Lower abdominal pain among women

 Introduction:

Pain in the lower abdomen is one of the most frequent symptoms experienced by women. It may occur as acute, chronic or recurrent pain.

Causes:

Acute pain:

• Genital: Acute salpingitis, Pelvic peritonitis, Bleeding Rupture or torsion of ovarian cyst, Threatened or incomplete abortion, Rupture or aborting tubal ectopic pregnancy, Rupture or bleeding endometrioma 
• Non-genital: Acute appendicitis, Bowel obstruction, Urinary tract infection (cystitis), Ureteric colic (calculus)
• Functional: Primary dysmenorrhoea, Retrograde menstruation 

Chronic pain:

• Genital: Endometriosis/adenomyosis, Pelvic inflammatory disease (chronic; adhesions), Ovarian neoplasm, Fibromyomata (rarely) 
• Non-genital: Diverticulitis, Bowel adhesions, Irritable bowel syndrome, Urinary disorders e.g. urethral syndrome
• Functional: Secondary dysmenorrhoea—IUCD, polyp; Irritable bowel, chronic bowel spasm

☝If the pain occurs with following features:

• Average patient in mid-20s
• First pregnancy in one-third of patients
• Patient at risk:  H/o previous ectopic pregnancy, PID, abdominal or pelvic surgery, especially sterilisation reversal, IUCD use, In vitro fertilization /GIFT
• Pre-rupture symptoms (many cases): Abnormal pregnancy, cramping pains in one or other iliac fossa, vaginal bleeding
• Rupture: excruciating pain, circulatory collapse
• Pain may radiate to rectum (lavatory sign), vagina or leg
• Signs of pregnancy (e.g. enlarged breasts and uterus) usually not present 

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🚗Immediately Visit your Gynecologist for examination & management

Examination finding :

• Deep tenderness in iliac fossa 

• Vaginal examination: tenderness on bimanual pelvic examination (pain on cervical provocation i.e. cervical motion tenderness),  palpable adenxal mass, soft cervix    

• Bleeding (prune juice appearance) 

• Temperature and pulse usually normal early 

Diagnostic tests: 

• Urine pregnancy tests may be +ve
• β-HCG assay (may need serial tests) if >1500 IU/L invariably +ve
• Vaginal US can diagnose at 5–6 weeks (empty uterus, tubal sac)
• Laparoscopy (the definitive diagnostic procedure)

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It may be Ectopic pregnancy

💊Management done according to the severity & possible options are surgery, medical or watchful expectancy 

• Treatment may be conservative (based on US and β-HCG assays); 

• medical, by injecting methotrexate into the ectopic sac; laparoscopic removal; or laparotomy for severe cases. 

• Rupture with blood loss demands urgent surgery.

☝If the pain occurs with following features:

• Onset of pain in mid-cycle
• Deep pain in one or other iliac fossa (RIF > LIF)
• Often described as a ‘horse kick pain’
• Pain tends to move centrally
• Heavy feeling in pelvis
• Relieved by sitting or supporting lower abdomen
• Pain lasts from a few minutes to hours (average 5 hours)  
• Patient otherwise well 

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It may be Ruptured ovarian (Graafian) follicle (mittelschmerz) (When the Graafian follicle ruptures a small amount of blood mixed with follicular fluid is usually released into the pouch of Douglas) 

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🚗Visit your Gynecologist for examination & to rule out other causes

💊Management done as 

• Explanation and reassurance to the patient
• Simple analgesics: aspirin or paracetamol is given for pain
• ‘Hot water bottle’ gives comfort if pain severe 

☝If the pain occurs with following features:

• Patient usually 15–25 years
• Sudden onset of pain in one or other iliac fossa
• May be nausea and vomiting
• No systemic signs
• Pain usually settles within a few hours 

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🚗Visit your Gynecologist for examination & to rule out other causes

Examination findings:

• Tenderness and guarding in iliac fossa
• PR: tenderness in rectovaginal pouch   

Diagnosis tests:

• Ultrasound  ±  colour Doppler (for enhancement)

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It may be Ruptured ovarian cyst (cysts tend to rupture just prior to ovulation or following coitus)

💊Management done as

• Appropriate explanation and reassurance  
• Conservative: For simple cyst <4 cm, internal haemorrhage,    minimal pain
• Needle vaginal drainage: By ultrasonography for a simple larger cyst
• Laparoscopic surgery: For complex cysts, large cysts, external bleeding 

☝If the pain occurs with following features:

• Severe cramping lower abdominal pain    
• Diffuse pain
• Pain may radiate to the flank, back or thigh
• Repeated vomiting 
• Exquisite pelvic tenderness 
• Patient looks ill 

                                  👇

🚗Immediately Visit your Gynecologist for examination & management

Examination findings:

• Smooth, rounded, mobile mass palpable in abdomen 
• May be tenderness and guarding over the mass, especially if leakage 

  Diagnostic tests:

•  Ultrasound  ±  colour Doppler 

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It may be Acute torsion of ovarian cyst ( Torsions are mainly from dermoid cysts and, when right-sided, may be difficult to distinguish from acute pelvic appendicitis)

💊Management done as

• Laparotomy and surgical correction 

References:

1. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
2. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
3. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012