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Chapter 95: Lower abdominal and pelvic pain in women

INTRODUCTION

Man endures pain as an undeserved punishment, woman accepts it as a natural heritage.

ANONYMOUS

Pain in the lower abdomen and pelvis is one of the most frequent symptoms experienced by women. The diagnostic approach requires a wide variety of consultative skills, especially when the pain is chronic. The examination of acute abdominal pain has been simplified by sensitive serum pregnancy tests, ultrasound and laparoscopy. However, an accurate history and examination for all types of pain will generally pinpoint the diagnosis. The ever-present problem of PID, a significant cause of infertility in women, demands an early diagnosis and appropriate management.

Key facts and checkpoints

  • A distinction has to be made between acute, chronic and recurrent pain.

  • Ectopic pregnancy remains a potentially lethal condition and its diagnosis still requires a high index of suspicion.

  • Sudden sharp pain in the pelvis that becomes more generalised indicates rupture of an ectopic pregnancy or an ovarian cyst.

  • Recurrent sharp, self-limiting pain indicates a ruptured Graafian follicle (mittelschmerz).

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

  • Endometriosis affects 1 in 9 women. On average, it takes 6½ years for endometriosis to be diagnosed.1

  • The principal afferent pathways of the pelvic viscera arise from T10–12, L1 and S2–4. Thus disorders of the bladder, rectum, lower uterus, cervix and upper vagina can refer pain to the low back, buttocks and posterior thigh.2

  • Chronic or persistent pelvic pain (PPP) is a complex neuromuscular-psychosocial disorder and estimated to affect 15–25% of women.3

A DIAGNOSTIC APPROACH

A summary of the diagnostic strategy model is presented in TABLE 95.1

Table 95.1Lower abdominal and pelvic pain in women: diagnostic strategy model
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Table 95.1 Lower abdominal and pelvic pain in women: diagnostic strategy model

Probability diagnosis

Primary dysmenorrhoea

Mittelschmerz

Pelvic/abdominal adhesions

Endometriosis

Serious disorders not to be missed

Ectopic pregnancy

Neoplasia:

  • ovary

  • cervix and uterus

  • other pelvic structures

Severe infections:

  • PID

  • pelvic abscess

Acute appendicitis

Internal iliac claudication

Pitfalls (often missed)

Endometriosis/adenomyosis

Torsion of ovary or pedunculated fibroid

Constipation/faecal impaction

Irritable bowel syndrome

Malpositioned IUD

Pudendal neuralgia

Referred pain (to pelvis):

  • appendicitis

  • cholecystitis

  • diverticulitis

  • urinary tract disorders

Transvaginal mesh complications

Ovarian vein incompetence/pelvic congestion syndrome

Seven masquerades checklist

Depression

Drugs

Spinal dysfunction (referred pain)

UTI

Is the patient trying to tell me something?

Often relevant

Probability diagnosis

The commonest causes are primary dysmenorrhoea, the pain of a ruptured Graafian follicle (mittelschmerz), endometriosis and adhesions. In many instances of pain no diagnosis is made as no pathological cause can be found.

Serious disorders not to be missed

The potentially lethal problem of a ruptured ectopic pregnancy must not be missed, hence the axiom ‘be ectopic minded’. PID can be overlooked, especially if chronic, and requires ...

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