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 unpredictable
Common 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 complaints
Medical 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
GynecologicEndometriosis
Leiomyomata
Infections-PID, TOA
Benign and Malignant Tumors
Vulvar 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
women
Evaluation focused on identification of underlying etiology
Treatment aimed at treating pain and underlying cause
Questions?
Good Luck!Welcome to the amazing world of Obstetrics and
Gynecology