evaluation of abdominal and pelvic pain in women setul pardanani, md assistant professor, ob/gyn...
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Evaluation of Abdominal and Pelvic
Pain in Women Setul Pardanani, MD
Assistant Professor, OB/GYN & Women’s HealthAssistant Residency Program DirectorAlbert Einstein College of Medicine
Montefiore Medical Center
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ObjectivesReview the common etiologies
of abdominal and pelvic pain
Review the evaluation of patients presenting with abdominal and pelvic pain
Review treatment options
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MilestoneAbdominal/Pelvic Pain
Level 1: Demonstrates a basic understanding of patients presenting with abdominal/pelvic pain regarding: Risk factors and Signs/Symptoms
Level 2: Demonstrates the ability to formulate a differential diagnosis and an understanding of the initial evaluation and treatment options
Level 3: Demonstrates the ability to utilize focused diagnostic approaches and formulate a comprehensive management plan
Level 4:Demonstrates an in-depth knowledge regarding patients presenting with abdominal/pelvic pain regarding: varying presentations, treatment options, refractory pelvic pain; manage and formulate comprehensive plans for patients with complex and atypical chronic pelvic pain and multiple comorbidities
Level 5: Lead multidisciplinary teams for care of patients with chronic pelvic pain; apply innovative approaches to complex and/or atypical chronic pelvic pain and implement treatment plans based on emerging evidence
The Milestones are a product of the Obstetrics and Gynecology Milestone Project, a Joint Initiative of the ACGME, ABOG, and ACOG
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Etiology Gynecologic
Infectious: PID, TOA, Endometritis, Cervicitis Ovarian: Functional cyst, Neoplasm, Torsion Endometriosis Leiomyomata Dysmenorrhea
Obstetric Early Pregnancy: Ectopic Pregnancy, Spontaneous Abortion Midtrimester/Late Pregnancy: Labor, Uterine Rupture, Abruptio Placenta,
Infection
Non Gynecologic Gastrointestinal: Appendicitis, Diverticulitis Genitourinary: Cystitis, Nephrolithiasis, Pyelonephritis Psychological: sexual abuse, depression Musculoskeletal
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Case 1
28 yo P1 presenting for acute onset of lower abdominal pain.
How do you evaluate her?
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Evaluation
History Identify life threatening condition requiring emergent
intervention Pain characteristics: Location, Quality, Timing, Alleviating or
Exacerbating factors, Associated symptoms Significant past history
Physical General: Vital signs, Appearance Abdominal Exam Pelvic Exam
Laboratory Pregnancy test and Type and Screen CBC Urinalysis, Urine culture Evaluation for Gonorrhea and Chlamydia
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Evaluation Imaging
Ultrasound CT abdomen/Pelvis X-ray MRI
Surgical Laparoscopy
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EndometriosisDefinition - extra uterine endometrial
tissue “glands and stromal”
Incidence 7-10% women35% infertile women75% women with chronic pelvic pain
Etiology- leading theories:Retrograde menstruationHematogenous or lymphogenous spreadCoelomic metaplasia
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EndometriosisSymptoms and signs variable and unpredictable
Common presenting complaints Dysmenorrhea Dyspareunia Infertility
Physical exam findings Uterorsacral nodularity Adnexal mass
Diagnosis Visualizations of lesions on laparoscopy Pathology of biopsy
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Endometriosis
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Endometriosis
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Endometriosis TreatmentDepends on the symptoms complaints
Medical NSAID’s Combined oral contraceptive pills Progestins GnRH agonists
Surgical Surgical ablation or removal of lesions LUNA Presacral Neurectomy TAH/BSO
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LeiomyomataBenign smooth muscle tumors of uterus
Prevalence - 1/3 of women
EvaluationHistory
Increased bleedingDysmenorrheaPelvic PainPelvic pressure
Physical exam findingsEnlarged uterusPelvic or Adnexal mass
Diagnostic Imaging Ultrasound
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Leiomyomata
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Leiomyomata
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LeiomyomataTreatment
MedicalNSAIDSCombined Oral Contraceptive PillsGnRH Agonist
InterventionalUterine Artery EmbolizationUltrasound/MRI guided ablation
SurgicalMyomectomyHysterectomy
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DysmenorrheaDefinitions:
Primary Dysmenorrhea-within 2-3 months of first menses Secondary Dysmenorrhea-usually with underlying cause
Etiologies-Endometriosis, Infections, adnexal mass, fibroids
Evaluation Assessment of underlying etiology
Management NSAIDS Combined Oral Contraceptives Treatment of underlying etiology
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Case 237 yo P2 presenting for her well woman visit
reports pelvic pain for the past year.
How do you evaluate her?
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Chronic Pelvic PainDefinition - lasting > 6 months, causing functional
disability
Incidence - 15% women
EtiologiesGYNGIGUNeurogenicPsychologicalMusculoskeletal
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Chronic Pelvic PainEvaluation
Focused on identification of underlying etiologyHistory
Focus on pain history and associated symptomsPhysical ExamLaboratory Imaging
TreatmentFocused on treatment of underlying etiology
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GynecologicEndometriosis
Leiomyomata
Infections-PID, TOA
Benign and Malignant Tumors
Vulvar and Vestibular Pain
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Non GynecologicGastrointestinal
Irritable Bowel syndrome Inflammatory Bowel DiseaseConstipationDiverticular Disease
GenitourinaryUTI-acute, recurrent, chronicCystitis-Infectious and interstitialUrolithiasisMalignancy
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Non GynecologicPsychological
AbuseDepression
MusculoskeletalAbdominal Wall and Pelvic Floor myofascial painHerniaDegenerative and Herniated Disc DiseaseFibromyalgia
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SummaryWide range of causes of pelvic pain in
women
Evaluation focused on identification of underlying etiology
Treatment aimed at treating pain and underlying cause
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Questions?
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Good Luck!Welcome to the amazing world of Obstetrics and
Gynecology
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