Abdominal pain, acute women

Question 1

Probability diagnosis

Answer 1

Primary dysmenorrhoea

Mittelschmerz

Pelvic/abdominal adhesions

Endometriosis

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• internal iliac claudication
• Neoplasms including cancer
• ovary
• uterus
• other pelvic structures

Infection:

• PID
• pelvic abscess
• appendicitis

Other:

• ectopic pregnancy

Question 3

Pitfalls (often missed)

Answer 3

1. Endometriosis/adenomyosis
2. Torsion of ovary or pedunculated fibroid
3. Constipation/faecal impaction
4. Pelvic congestion syndrome
5. Misplaced IUCD
6. Nerve entrapment
7. Referred pain (to pelvis):

• appendicitis
• cholecystitis
• diverticulitis
• UTI

Question 4

Masquerades checklist

Answer 4

Depression

Drugs

Spinal dysfunction (referred pain)

UTI

Question 5

Is the patient trying to tell me something?

Answer 5

Can be very relevant.

Consider various problems and sexual dysfunction.

Question 6

Key history

Answer 6

The pain should be linked with the menstrual history, coitus and the possibility of an early pregnancy.

For recurrent and chronic pain, it is advisable to instruct pt to keep a diary over two menstrual cycles.

Risk factors in the past history should be assessed, for example:

• IUCD (salpingitis, ectopic pregnancy)
• infertility (endometriosis, salpingitis)
• tubal surgery (ectopic).

Question 7

Key examination

Answer 7

Traditional abdominal and pelvic exam to identify site of tenderness, rebound tenderness, and any abd or pelvic masses.

Speculum (preferably bivalve type) and bimanual palpation.

Proper assessment can be difficult if;

• pt cannot relax or overreacts
• there is abdominal scarring or obesity
• extreme tenderness is present.

Therefore conduct a gentle, caring vaginal examination with appropriate explanation and reassurance.

Question 8

Key investigations

Answer 8

FBE/ESR/CRP

Urine MC

Chlamydia PCR

Cervical swabs MC

Serum β-HCG

Vaginal and/or pelvic ultrasound

Laparoscopy if appropriate

Question 9

Diagnostic tips

Answer 9

Think of endometriosis and ovarian cysts with lower abd pain.

Recurrent pain related to menstruation is typical of dysmenorrhoea or endometriosis.

Ectopic pregnancy remains a potentially lethal condition so always be ‘ectopic minded’.

A position β-HCG + empty uterus + adnexal mass are the classic diagnostic features of ectopic pregnancy.