lower urinary tract symptom typically seen is hematuria, unless there is a superimposed infection.
How do you feel?
Feeling lightheaded is caused by
inadequate cerebral perfusion, such as is seen in hypovolemia
(bleeding, dehydration), or strong vagal stimulation (diarrhea,
stretching of the peritoneum).
If she cannot be upright without losing consciousness, this is a symptom of severe hypovolemia, such as might be seen in a ruptured ectopic pregnancy.
Right shoulder pain is:
Right shoulder pain usually indicates
irritation of the undersurface of the right hemi-diaphragm and
consequent stimulation of the phrenic nerve with referred pain to
the right shoulder.
This can be seen with significant hemoperitoneum (ruptured tubal ectopic pregnancy, sometimes ruptured ovarian cysts), free air (ruptured diverticulum or appendix), or pus (moderate-severe PID).
The pain is worse with:
Pain that worsens with coughing or
moving suggests peritoneal irritation, such as is seen in
ovarian cyst or
ectopic pregnancy, torsed
ovarian cyst, diverticulitis and bowel obstruction.
Pain that worsens with eating points towards GI problems (gastroenteritis, diverticulitis, functional bowel syndrome or bowel obstruction) as its' cause.
The pain improves with:
Most abdominal and pelvic pain from
any cause will improve with rest.
Antacids are helpful only for upper GI distress, such as is seen in gastritis, esophagitis, or duodenitis.
Eating improves esophagitis (heartburn) briefly as it buffers the chemical burn in the lower esophagus.
Has this happened before?
Past medical history?
|Prior history can provide insight into the current condition. Problems such as dysmenorrhea, endometriosis, mittelschmerz, and diverticular disease and functional bowel syndrome tend to have recurrent symptoms.|
Past surgical history:
Women with a previous bowel
resection are at increased risk for having bowel obstruction.
Those with a history of tubal ligation or hysterectomy are very unlikely to have a pregnancy or pregnancy problems. They are at decreased risk of endometriosis.
Those with a history of ectopic pregnancy are at increased risk of having another ectopic pregnancy.
Negative laparoscopy within the last 2 years decreases the chance of endometriosis and uterine fibroids.
Past gynecologic history:
A history of cystitis or
pyelonephritis increases the risk for future cystitis and
Prior history of ovarian cyst increases the likelihood of future ovarian cysts. The same is true for PID, and endometriosis.
Painful intercourse on deep penetration is associated with appendicitis, PID, ectopic pregnancy, ovarian cyst, endometriosis and degenerating uterine fibroids.
Moderate to severe menstrual cramps are seen with endometriosis and degenerating uterine fibroids.
Current and previous IUD use increases
the risk of PID. Current IUD use of the IUD decreases the risk of
pregnancy, but if a pregnancy is present, increases the risk that
the pregnancy will be an
Current use of OCPs (without skipping pills) and other hormonal contraceptives very much decreases the chance of a pregnancy-related problems. They also protect to some extent against ovarian cysts, PID, mittelschmerz, dysmenorrhea, and endometriosis.
Unless the patient is not sexually active, failing to use contraception or active seeking of a pregnancy increases the chance that her pain is due to a pregnancy-related problem.
If the patient has never had
intercourse or a "near intercourse experience," then
pregnancy-related problems, STDs, cystitis and
very unlikely. Some patients have very good recollections of this
issue and others are more forgetful.
A woman who has not had intercourse in the last 3 months is not very likely to have PID(it would have shown up earlier) or a tubal ectopic pregnancy (it would have already ruptured).
When did your last normal menstrual begin?
Problems associated with menses
include dysmenorrhea, endometriosis, ruptured
ovarian cysts, and
PID. The pain can begin just before menses and continue throughout
Mid-cycle pain is characteristic of mittelschmerz.
Although the greatest amount of helpful information will come from the patient's history, the physical exam will be helpful in making some diagnoses clear and ruling out others.
Temperature greater than 100.4 favors
pyelonephritis, septic abortion, and moderate-severe
Temperature less than 99 is not often seen in these conditions.
Elevated pulse >100 is seen in hypovolemia (ruptured ectopic pregnancy), fever, and increased metabolic states (pyelonephritis, PID)
Respiratory rate increases some with fever, but increases quite a bit with hypovolemia.
A normal mood is very uncharacteristic
of patients with such serious medical problems as
pyelonephritis, renal colic, ruptured
ectopic pregnancy, torsioned ovary, and bowel obstruction.
A confused, inappropriate or lethargic mood may be due to the hypovolemia of ruptured ectopic pregnancy, or the sepsis associated with pyelonephritis, moderate-severe PID, or septic abortion.
Patient's color is:
Any pain can cause a pale appearance
to the skin, but the peripheral vasoconstriction that
accompanies hypovolemia from acute blood loss often creates a
distinct pallor, or ashen-grey appearance.
Patients who have a fever are often flushed in appearance.
Neither jaundice nor cyanosis are associated with any of the common causes for pelvic or lower abdominal pain.
Greatest tenderness is:
Diffuse tenderness is associated with
ruptured ectopic pregnancy,
functional bowel syndrome and bowel obstruction.
Upper abdominal tenderness is rarely associated with gynecologic illness.
Right lower quadrant tenderness increases the likelihood of appendicitis, ectopic pregnancy, ovarian cystovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.
Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, mittelschmerz, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.
Suprapubic pain favors cystitis, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.
The abdomen is:
The presence of voluntary guarding
implies the patient is consciously protecting a sore area within
the abomen, such as appendicitis,
Involuntary guarding and moderate/marked rebound tenderness are characteristic of peritonitis, such as might be seen in appendicitis, moderate-severe PID, ruptured ectopic pregnancy, torsioned ovarian cyst, diverticulitis, or bowel obstruction.
On abdominal palpation:
A mass in the central lower abdomen is
usually the uterus. It may be enlarged because of a pregnancy or
fibroid tumors. A uterus that can be palpated on abdominal exam is
at least 12-weeks size.
Bowel obstruction may lead to a mass, but is less common than uterine enlargement.
Diverticulitis can form a mass, but it is usually in the LLQ and usually not felt abdominally.
Appendicitis can form a mass, but it is usually in the RLQ and usually not felt abdominally.
Bowel sounds are:
Diminished bowel sounds are
non-diagnostic and common.
Absent bowel sounds are seen in appendicitis, diverticulitis, bowel obstruction and moderate-severe PID.
Bowel obstruction may also demonstrate high-pitched sounds, coming in rushes as bowel contents are squeezed through a constricted lumen.
CVA pain/tenderness is:
Pain and tenderness in the area of the
costovertebral angle is classically associated with
and sometimes renal colic. In these cases, the findings are
Conversely, the absence of CVA pain/tenderness makes the diagnosis of pyelonephritis very unlikely.
The vagina contains:
||Blood in the vagina at times other than the menstrual flow is usually associated (in the presence of abdominal and pelvic pain) with|
The hymen is:
||An intact hymen speaks against pregnancy complications and PID.|
The bladder is:
Bladders are normally non-tender.
Cystitis or endometriosis can cause the bladder to become tender.
Conversely, a non-tender bladder makes cystitis very unlikely.
Purple discoloration of the cervix is
associated with any of the pregnancy abnormalities.
Purulent discharge is found in PIDand septic abortion.
Tissue protruding from the os is usually pregnancy tissue in a patient with abdominal pain. Other causes include polyps and prolapsing uterine fibroids.
Bleeding is usually associated with pregnancy abnormalities or hormonal abnormalities.
Cervical softness occurs during
Tenderness of the cervix to touch (without movement) is a symptom of cervicitis.
Mild cervical motion tenderness is a non-specific finding demonstrated in many patients with pelvic pain from a variety of sources.
Moderate to severe cervical motion tenderness is characteristic of PID, ectopic pregnancy, appendicitis, endometriosis, and a torsioned ovarian cyst.
The uterine size is:
A normal-sized uterus does not give
any insight into the source of the abdominal pain.
Uterine enlargement is seen with pregnancy, pregnancy complications (including ectopic pregnancy), and fibroid tumors.
Unusual amounts of uterine softness
correlates with pregnancy and pregnancy-related complications.
An irregular contour almost always indicates the presence of fibroid tumors.
The uterus is not normally tender. Uterine tenderness is seen in pregnancy complications, PID, and endometriosis.
Adnexal masses can be very difficult
to palpate, particularly if the patient cannot fully cooperate or
if she is large in body mass. That said, negative findings are
still of value in ruling out
PID. It would be nearly impossible
for the patient to have PIDand not have significant adnexal
A tender adnexal mass suggests an ovarian cyst, ectopic pregnancy, endometriosis, or tubo-ovarian abscess.
A non-tender mass usually indicates an un-ruptured ovarian cyst or endometrioma. In the presence of a positive pregnancy test, a non-tender mass in the adnexa is usually a corpus luteum cyst.
Tenderness without a mass is characteristic of PID.
A tender mass in the culdesac suggests
appendicitis, diverticulitis, moderate/severe
abscess, ovarian cyst or
Non-tender masses are usually ovarian cysts or stool in the colon.
Generalized tenderness in the culdesac without a mass is usually related to peritoneal irritation from endometriosis, ruptured ectopic pregnancy, appendicitis, PIDor diverticulitis.
Tender nodules on the uterosacral ligaments (often best felt through combined vaginal-rectal exam) are characteristic of endometriosis.
Laboratory tests and imaging studies can be helpful in guiding you in the right direction on abdominal and pelvic pain. Not all tests are needed in all patients with abdominal pain. You will need to make a judgment, based on the clinical presentation, history and physical exam, and availability. Among these tests are:
||Often the single most useful test in this setting. Modern urine or serum pregnancy tests are highly reliable. A positive pregnancy test helps focus your attention in the right direction, while a negative pregnancy test helps eliminate some of the more common abnormalities.|
|Quantitative HCG||If the pregnancy test is positive, it may be useful to know how much HCG is present. Generally, if the quantitative HCG is greater than 1500-2000 units, an intrauterine pregnancy will be consistently seen on transvaginal ultrasound. This is useful in ruling in or out ectopic pregnancies.|
|Transvaginal Ultrasound||This is very reliable in identifying ovarian cysts, fibroids, pregnancies, and free fluid in the pelvis. It can identify appendicitis, but is less reliable, with false negatives and occasional false positives.|
|CT Scan of the Abdomen||Most useful in identifying or ruling out such GI problems as appendicitis, diverticulitis, bowel obstruction, renal stone, and intra-abdominal abscesses.|
Often ordered and infrequently helpful, the results are most
helpful in the extreme:
|Gonorrhea/Chlamydia Cultures||Sometimes helpful in identifying those patients needing treatment for these sexually-transmitted infections. Even when positive, however, the presence of gonorrhea or chlamydia does not necessarily mean that they are responsible for the pelvic or abdominal pain.|
Uncertainty of Diagnosis
When treating a female patient with abdominal pain, I sometimes don't have a clue as to what the problem is. I say this as a board-certified OB-GYN, with more than 20 years in clinical practice, practicing in a 600-bed teaching hospital, with ultrasound, MRI scans, and full lab support. Sometimes all I can say is: "This patient is sick with something."
Sometimes these patients get well before I can figure out the diagnosis. Sometimes these patients get worse and I end up performing surgery and find PID, or endometriosis, or an ovarian cyst or almost any other gynecologic, surgical or medical problem. Sometimes I do laparoscopy and find nothing abnormal, but the pain goes away.
The First Point is: In clinical gynecology, the diagnosis is often unclear. Just because you're unsure of the diagnosis doesn't mean you can't take good care of the patient. Often you must treat the patient before knowing the diagnosis.
The Second Point is: More important than knowing the correct diagnosis is doing the right thing for the patient.
Pain and Bedrest
If the patient has pelvic/abdominal pain or tenderness, bedrest will usually help and is never the wrong thing to do. For many of your patients, the pain will simply resolve (although you won't know why).
Pain and Fever
If the patient has a fever and pain (without an innocent explanation for the fever), I would recommend you give her antibiotics to cover PID. With mild pain and fever, oral antibiotics should work well, so long as they are effective against chlamydia (Doxycycline, tetracycline, erythromycin, azithromycin , etc.).
If the fever is high or the pain is moderate to severe, I would recommend IV antibiotics (such as clindamycin/gentamicin or cefoxitin or cefotetan or Flagyl/gentamicin) to cover the possibility of pelvic abscess.
CDC Protocols for PID
If there is no fever, but your patient complains of chronic pelvic pain, a course of oral Doxycycline is wise. Some of these women will be suffering from chlamydia and you may cure them through the use of an antibiotic effective against chlamydia. Others will not improve and will need further evaluation by experienced providers in well-equipped settings.
Any patient complaining of pelvic pain should have a pregnancy test. I am surprised at how often it is positive despite the patient saying "that's impossible."
Read more about Pregnancy Tests
BCPs and Pain
Most patients complaining of intermittent, chronic pelvic pain will benefit from oral contraceptive pills. BCPs reduce or eliminate most dysmenorrhea and have a favorable influence on other gynecologic problems such as endometriosis, ovarian cysts, and adenomyosis, a benign condition in which the uterine lining grows into the underlying muscle wall, causing pain and heavy periods.
When using BCPs to treat chronic pelvic pain, I have found multiphasic BCPs such as Ortho Novum 7/7/7, Triphasil or Tri-Norinyl have not been as effective as the stronger, monophasic BCPs such as LoOvral, Ortho Novum 1+35 or Demulen 1/35 (in my experience). I believe the reason is that the multiphasic pills, by virtue of their lower dose and changing dosage, do not suppress ovulation as consistently as the higher-dose pills.
If the BCPs do not help or if the patient continues to have pain during her menstrual flow, change the BCP schedule so the patient takes a monophasic (LoOvral, 1+35, etc.) BCP every day. She will:
If she doesn't have a menstrual flow, she can't get dysmenorrhea. Taken continuously, BCPs are effective and safe. The only important drawback is that she will not have a monthly menstrual flow to reassure her that she is not pregnant.
Because the birth control pills are so very effective in treating dysmenorrhea, the emergence of cyclic pelvic pain while taking BCPs is a worrisome symptom. Endometriosis can cause these symptoms. Happily, birth control pills, particularly if taken continuously, are a very effective treatment for endometriosis.
After a number of months, women on continuous BCPs will usually experience spotting or breakthrough bleeding. It is not dangerous. If this becomes a nuisance, stop the BCPs for one week (she'll have a withdrawal bleed), and then restart the BCPs continuously.
Read more about Birth Control Pills