1. Abdominal and Pelvic Pain
CAPT Mike Hughey, MC, USNR

2. Uncertainty of Diagnosis
“When I see a woman with abdominal or pelvic pain, I often haven't a clue as to what the problem is, even using ultrasound, a full lab, and countless consultants.”
“All I know is that the patient is sick with something.”

3. The Point is: “In gynecology, the diagnosis is often obscure.”
“You must frequently treat the patient before you know the correct diagnosis.”

4. The Other Point is:
“More important than knowing the correct diagnosis is doing the right thing for the patient.”

5. Pain of Unknown Cause
Bedrest for a few days is never the wrong thing to do.

6. Pain and Fever Give antibiotics to cover PID
Mild symptoms respond to PO drugs.
Severe symptoms respond to IVs.

7. Chronic Pelvic Pain
Doxycycline
OCPs
Refer to GYN if pain persists

8. Pregnancy Test
Every patient complaining of lower abdominal pain should have a pregnancy test.

9. BCPs and Pain
Most with chronic pain benefit from BCPs -dysmenorrhea -ovarian cysts -endometriosis -adenomyosis
Monophasic better
Cyclic vs. Continuous

10. Dysmenorrhea Painful Periods NSAIDs BCPs
Back ache
Pelvic cramps
NSAIDs
BCPs
If persistent and severe, laparoscopy to rule out endometriosis

11. Mittelschmerz Mid-cycle pain Unilateral NSAIDs BCPs P SUN TUE MON WED
THU
FRI
SAT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Mid-cycle pain
Unilateral
NSAIDs
BCPs P

12. IUDs and Pain
ALWAYS, remove the IUD

13. IUDs and Pain
•5% become infected •Pain, tenderness, fever •Remove IUD and begin ABx •Oral or IV, depending on high fever or severe symptoms.

14. IUDs and Pain
Never push an IUD back in place if it is partway expelled.
Always remove an IUD if the patient complains of: pelvic pain tenderness abnormal bleeding

15. Ovarian Cysts May be normal (<4 cm) 95% disappear within 1-2 months
May cause problems: -delay menstruation -Rupture -Torsion -Pain

16. Ovarian Cyst: Ruptured
May go unnoticed
May cause abdominal or shoulder pain
Usually resolves with rest alone
Sometimes requires surgery (bleeding)

17. Ovarian Cyst: Unruptured
May go unnoticed
May cause pain
Usually resolve spontaneously
Sometimes requires surgery (pain)
Ultrasound scan of persistent cysts

18. Ovarian Cyst: Torsioned
Severe unilateral pain
Marked rebound and rigidity
Surgery indicated within 24 hours
If surgery unavailable: -IVs, NPO, bedrest -Metabolic acidosis % Mortality

19. Pelvic Inflammatory Disease (PID)
Bacterial inflammation of cervix, uterus, tubes and ovaries
Bilateral disease
1st infection single agent
Repeat:multiple agents
Two categories:
Mild
Moderate to Severe

20. PID: Mild No fever Bilateral pelvic pain Cervical motion tenderness
WBC near normal
Doxy 100 BID #28, plus
Cefoxitin/Probenecid
Ceftriaxone
Ceftizoxime
Cefotaxime

21. PID: Moderate to Severe
Fever > 100.4
Bilateral pelvic pain
Cervical motion tenderness
WBC elevated
IV antibiotics

22. PID Treatment : Moderate to Severe
Clinda/Gent
Ofloxacin/Flagyl
Amp/Sulbactam/Doxy
Cipro/Doxy/Flagyl
Doxy/Cefoxitin/Cefotetan

23. Endometriosis Progressive pelvic pain Deep Dysparunia Dysmenorrhea
Tender nodules in cul-du-sac

24. Endometriosis: Treatment
Conservative Surgery
Radical Surgery
Danazol, Lupron
Continuous BCPs

25. Degenerating Fibroid Bulky, irregular, tender uterus
40% of women >40 have them
Supportive treatment
Symptoms gradually resolve over ~3 weeks
Surgery for anemia, chronic pain, size >12 weeks

26. Cystitis Urgency, frequency, dysuria Always treat
Push fluids (citric acid)
Any broad-spectrum ABx -Ampicillin (Amox) -Keflex -Bactrim DS -Doxycycline
Pyridium helps symptoms

27. Pyelonephritis Urgency, frequency, dysuria
Fever, flank pain/tenderness, chills
Push fluids (citric acid)
Any broad-spectrum Abx
Probably will need IV antibiotics

28. Gastroenteritis Diffuse, cramping pain Nausea, vomiting, diarrhea
Fever, chills, distension
Pain moves from place to place
Supportive therapy
IV’s
Antibiotics
Cultures

29. Functional Bowel Syndrome
Intermittent pain
Diarrhea/Constipation
Stress related
Moves from place to place
Supportive Rx:
Antispasmotics
No narcotics
No psychoactives

30. Appendicitis Progressive RLQ pain Nausea/Anorexia Guarding/Rigidity
Rebound
WBC variable

31. Appendicitis: Treatment
Surgery
NPO/IVs
Antibiotics
Mefoxin/Gent
Flagyl/Gent
Amp/Sulbactam/Doxy
Clinda/Gent
Oflaxacin/Flagyl
Cipro/Doxy/Flagyl
Doxy/Cefoxitin/Cefotetan

32. Bowel Obstruction Cramping pain and distension Hx: abdominal surgery
X-ray: distended loop
Most are partial obstructions
IV fluids
Decompression
Surgery

33. Diverticular Disease Variable presentation (mild to severe)
Cramping pain and distension
Blood streaked stool
Fever, WBC
IV fluids
Antibiotics
Sometimes Surgery