OB-GYN 101

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Abdominal Pain

Introduction
Clinical Evaluation
Clinical Evaluation Form
Patient History
Patient Physical Exam
Lab and Imaging
Uncertainty of Diagnosis
Pain and Bedrest
Pain and Fever
Chronic Pain
Pregnancy Test
Pain and BCPs
Threatened Abortion
Ectopic Pregnancy
Placental Abruption
IUD Problems
Ovarian Cyst
Ruptured Ovarian Cyst

Introduction
The diagnosis and management of abdominal and pelvic pain in women can be challenging. While some diagnoses are obvious or nearly so, others are elusive. While the diagnosis is most often made on the basis of clinical history, the relative certainty of diagnosis is often strengthened through the use of laboratory, imaging studies, and the physical examination.

I'm going to provide you with some general guidelines and a structure for evaluating patients with abdominal or pelvic pain, but I must caution you:

These insights do not apply well to an acutely traumatized patient (a vehicular accident victim, for example).
They also don't apply well to post-op patients or postpartum patients, where the issues can be quite different.
In this discussion, I am presuming that there is only one thing wrong with the patient. Usually that's the case, but sometimes it's not.

Clinical Evaluation
A structured approach usually works best for for those learning these skills, later, with more experience, you may skip over some parts of this process. The process involves asking a series of questions (history), examining the patient with an abdominal exam and pelvic exam (exam), obtaining a set of vital signs, and some basic laboratory tests. While learning these skills, you may find the Abdominal and Pelvic Pain Patient Evaluation Form useful as a teaching aid.

Patient History

"Where is the pain?"

Whole abdomen
Upper Abdomen
Lower Abdomen
Right Lower Quadrant
Left Lower Quadrant
Suprapubic area
Different places at different times

"Did the pain start suddenly (within a few minutes) or gradually (over hours or days)?"

Suddenly
Gradually

How long has the pain lasted?

Hours
Days
Months

How intense is the pain?

Mild
Moderate (Interferes with some activities)
Severe (Unable to function without extreme effort)

Is the pain constant?

Constant
Cramping
Intermittent

Is the pain getting worse?

Worse and worse
Better and better
Unchanging

Pain throughout the whole abdomen favors moderate to severe PID, ruptured ectopic pregnancy, gastroenteritis and functional bowel syndrome

Upper abdominal pain makes any gynecologic diagnosis unlikely, while lower abdominal pain makes a gynecologic diagnosis (PID, endometriosis, degenerating fibroids, etc.) more likely.

Right lower quadrant pain increases the likelihood of appendicitis, ectopic pregnancy, ovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.

Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.

Suprapubic pain favors cystitits, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.

Pain moving to different places at different times is characteristic of such GI problems as gastroenteritis and functional bowel syndrome, and is very uncharacteristic of any gynecologic problem.

Sudden onset of pain is typically seen in ruptured ectopic pregnancy, ruptured or torsioned ovarian cysts, mittelschmerz, renal colic, gastroenteritis and functional bowel syndrome.

If the pain has lasted for months, it is unlikely to be from appendicitis, ectopic pregnancy, gastroenteritis or renal colic.

Mild pain favors mild PID, threatened abortion, ovarian cyst, cystitis, mittelschmerz, dysmenorrhea, endometriosis, degenerating uterine fibroid, infected/rejected IUD, gastroenteritis and functional bowel syndrome. It makes renal colic unlikely.

Moderate pain (interferes with some activities) can be seen with all gynecologic diagnoses, appendicitis, functional bowel syndrome, gastroenteritis, and pyelonephritis.

Severe pain (unable to function without extreme effort) can be caused by moderate-severe PID, ruptured ectopic pregnancy, abortion, labor, torsioned ovarian cysts, pyelonephritis, renal stones, degenerating uterine fibroids, infected/rejected IUD, gastroenteritis, bowel obstruction, and diverticulitis. This degree of pain is not often seen in ruptured ovarian cysts, cystitis or endometriosis.

Cramping indicates the rhythmic contractions of smooth muscle, such as is found in bowel, uterus, and ureter. Appendicitis may be both cramping and constant, as is diverticulitis. PIDmay also cause constant pain (from stretching and inflammation of the peritoneum) and cramping (from local irritation of the bowel).

Progressive pain points towards more serious problems (appendicitis, ovarian torsion, moderate-severe PID, sepsis, etc.) and toward a deteriorating clinical condition. Pain that is steadily improving often requires no intervention at all.

How's your appetite?

Decreased
Increased
Normal

Are you nauseated?

Have you vomited?

Nausea (feeling sick to your stomach) and loss of appetite are characteristic of such GI problems as appendicitis, bowel obstruction, diverticulitis, gastroenteritis, and those other conditions that stimulate the peritoneum or otherwise provoke a vagal stimulation. Among these are torsioned ovarian cysts, ruptured ectopic pregnancy and moderate-severe PID.

Presence of a normal appetite or increased appetite are favorable signs that whatever has caused the pain is either of a mild nature or is resolving.

Vomiting is associated with appendicitis, gastroenteritis, and bowel obstruction.

How are your bowel movements?

Normal
Constipated
Diarrhea
Bloody
Mucousy

Normal BMs speak against gastroenteritis, diverticulitis, functional bowel syndrome and bowel obstruction.

Constipation is seen in bowel obstruction, functional bowel syndrome, and not often seen in gastroenteritis or diverticulitis. There is a symptoms, tenesmus, in which the patient describes the sensation that if she could just have a good bowel movement, the pain would be relieved. Tenesmus can be seen in any acute process in the pelvis, but is characteristic of diverticulitis.

Diarrhea is associated with gastroenteritis, diverticulitis and functional bowel syndrome. Bloody and mucousy diarrhea is seen usually associated with diverticulitis, but can also be seen in functional bowel syndrome.

Is your urination normal?

Painful
Frequent
Bloody
Normal

The presence of urinary symptoms directs your attention to such conditions as cystitis, pyelonepritis and renal stones.

Cystitis usually provokes frequent, painful urination, and occasionally bloody urine. The absence of these symptoms makes cystitis very unlikely.

pyelonephritis can have the same symptoms as cystitis, but also kidney pain. Not all cases of pyelonepritis have these lower urinary tract symptoms, however.

With renal colic due to ureteral stones, the only lower urinary tract symptom typically seen is hematuria, unless there is a superimposed infection.

How do you feel?

Lightheaded
Cannot be upright
Doesn't feel faint

Feeling lightheaded is caused by inadequate cerebral perfusion, such as is seen in hypovolemia (bleeding, dehydration), or strong vagal stimulation (diarrhea, stretching of the peritoneum).

If she cannot be upright without losing consciousness, this is a symptom of severe hypovolemia, such as might be seen in a ruptured ectopic pregnancy.

Right shoulder pain is:

Present
Absent

Right shoulder pain usually indicates irritation of the undersurface of the right hemi-diaphragm and consequent stimulation of the phrenic nerve with referred pain to the right shoulder.

This can be seen with significant hemoperitoneum (ruptured tubal ectopic pregnancy, sometimes ruptured ovarian cysts), free air (ruptured diverticulum or appendix), or pus (moderate-severe PID).

The pain is worse with:

Coughing
Moving
Eating
Nothing
Other

Pain that worsens with coughing or moving suggests peritoneal irritation, such as is seen in appendicitis, PID, ruptured ovarian cyst or ectopic pregnancy, torsed ovarian cyst, diverticulitis and bowel obstruction.

Pain that worsens with eating points towards GI problems (gastroenteritis, diverticulitis, functional bowel syndrome or bowel obstruction) as its' cause.

The pain improves with:

Lying still
Antacids
Eating
Nothing
Other

Most abdominal and pelvic pain from any cause will improve with rest.

Antacids are helpful only for upper GI distress, such as is seen in gastritis, esophagitis, or duodenitis.

Eating improves esophagitis (heartburn) briefly as it buffers the chemical burn in the lower esophagus.

Has this happened before?

Past medical history?

Functional bowel syndrome
Diverticular illness
Other

Prior history can provide insight into the current condition. Problems such as dysmenorrhea, endometriosis, mittelschmerz, and diverticular disease and functional bowel syndrome tend to have recurrent symptoms.

Past surgical history:

None
Appendectomy
Bowel resection
Tubal Ligation
Ectopic pregnancy
Hysterectomy
One tube or ovary
Both ovaries
Negative laparoscopy in the last two years

Women with a previous bowel resection are at increased risk for having bowel obstruction.

Those with a history of tubal ligation or hysterectomy are very unlikely to have a pregnancy or pregnancy problems. They are at decreased risk of endometriosis.

Those with a history of ectopic pregnancy are at increased risk of having another ectopic pregnancy.

Negative laparoscopy within the last 2 years decreases the chance of endometriosis and uterine fibroids.

Past gynecologic history:

Cystitis
Pyelonephritis
Ovarian Cyst
Endometriosis
PID or some STD
Deep dysparunia
Dysmenorrhea
Fibroids
None
Other

A history of cystitis or pyelonephritis increases the risk for future cystitis and pyelonephritis.

Prior history of ovarian cyst increases the likelihood of future ovarian cysts. The same is true for PID, and endometriosis.

Painful intercourse on deep penetration is associated with appendicitis, PID, ectopic pregnancy, ovarian cyst, endometriosis and degenerating uterine fibroids.

Moderate to severe menstrual cramps are seen with endometriosis and degenerating uterine fibroids.

Contraceptive History:

Previous IUD
Current IUD
Current OCPs - skips some
Current OCPs - never skips
Other hormonal contraceptive
Other
Using no contraception or seeking a pregnancy
No need for contraception

Current and previous IUD use increases the risk of PID. Current IUD use of the IUD decreases the risk of pregnancy, but if a pregnancy is present, increases the risk that the pregnancy will be an ectopic pregnancy.

Current use of OCPs (without skipping pills) and other hormonal contraceptives very much decreases the chance of a pregnancy-related problems. They also protect to some extent against ovarian cysts, PID, mittelschmerz, dysmenorrhea, and endometriosis.

Unless the patient is not sexually active, failing to use contraception or active seeking of a pregnancy increases the chance that her pain is due to a pregnancy-related problem.

Sexual History:

Never had intercourse
No intercourse since her LMP
No intercourse in the last 3 months
Other

If the patient has never had intercourse or a "near intercourse experience," then pregnancy-related problems, STDs, cystitis and pyelonephritis are very unlikely. Some patients have very good recollections of this issue and others are more forgetful.

A woman who has not had intercourse in the last 3 months is not very likely to have PID(it would have shown up earlier) or a tubal ectopic pregnancy (it would have already ruptured).

When did your last normal menstrual begin?

Problems associated with menses include dysmenorrhea, endometriosis, ruptured ovarian cysts, and PID. The pain can begin just before menses and continue throughout menses.

Mid-cycle pain is characteristic of mittelschmerz.

Although the greatest amount of helpful information will come from the patient's history, the physical exam will be helpful in making some diagnoses clear and ruling out others.

Patient Physical Examination

Vital Signs:

Temperature
Pulse
Respirations
Blood pressure

Temperature greater than 100.4 favors appendicitis, pyelonephritis, septic abortion, and moderate-severe PID. Temperature less than 99 is not often seen in these conditions.

Elevated pulse >100 is seen in hypovolemia (ruptured ectopic pregnancy), fever, and increased metabolic states (pyelonephritis, PID)

Respiratory rate increases some with fever, but increases quite a bit with hypovolemia.

Mood:

Normal
Anxious/worried
Confused/inappropriate
Lethargic

A normal mood is very uncharacteristic of patients with such serious medical problems as appendicitis, moderate-severe PID, pyelonephritis, renal colic, ruptured ectopic pregnancy, torsioned ovary, and bowel obstruction.

A confused, inappropriate or lethargic mood may be due to the hypovolemia of ruptured ectopic pregnancy, or the sepsis associated with pyelonephritis, moderate-severe PID, or septic abortion.

Patient's color is:

Normal
Pale
Flushed
Jaundiced
Cyanotic

Any pain can cause a pale appearance to the skin, but the peripheral vasoconstriction that accompanies hypovolemia from acute blood loss often creates a distinct pallor, or ashen-grey appearance.

Patients who have a fever are often flushed in appearance.

Neither jaundice nor cyanosis are associated with any of the common causes for pelvic or lower abdominal pain.

Greatest tenderness is:

Entire abdomen
Upper abdomen
RLQ
LLQ
Suprapubic
Lower abdomen
No tenderness

Diffuse tenderness is associated with ruptured ectopic pregnancy, gastroenteritis, functional bowel syndrome and bowel obstruction.

Upper abdominal tenderness is rarely associated with gynecologic illness.

Right lower quadrant tenderness increases the likelihood of appendicitis, ectopic pregnancy, ovarian cystovarian cyst, mittelschmerz and pyelonephritis, but diminishes the likelihood of diverticulitis.

Left lower quadrant pain favors an ovarian cyst, ectopic pregnancy, mittelschmerz, pyelonephritis, and diverticulitis, but makes appendicitis very unlikely.

Suprapubic pain favors cystitis, PID, abortion, endometriosis, dysmenorrhea, degenerating fibroid, gastroenteritis and functional bowel syndrome.

The abdomen is:

Soft
Voluntary guarding
Involuntary guarding
Mild rebound tenderness
Moderate/marked rebound tenderness

The presence of voluntary guarding implies the patient is consciously protecting a sore area within the abomen, such as appendicitis, ovarian cyst, ectopic pregnancy, PID.

Involuntary guarding and moderate/marked rebound tenderness are characteristic of peritonitis, such as might be seen in appendicitis, moderate-severe PID, ruptured ectopic pregnancy, torsioned ovarian cyst, diverticulitis, or bowel obstruction.

On abdominal palpation:

No masses
Mass central lower abdomen
Mass RLQ
Mass LLQ
Mass upper abdomen

A mass in the central lower abdomen is usually the uterus. It may be enlarged because of a pregnancy or fibroid tumors. A uterus that can be palpated on abdominal exam is at least 12-weeks size.

Bowel obstruction may lead to a mass, but is less common than uterine enlargement.

Diverticulitis can form a mass, but it is usually in the LLQ and usually not felt abdominally.

Appendicitis can form a mass, but it is usually in the RLQ and usually not felt abdominally.

Bowel sounds are:

Normal
Silent
Hyperactive
High-pitched, rushes

Diminished bowel sounds are non-diagnostic and common.

Absent bowel sounds are seen in appendicitis, diverticulitis, bowel obstruction and moderate-severe PID.

Bowel obstruction may also demonstrate high-pitched sounds, coming in rushes as bowel contents are squeezed through a constricted lumen.

CVA pain/tenderness is:

Present
Absent

Pain and tenderness in the area of the costovertebral angle is classically associated with pyelonephritis and sometimes renal colic. In these cases, the findings are usually one-sided.

Conversely, the absence of CVA pain/tenderness makes the diagnosis of pyelonephritis very unlikely.

The vagina contains:

Nothing abnormal
Small amounts of blood
Large amounts of blood
Clots
Pregnancy tissue
Other

Blood in the vagina at times other than the menstrual flow is usually associated (in the presence of abdominal and pelvic pain)

The hymen is:

Intact
Not intact
Not visualized

An intact hymen speaks against pregnancy complications and PID.

The bladder is:

Tender
Non-tender

Bladders are normally non-tender. Cystitis or endometriosis can cause the bladder to become tender.

Conversely, a non-tender bladder makes cystitis very unlikely.

Cervix inspection:

No abnormal findings
Purple discoloration
Purulent (muco) discharge
Tissue protruding from the os
Bleeding from the os
Other

Purple discoloration of the cervix is associated with any of the pregnancy abnormalities.

Purulent discharge is found in PIDand septic abortion.

Tissue protruding from the os is usually pregnancy tissue in a patient with abdominal pain. Other causes include polyps and prolapsing uterine fibroids.

Bleeding is usually associated with pregnancy abnormalities or hormonal abnormalities.

Cervical Palpation:

No abnormal findings
Cervix is softer than expected
Tender to touch
Mild pain on movement
Moderate/severe pain on movement
Dilated at least 1 cm.
Other

Cervical softness occurs during pregnancy.

Tenderness of the cervix to touch (without movement) is a symptom of cervicitis.

Mild cervical motion tenderness is a non-specific finding demonstrated in many patients with pelvic pain from a variety of sources.

Moderate to severe cervical motion tenderness is characteristic of PID, ectopic pregnancy, appendicitis, endometriosis, and a torsioned ovarian cyst.

The uterine size is:

Normal
Slightly enlarged
Moderately enlarged

A normal-sized uterus does not give any insight into the source of the abdominal pain.

Uterine enlargement is seen with pregnancy, pregnancy complications (including ectopic pregnancy), and fibroid tumors.

Uterine palpation:

No abnormal findings
Soft
Irregular contour
Mildly tender
Mod/severe tenderness

Unusual amounts of uterine softness correlates with pregnancy and pregnancy-related complications.

An irregular contour almost always indicates the presence of fibroid tumors.

The uterus is not normally tender. Uterine tenderness is seen in pregnancy complications, PID, and endometriosis.

Left adnexa:

Normal
Tender mass
Non-tender mass
Tenderness, no mass

Right adnexa:

Normal
Tender mass
Non-tender mass
Tenderness, no mass

Adnexal masses can be very difficult to palpate, particularly if the patient cannot fully cooperate or if she is large in body mass. That said, negative findings are still of value in ruling out PID. It would be nearly impossible for the patient to have PIDand not have significant adnexal tenderness.

A tender adnexal mass suggests an ovarian cyst, ectopic pregnancy, endometriosis, or tubo-ovarian abscess.

A non-tender mass usually indicates an un-ruptured ovarian cyst or endometrioma. In the presence of a positive pregnancy test, a non-tender mass in the adnexa is usually a corpus luteum cyst.

Tenderness without a mass is characteristic of PID.

Culdesac:

Normal
Tender mass
Non-tender mass
Tenderness, no mass
Tender nodules on uterosacral ligaments

A tender mass in the culdesac suggests appendicitis, diverticulitis, moderate/severe PIDwith tubo-ovarian abscess, ovarian cyst or ectopic pregnancy.

Non-tender masses are usually ovarian cysts or stool in the colon.

Generalized tenderness in the culdesac without a mass is usually related to peritoneal irritation from endometriosis, ruptured ectopic pregnancy, appendicitis, PIDor diverticulitis.

Tender nodules on the uterosacral ligaments (often best felt through combined vaginal-rectal exam) are characteristic of endometriosis.

Laboratory tests and imaging studies can be helpful in guiding you in the right direction on abdominal and pelvic pain. Not all tests are needed in all patients with abdominal pain. You will need to make a judgment, based on the clinical presentation, history and physical exam, and availability. Among these tests are:

Laboratory and Imaging Studies
Pregnancy test: Positive Negative	Often the single most useful test in this setting. Modern urine or serum pregnancy tests are highly reliable. A positive pregnancy test helps focus your attention in the right direction, while a negative pregnancy test helps eliminate some of the more common abnormalities.
Quantitative HCG	If the pregnancy test is positive, it may be useful to know how much HCG is present. Generally, if the quantitative HCG is greater than 1500-2000 units, an intrauterine pregnancy will be consistently seen on transvaginal ultrasound. This is useful in ruling in or out ectopic pregnancies.
Transvaginal Ultrasound	This is very reliable in identifying ovarian cysts, fibroids, pregnancies, and free fluid in the pelvis. It can identify appendicitis, but is less reliable, with false negatives and occasional false positives.
CT Scan of the Abdomen	Most useful in identifying or ruling out such GI problems as appendicitis, diverticulitis, bowel obstruction, renal stone, and intra-abdominal abscesses.
CBC	Often ordered and infrequently helpful, the results are most helpful in the extreme: A very high WBC (>15,000) usually means the patient is pretty sick with something. A very low (<9 gm) hemoglobin usually means the patient has experienced significant but relatively slow bleeding. Rapidly bleeding patients usually go into shock before they are able to mobilize enough fluid to dilute their hemoglobin. A patient with a slowly-bleeding ectopic pregnancy may have a low blood count, if enough time passes. A patient without any previous bleeding from her ectopic who suddenly and catastrophically blows out the ectopic with torrential internal hemorrhage probably will have a near normal blood count when she arrives in the emergency room in hypovolemic shock, but with fluid resuscitation, the Hgb and Hct will dilute down significantly.
Gonorrhea/Chlamydia Cultures	Sometimes helpful in identifying those patients needing treatment for these sexually-transmitted infections. Even when positive, however, the presence of gonorrhea or chlamydia does not necessarily mean that they are responsible for the pelvic or abdominal pain.

Uncertainty of Diagnosis
When treating a female patient with abdominal pain, I sometimes don't have a clue as to what the problem is. I say this as a board-certified OB-GYN, with more than 20 years in clinical practice, practicing in a 600-bed teaching hospital, with ultrasound, MRI scans, and full lab support. Sometimes all I can say is: "This patient is sick with something."

Sometimes these patients get well before I can figure out the diagnosis. Sometimes these patients get worse and I end up performing surgery and find PID, or endometriosis, or an ovarian cyst or almost any other gynecologic, surgical or medical problem. Sometimes I do laparoscopy and find nothing abnormal, but the pain goes away.

The First Point is: In clinical gynecology, the diagnosis is often unclear. Just because you're unsure of the diagnosis doesn't mean you can't take good care of the patient. Often you must treat the patient before knowing the diagnosis.

The Second Point is: More important than knowing the correct diagnosis is doing the right thing for the patient.

Pain and Bedrest
If the patient has pelvic/abdominal pain or tenderness, bedrest will usually help and is never the wrong thing to do. For many of your patients, the pain will simply resolve (although you won't know why).

Pain and Fever
If the patient has a fever and pain (without an innocent explanation for the fever), I would recommend you give her antibiotics to cover PID. With mild pain and fever, oral antibiotics should work well, so long as they are effective against chlamydia (Doxycycline, tetracycline, erythromycin, azithromycin , etc.).

If the fever is high or the pain is moderate to severe, I would recommend IV antibiotics (such as clindamycin/gentamicin or cefoxitin or cefotetan or Flagyl/gentamicin) to cover the possibility of pelvic abscess.

CDC Treatment Guidelines for PID

Chronic Pain
If there is no fever, but your patient complains of chronic pelvic pain, a course of oral Doxycycline is wise. Some of these women will be suffering from chlamydia and you may cure them through the use of an antibiotic effective against chlamydia. Others will not improve and will need further evaluation by experienced providers in well-equipped settings.

Pregnancy Test
Any patient complaining of pelvic pain should have a pregnancy test. I am surprised at how often it is positive despite the patient saying "that's impossible."