A. Description

1. Sudden onset versus Chronic
2. Often referred pain in contrast to true visceral pain
3. Patient Profile
   1. Age and Menstrual History
   2. Parity
   3. Sexual history including Oral Contraceptive Use
   4. Intrauterine Devices
   5. History of sexually transmitted disease
   6. Previous Appendectomy
4. Other Symptoms
   1. Fever
   2. Bleeding or Discharge

B. Pathophysiology

1. Stretching of hollow viscera or solid organ
2. Hypoxemia
3. Inflammation (edema) - peritoneal irritation
4. Traction, Stretching of Ligaments

C. Causes

1. Pregnancy
   1. Ectopic Pregnancy
   2. Persistent Ectopic Pregnancy
2. Pelvic Inflammatory Disease
   1. Salpingitis, Tubo-Ovarian Abscess (TOA)
   2. Adhesions, Fitz-Hugh-Curtis Syndrome
3. Endometriosis
4. Leiomyoma
5. Gastrointestinal
   1. Appendicitis
   2. Lactose Intolerance
   3. Irritable Bowel Syndrome
   4. Diverticulitis
6. Urinary
   1. Urethritis
   2. Stones
7. Cystic Disease
   1. Corpus Luteum, Ovarian Cyst
   2. Hemorrhage
   3. Rupture
8. Ovarian Torsion
9. Septic Abortion

D. Evaluation

1. Detailed History and Physical Examination including Pelvic Examination
2. Complete blood count, electrolytes, liver and renal functions, and PREGNANCY TEST
3. Rule Out Surgical Emergency
   1. Abdominal and Pelvic Examination - carefully
   2. Abdominal radiography (Supine and Upright)
4. Ultrasound
   1. Renal / Pelvic
   2. Vaginal

E. Diagnosis of Ectopic Pregnancy [1]

1. Diagnosis using ß-hCG levels, with or without serum progesterone levels
2. Can usually be made before 7th week of pregnancy (~4.5 weeks after conception)
3. If quantitative ß-hCG is >1500 then should see gestational sac on transvaginal ultrasound
4. If quantitative ß-hCG >5000 then should see sac on abdominal ultrasound
5. Pelvic or transvaginal ultrasound to rule out intrauterine pregnancy and confirm diagnosis

F. Cystic Disease

1. Presentation
   1. Cyclical or constant pain, localized to ovarian area
   2. Evidence of cystic Disease on Sonogram
2. Types of Cysts
   1. Simple (fluid filled) Ovarian Cyst
   2. Hemorrhagic Cyst
   3. Corpus Luteal Cyst
   4. Ruptured Cyst - sudden severe pain
3. Diagnosis and Treatment
   1. Ultrasound
   2. Laparoscopy with drainage
   3. Laparotomy: blood in peritoneum, with cystectomy
   4. Pathology Report
   5. Abdominal/Pelvic ultrasound with doppler to show restricted blood flow

G. Ovarian Torsion

1. Sudden, unilateral pain
2. Often radiates to flank
3. Nausea and Vomiting Common
4. Palpable Adnexal mass on examination
   1. Right to Left sided ratio 1.5 in most studies
   2. Obstruction of venous and lymphatic flow with edema formation
5. Treatment:
   1. Surgical correction
   2. Supportive Therapy with good Pain Management

H. Septic Abortion

1. Usually with non-sterile abortion conditions
2. Trauma to vagina and cervix
3. Diagnosis
   1. Appropriate History
   2. Pelvic Pain, Vaginal Bleeding and/or Discharge
   3. Fever / Chills
   4. Possible Septic Shock including DIC
   5. Gram Stain may show G+ Rods (Clostridium)
   6. Abdominal Radiograph
4. Treatment
   1. Tetanus Prophylaxis
   2. Supportive therapy for tetanus
   3. Laparotomy with total hysterectomy if severe or unstable
   4. Broad Spectrum antibiotics, with anaerobic coverage
   5. Vancomycin, Gentamicin (or Ceftriaxone), and Metronidazole may be used
   6. Single agent such as Timentin® (Ticarcillin-Clavulonate) or Piperacillin-Sulbactam

I. Other Causes of Pain

1. Infection of Glands of Female Reproductive Tract
   1. Periurethral Glands
   2. Bartholemic Glands
   3. Vestibular Glands
2. Mass on Pelvic Sonogram
   1. Cyst
   2. Abscess
   3. Hydrocele

References

1. Pisarska MD, Carson SA, Buster JE. 1998. Lancet. 351(9109):1115