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

ObjectivesReview the common etiologies

of abdominal and pelvic pain Review the evaluation of

patients presenting with abdominal and pelvic pain

Review treatment options

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

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

Case 1

28 yo P1 presenting for acute onset of lower abdominal pain.

How do you evaluate her?

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

Evaluation Imaging

Ultrasound CT abdomen/Pelvis X-ray MRI

Surgical Laparoscopy

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

EndometriosisSymptoms and signs variable and unpredictableCommon presenting complaints

Dysmenorrhea Dyspareunia Infertility

Physical exam findings Uterorsacral nodularity Adnexal mass

Diagnosis Visualizations of lesions on laparoscopy Pathology of biopsy

Endometriosis

Endometriosis

Endometriosis TreatmentDepends on the symptoms complaintsMedical

NSAID’s Combined oral contraceptive pills Progestins GnRH agonists

Surgical Surgical ablation or removal of lesions LUNA Presacral Neurectomy TAH/BSO

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

Leiomyomata

Leiomyomata

LeiomyomataTreatment

MedicalNSAIDSCombined Oral Contraceptive PillsGnRH Agonist

InterventionalUterine Artery EmbolizationUltrasound/MRI guided ablation

SurgicalMyomectomyHysterectomy

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

Case 237 yo P2 presenting for her well woman visit

reports pelvic pain for the past year. How do you evaluate her?

Chronic Pelvic PainDefinition - lasting > 6 months, causing functional

disability

Incidence - 15% women

EtiologiesGYNGIGUNeurogenicPsychologicalMusculoskeletal

Chronic Pelvic PainEvaluation

Focused on identification of underlying etiologyHistory

Focus on pain history and associated symptomsPhysical ExamLaboratory Imaging

TreatmentFocused on treatment of underlying etiology

GynecologicEndometriosisLeiomyomataInfections-PID, TOABenign and Malignant TumorsVulvar and Vestibular Pain

Non GynecologicGastrointestinal

Irritable Bowel syndrome Inflammatory Bowel DiseaseConstipationDiverticular Disease

GenitourinaryUTI-acute, recurrent, chronicCystitis-Infectious and interstitialUrolithiasisMalignancy

Non GynecologicPsychological

AbuseDepression

MusculoskeletalAbdominal Wall and Pelvic Floor myofascial painHerniaDegenerative and Herniated Disc DiseaseFibromyalgia

SummaryWide range of causes of pelvic pain in

womenEvaluation focused on identification of

underlying etiologyTreatment aimed at treating pain and

underlying cause

Questions?

Good Luck!Welcome to the amazing world of Obstetrics and

Gynecology