1. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 1 Abdominal and Pelvic Pain CAPT Mike Hughey, MC, USNR

2. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 3 The Point is: “In gynecology, the diagnosis is often obscure.” “You must frequently treat the patient before you know the correct diagnosis.”

4. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 4 The Other Point is: “More important than knowing the correct diagnosis is doing the right thing for the patient.”

5. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 5 Pain of Unknown Cause Bedrest for a few days is never the wrong thing to do.

6. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 6 Pain and Fever Give antibiotics to cover PID Mild symptoms respond to PO drugs. Severe symptoms respond to IVs.

7. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 7 Chronic Pelvic Pain Doxycycline OCPs Refer to GYN if pain persists

8. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 8 Pregnancy Test Every patient complaining of lower abdominal pain should have a pregnancy test.

9. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 9 BCPs and Pain Most with chronic pain benefit from BCPs -dysmenorrhea -ovarian cysts -endometriosis -adenomyosis Monophasic better Cyclic vs. Continuous

10. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 10 Dysmenorrhea Painful Periods –Back ache –Pelvic cramps NSAIDs BCPs If persistent and severe, laparoscopy to rule out endometriosis

11. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 11 Mittelschmerz SUN TUEMONWEDTHUFRISAT 123456 78910111213 14151617181920 21222324252627 28293031 P Mid-cycle pain Unilateral NSAIDs BCPs

12. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 12 IUDs and Pain ALWAYS, remove the IUD

13. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 15 Ovarian Cysts May be normal (<4 cm) 95% disappear within 1-2 months May cause problems: -delay menstruation -Rupture -Torsion -Pain

16. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 16 Ovarian Cyst: Ruptured May go unnoticed May cause abdominal or shoulder pain Usually resolves with rest alone Sometimes requires surgery (bleeding)

17. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 17 Ovarian Cyst: Unruptured May go unnoticed May cause pain Usually resolve spontaneously Sometimes requires surgery (pain) Ultrasound scan of persistent cysts

18. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 18 Ovarian Cyst: Torsioned Severe unilateral pain Marked rebound and rigidity Surgery indicated within 24 hours If surgery unavailable: -IVs, NPO, bedrest -Metabolic acidosis -20-50% Mortality

19. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 21 PID: Moderate to Severe Fever > 100.4 Bilateral pelvic pain Cervical motion tenderness WBC elevated IV antibiotics

22. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 22 PID Treatment : Moderate to Severe Clinda/Gent Ofloxacin/Flagyl Amp/Sulbactam/Doxy Cipro/Doxy/Flagyl Doxy/Cefoxitin/Cefotetan

23. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 23 Endometriosis Progressive pelvic pain Deep Dysparunia Dysmenorrhea Tender nodules in cul-du- sac

24. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 24 Endometriosis: Treatment Conservative Surgery Radical Surgery Danazol, Lupron Continuous BCPs

25. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 27 Pyelonephritis Urgency, frequency, dysuria Fever, flank pain/tenderness, chills Push fluids (citric acid) Any broad-spectrum Abx Probably will need IV antibiotics

28. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 28 Gastroenteritis Diffuse, cramping pain Nausea, vomiting, diarrhea Fever, chills, distension Pain moves from place to place Supportive therapy IV’s Antibiotics Cultures

29. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 29 Functional Bowel Syndrome Intermittent pain Diarrhea/Constipation Stress related Moves from place to place Supportive Rx: Antispasmotics No narcotics No psychoactives

30. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 30 Appendicitis Progressive RLQ pain Nausea/Anorexia Guarding/Rigidity Rebound WBC variable

31. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 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. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 32 Bowel Obstruction Cramping pain and distension Hx: abdominal surgery X-ray: distended loop Most are partial obstructions IV fluids Decompression Surgery

33. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 33 Diverticular Disease Variable presentation (mild to severe) Cramping pain and distension Blood streaked stool Fever, WBC IV fluids Antibiotics Sometimes Surgery

34. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 34