Gynecological causes of acute abdominal pain

1. Gynecological causes of acute
abdominal pain
Prof. Aboubakr Elnashar, Egypt
elnashar53@hotmail.comAboubakr Elnashar

2. CONTENTS
INTRODUCTION
CAUSES
SYSTEMATIC APPROACH
ALGORITHM
CONCLUSION
Aboubakr Elnashar

3. INTRODUCTION
Challenging clinical scenario:
History and physical examination findings:
often nonspecific
Early diagnosis
important to prevent sequelae of delayed
diagnosis
PID and ovarian torsion: infertility
Ectopic pregnancy: hemoperitoneum
Aboubakr Elnashar

4. Types of pain
Acute pain:
Chronic pain:
Recurrent pain:
Cyclic episodic pain
rather than acute or chronic pain.
Mittelschmerz
Dysmenorrhea
Endometriosis
Aboubakr Elnashar

5. Organic pain:
Pain with an identifiable specific cause
Functional pain:
without a clearly identifiable cause that is
exacerbated by psychosocial factors
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6. Typical sites of various causes of acute abdominal pain
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7. Typical sites of various causes of chronic or recurrent
abdominal pain
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8. CAUSES
A. Women of reproductive age
I. Pregnancy related
Ectopic
Septic abortion
Endometritis: post-partum or post-abortion
II. Infection
PID
TOA
III. Complicated ovarian cyst
Torsion, rupture, hemorrhage, OHSS
IV. Complicated fibroid
Degenerating
Torsion
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9. B. Adolescents
Similar +
imperforate hymen and
transverse vaginal septum
C. Postmenopausal women
Similar –
ectopic pregnancy and
ovarian torsion
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10. Most common causes of acute lower
abdominal pain
1. PID
2. Ruptured ovarian cysts
3. Appendicitis
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11. CDC Criteria for Diagnosis of PID. (2006)
At least one of the following criteria:
1. Adnexal tenderness
2. Cervical motion tenderness
3. Uterine tenderness
Additional diagnostic criteria (enhances specificity if present):
1. Cervical or vaginal mucopurulent discharge
2. Elevated CRP
3. Elevated ESR
4. Lab documentation of cervical infection with N
gonorrhoeae or C trachomatis
5. Tem >38.3° C
6. Saline microscopy of vaginal secretions: abundant
numbers of WBC
Aboubakr Elnashar

12. The most specific criteria for diagnosing
PID:
1. Endometrial biopsy: histopathologic
evidence of endometritis
2. Laparoscopy: abnormalities consistent with
PID
3. TVS or MRI: thickened, fluid-filled tubes with
or without free pelvic fluid or tubo-ovarian
complex, or
Doppler studies suggesting pelvic infection
(e.g., tubal hyperemia)
Aboubakr Elnashar

13. Adenxal torsion
 Pain:
Twisting
Lateral lower quadrant
sudden onset
 Peritonism
 Fever, leucocytosis, N/V
US colour Doppler: no flow
Right adnexal torsion at the
utero-ovarian pedicle.
Aboubakr Elnashar

14. Endometriosis
Pain:
Acute Abdominal Pain
{Rupture of an endometrioma}
usually at menstruation
Most commonly between 30 and 45 y
Usually preceded by premenstrual lower abdominal
pain
Diagnosis: confirmed at laparoscopy
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15. SYSTEMATIC APPROACH
Objective:
To rule out:
urgent life-threatening conditions :
ectopic pregnancy, ruptured ovarian cyst,
appendicitis
fertility-threatening conditions: PID, ovarian
torsion
Aboubakr Elnashar

16. I. HISTORY
1. Personal:
Age:
Adolescents
Women of reproductive age
Postmenopausal women.
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17. 2. Present:
Location
Radiation
Time of onset
Duration
Relation to menstrual cycle
Frequency: constant, intermittent
Type: severe, crampy, achy, dull
Exacerbating and relieving factors
Associated symptoms
Treatment tried
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18. Minutes Minute to
hours to few
days
Days to
weeks
Weeks to months
Ov cyst rupture Dysmenorrhea PID Endometriosis
Ov torsion Mittelschmerz Fibroids
TO abscess
rupture
OHSS Sexual abuse
Appendicitis Diverticulitis Cystitis IBS
Ureterolithiasis GE PNP Inflammatory BD
Neoplasm
Ab wall myositis
Time of onset
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19. Fibroids, Dysmenorhea, UTIMid lower
Just above SP
Late appendicitis
GE, IBS, IBD, diverticulitis
RLQ only
LLQ only
Endometriosis, PID,Both sides
Ovarian cyst, ovarian torsion,
mittelschmerz, Endometriosis
On either one
side or the
other
Location
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20. Right-sided pelvic pain
challenging and can be confusing
{close proximity of the appendix, uterus, right
fallopian tube, and right ovary}.
imaging to determine etiology.
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21. 3. Past:
Surgery: abdominal and gynecologic.
Gynecologic problems:
53% with ovarian torsion had a known history
of ovarian cyst or mass
(Houry D, Abbott,2001).
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22. 4. Sexual and STI history
-Husband symptoms:
Risks for PID and ectopic pregnancy.
-Recent IUCD:
PID risk
1st 3w: 6 times higher
After that:
similar to that in the general population
(Farley et al, 1992)
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23. II. PHYSICAL EXAMINATION
1. Vital signs
2. Abdominal
3. Pelvic
most important part
required for any woman with abdominal or
pelvic pain.
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24. III. LABORATORY TESTING
1. Urine analysis
2. Pregnancy test
Serum is more sensitive than urinary
β-hCG
Sensitive to 25 mIU/mL
3-4 days after implantation: positive
7 days after implantation, or
At time of the expected menses:
98% of the tests: positive.
Aboubakr Elnashar

25. 3. Vaginal wet mount
WBCs: support PID.
4. Nucleic acid amplification tests (NAATs)
Chlamydia and gonorrhea.
Amplify and detect DNA and RNA
sequences
More sensitive than previous chlamydia and
gonorrhea tests.
Urine NAATs have sensitivities and
specificities similar to those of cervical
samples.
Aboubakr Elnashar

26. 4. Other tests
Based on the history and physical examination
-Rh blood typing (if pregnant)
-Urine culture
-CBC
-ESR: nonspecific marker of inflammation that
can be associated with ectopic pregnancy .
-Fecal occult blood test.
Aboubakr Elnashar

27. IV. IMAGING
Goal:
Accurate diagnosis using the least amount of
radiation
TVS:
imaging modality of choice
CT or MRI:
negative or inconclusive TVS:
most sensitive strategy
{abdominal or pelvic CT: radiation dose 200
radiographs}
Aboubakr Elnashar

28.  Ectopic pregnancy
TVS should be conducted immediately
Serum β-hCG level
o Discriminatory zone: β-hCG >1,500 mIU per mL
gestational sac should be visible
if not, ectopic pregnancy should be suspected.
However, one half of women presenting with ectopic pregnancy have β-
hCG levels less than 2,000 mIU per mL, which can make the
distinction between early pregnancy and ectopic pregnancy difficult
when an empty uterus is seen on TVS.
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29. o Pseudo sac
5 to 10% of ectopic pregnancies.
Single echogenic ring.
True sac: double echogenic rings (double decidual
sac sign).
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30. o Heterotopic pregnancy:
Ectopic pregnancy simultaneously with an
intrauterine pregnancy
1: 7,000 pregnancies
ART:
1:100 pregnancies.
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31. PID:
Most common gynecologic cause of acute
pelvic pain
Early PID changes: ± not apparent on US
later changes: pyosalpinx and tubo-ovarian
abscess, will be seen.
Aboubakr Elnashar

32. Tuboovarian abscess.
(a) TVS: bilateral dilated folding tubular structures with thickened
walls, internal echogenic fluid, and debris.
(b) Axial contrast-enhanced CT: dilated tubular structures with thick
enhancing walls. Inflammatory stranding of the surrounding fat is
most demonstrable on the right (arrow).
Aboubakr Elnashar

33. Pelvic abscess.
(a) TVS: a well-defined mass with thick walls and an internal fluid-
debris level.
(b) Axial contrast-enhanced CT: left adnexal tuboovarian abscess
(arrow) with thick enhancing walls and complex internal fluid.
The abscess resolved with conservative therapy.
Aboubakr Elnashar

34. Appendicitis:
most common cause of nongynecologic pain
Can be diagnosed by US
US: sensitivity: 75 to 90%
CT: sensitivity: 87 to 98%.
Normal US:
makes appendicitis less likely, but does not
rule it out.
Aboubakr Elnashar

35. Other urgent conditions
US: sensitive
Hemorrhagic ovarian cyst
Uterine fibroids
Ovarian torsion.
Aboubakr Elnashar

36. TVS: Hemorrhagic ovarian cyst:
with the characteristic lacelike echogenic pattern of fibrin
strands that form as blood clots and retracts.Aboubakr Elnashar

37. TVS: Adnexal torsion.
an enlarged ovary (maximal diameter, >5 cm) with
prominent peripheral nonovulatory follicles and a small
amount of free fluid (arrow) around the inferior margin.
Aboubakr Elnashar

38. Color Doppler: Ovarian Torsion
Red arrowheads shows absence of blood flow demonstrating
ovarian torsion.
diagnosis rests on ovarian enlargement with normal ovarian
volume being up to approximately 15 cc. Other suggestive
findings are multiple peripherally based follicles.Aboubakr Elnashar

39. TVS: Ruptured ovarian cyst.
thick-walled ovarian cyst (corpus luteum) with
surrounding anechoic free fluid, a finding indicative of
rupture. Aboubakr Elnashar

40. TVS: Pedunculated fibroid
heterogeneous, slightly hypoechoic mass (arrow) that is
clearly attached to the anterior margin of the uterine
fundus.
Aboubakr Elnashar

41. Degenerating fibroid.
(a) Longitudinal TV color Doppler
inferior part of the uterus demonstrates a complex cystic mass
with internal echogenicity and no internal vascularity.
(b) Axial contrast-enhanced CT: an isoattenuating uterine mass
with a well-defined complex cystic center (arrow) containing fluid
and debris layering, a feature indicative of hemorrhagic
degeneration. Aboubakr Elnashar

42. TVS: Endometrioma
large,well-defined, complex cystic mass with low-level
internal echoes.
Aboubakr Elnashar

43. V. DIAGNOSTIC LAPAROSCOPY
Rarely needed to make the diagnosis.
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44. ALGORITHM
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45. History, Examination, Pregnancy test
Pregnant
Yes: evaluate for ectopic: BHCG, TVSNo
Right lower quadrant pain or pain migrating from umbilicus to RT lower
quadrant
Yes: surgical consultation and laparotomy for appendicitis; if
diagnosis in doubt: US or CT with IV contrast
No
Cervical motion, uterine, or adenxal tenderness
Yes: Consider PID: TVS for TOANo
Pelvic mass on examination
Yes: consider complicated ovarian cyst , complicated fibroid or
endometriosis: TVS
No
Dysuria and WBC on urine analysis
Yes: Evaluate for UTI or PNP: urine cultureNo
Gross or microscopic hematuria
Yes: may be 2ndry to vaginal bleeding: consider stone kidney: stone
protocol CT
No
TVS to evaluate for other diagnosisAboubakr Elnashar

46. CONCLUSION
The most common urgent causes are
ectopic pregnancy, ruptured or torsion
ovarian cyst, PID
Early diagnosis is important to prevent
sequelae of delayed diagnosis
Most diagnosis can be made with
History examination , pregnancy test and
TVS
Aboubakr Elnashar

47. As the first priority, urgent life-
threatening conditions and fertility-
threatening conditions must be
considered.
A high index of suspicion should be
maintained for PID when other
etiologies are ruled out, because the
presentation is variable and the
prevalence is high.
Aboubakr Elnashar

48. Benha University Hospital, Egypt
Email: elnashar53@hotmail.com
Prof. Aboubakr Elnashar
Thank you
Aboubakr Elnashar