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LaureMorin-Papunen

Lower Abdominal Pain of Gynaecological Origin

Essentials

  • The cause of lower abdominal pain is more often intestinal Acute Abdomen in the Adult than gynaecological.
  • Cyclic pain, bleeding disorders or a foul-smelling vaginal discharge suggests a gynaecological cause.

Status

  • Remember abdominal palpation (consider appendicitis in differential diagnosis).
  • When assessing the gynaecological status observe for the following
    • purulent cervical discharge
    • does moving the cervix produce pain
    • resistance next to the uterus.

Laboratory tests

  • Pregnancy test, chemical urinalysis, CRP, basic blood count with platelet count, chlamydia and gonorrhoea samples (first-void urine sample).

Other investigations

Patients of fertile age

Infection

  • Pelvic inflammatory disease Pelvic Inflammatory Disease (PID)
  • Acute endometritis
    • Infection after recent childbirth, spontaneous or induced abortion or the insertion of an IUD or other instrumentation.
    • Aetiological organisms are most commonly those of normal vaginal flora, aerobic or anaerobic cocci.
    • A foul-smelling discharge is an indicator of an anaerobic infection.
    • Symptoms
      • Acute illness a few days after insertion of the device or childbirth
      • Cold shivers
      • Lower abdominal pain
      • Tiredness
      • Fever, 39-40°C
      • Sometimes malaise
      • Sometimes headache or aching of the muscles
    • Signs
      • Pain on palpation in the lower abdomen around the uterus and the adnexa of the uterus. The upper abdomen is soft and painless.
      • In the pelvic examination the uterus is tender, firm and moveable.
      • Adnexa are of normal size.
    • Diagnosis
      • History of a procedure on the internal genitalia, and a typical clinical picture.
    • Treatment
  • Chlamydial infection often causes only few symptoms.

Extrauterine pregnancy

  • See Ectopic Pregnancy.
  • The severity of pain and bleeding varies.
  • The previous cycle may have been irregular, or there may have been extra bleeding. Amenorrhoea does not always occur.
  • Should always be considered when the pregnancy test is positive but there is no ultrasonographic evidence of pregnancy inside the uterus.
  • Ultrasonography
    • If the serum human chorionic gonadotrophin concentration is ≥ 1000 IU/l, the pregnancy should be detectable in the uterus. The pregnancy may sometimes be located in an old caesarean section scar.
      • If the uterine cavity is empty or only a small fluid cavity (pseudogestational sac) is visible, an ectopic pregnancy should be suspected. In such a case, a tubal or ovarian pregnancy is usually detected.
      • A typical view resembles a millstone; the homogenous placental tissue forms a thick ring around an anechoic central cavity. A minute foetus or a pulsating heart may sometimes be detected within the central cavity.
    • The detection of an abdominal pregnancy with ultrasound examination may be very difficult, or even impossible, in early pregnancy.
    • An ectopic pregnancy may also be located in the cervical canal or in the uterine cornua.

Ovulation

  • An acute, often unilateral pain in the middle of the cycle that usually subsides in 24 hours.

Torsion or rupture of an ovary or an ovarian cyst

  • See article Benign Gynaecological Lesions and Tumours.
  • The history may include twisting of the body, e.g. bowling, belly dancing or washing the floor on the knees.
  • In ultrasound the cyst may appear irregular and free fluid may be detected in the peritoneal cavity.
  • Rupture of the corpus luteum
    • The symptoms are similar to extrauterine pregnancy yet the pregnancy test is negative.
    • There is blood in the peritoneal cavity.
    • Treatment is operative if the pain is severe.
  • Rupture of an endometriosis cyst
    • The symptom is an acute and very severe irritation of the peritoneum.
    • Treatment is usually an acute operation.
  • Rupture of a dermoid cyst
    • Rare
    • Very painful because the sebum causes strong irritation in the peritoneal cavity.
  • Torsion of the ovary or the tube
    • The cause is usually a cyst.
    • Gynaecological investigation reveals a tender, possibly moveable mass.
    • In ultrasound the ovary may appear oedematous and hyperechoic. Rotated Fallopian tubes may form fluid cavities. In multiple torsion, colour Doppler usually fails to detect vascularity in the ovarian tissue.

Ovarian hyperstimulation syndrome (OHSS)

  • See Infertility.
  • All medicines used for the induction of ovulation (letrozole rarely) may cause OHSS, in which the reaction of the ovaries to the hormonal medication is excessive.
  • The syndrome typically begins 3-10 days after the induction.
  • The symptoms include abdominal pain, oedema, nausea, and in a severe case dyspnoea.
  • Ovarian ultrasonography Gynaecological Ultrasound Examination and basic blood count with platelet count are the primary tests, and CRP is used for differential diagnosis.
  • In strong suspicion of OHSS, gynaecological investigation should be avoided.
  • Refer readily to hospital or to the doctor in charge of the fertility treatment.

Torsion and necrosis of a pedunculated uterine myoma

  • The symptom is cyclic pain resembling childbirth.
  • The myoma may grow into the vagina through the cervix.
  • CRP is usually elevated.
  • Ultrasound: in case of necrosis the shape and structure of the myoma may change and it may shrink.

Malignant neoplasms

  • See Benign Gynaecological Lesions and Tumours.
  • May cause acute pelvic pain when they rupture or bleed, although this is rare.
  • The patient has a tender mass in the lower abdomen and often ascites.
  • Ultrasonography
    • As an ovarian tumour grows it may bleed either inside the tumour itself or to the surrounding tissues. The tumour may become twisted. Malignant tumours are often associated with ascites which may cause sudden and significant swelling of the abdomen.

Labour

  • Sudden severe acute pelvic pain may originate from a labour without the pregnant woman or her parents knowing of the pregnancy. Sometimes the pregnant female (usually a schoolgirl) knows but her mother does not.

Perforation of the vagina

  • The most common aetiologies are intercourse, or trauma caused by a foreign body.

Young patient without menses

Structural anomalies

  • The normal route for bleeding is blocked.
  • Symptoms
    • The pain is preceded by milder cyclic lower abdominal pain, and sometimes cyclic retention of urine.
    • Sudden severe pelvic pain, strong peritoneal irritation
  • Cause
    • The most common is an unperforated hymen.
    • Various anomalies of the uterus (e.g. a bifurcated uterus, one of part emptying into the vagina while blood collects in the other.
  • The treatment is operative.

Torsion or rupture of an ovarian cyst

  • Sudden pain
  • The treatment is operative

Postmenopausal women

Purulent endometritis (pyometra)

  • The cause is tightness of the cervix that is often due to treatment of the cancer of the cervix (e.g. loop electrosurgical, cryo- or laser-conization).
  • Symptoms
    • Begins gradually.
    • The condition becomes acute when a bloody and purulent discharge appears, and pain and fever begins.
  • Treatment
    • Depends on a specialist consultation.

Malignant neoplasm of the uterus

Ovarian neoplasm

Chronic lower abdominal pain

Causes