Lower Abdominal Pain - an overview (2022)

Defined as cyclic lower abdominal pain of at least 6 months' duration or noncyclic pain of 3 months' duration, either of which affects normal activities.

From: Clinical Gynecology, 2006

Related terms:

  • Pelvic Inflammatory Disease
  • Pelvis
  • Strangury
  • Vaginal Discharge
  • Diarrhea
  • Abdominal Pain
  • Ectopic Pregnancy
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Gynecologic Procedures

James R. Roberts MD, FACEP, FAAEM, FACMT, in Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 2019

Pelvic and Lower Abdominal Pain

Pelvic examination, particularly bimanual examination, is often performed for pelvic and lower abdominal pain. The pain can be caused by problems in the urinary tract, intestinal tract and the reproductive tract (in both pregnant and nonpregnant patients). Urinary tract conditions include ureteral colic, cystitis and pyelonephritis. Intestinal tract conditions include appendicitis, diverticulitis, inflammatory bowel disease, bowel obstruction or ischemia, and a perforated viscus. Reproductive tract conditions include ectopic pregnancy, threatened abortion, endometritis, endometriosis, corpus luteal cyst, salpingitis (PID and TOA), ovarian cyst, ovarian torsion, round ligament pain, uterine fibroids, and uterine perforation. Later in pregnancy three conditions of importance are ectopic pregnancy, placenta previa (which is most often painless), and placenta abruption, all of which are suggested by vaginal bleeding. Conditions that may cause pain in the nonpregnant patient include salpingitis (PID), TOA, ovarian cyst, ovarian torsion, endometriosis, round ligament pain, uterine perforation, or uterine fibroids. Painless third trimester bleeding may be caused by placenta previa, in which a separated placenta is near or at the cervical os. Because manipulation of the uterus may further dislodge the placenta, defer rectal examination, speculum examination, and manual examination of the vagina to an obstetric professional. PID and TOA are often associated with vaginal discharge and fever. Endometriosis is often associated with dyspareunia and dysmenorrhea.

The paediatric uterus, ovaries and testes

Gurdeep S. Mann, ... Paul S. Sidhu, in Clinical Ultrasound (Third Edition), 2011

Gynaecological causes of pelvic pain

Lower abdominal and pelvic pain is a common indication for ultrasound examination in the paediatric population. Pelvic pain in children is often a fairly non-specific clinical symptom. Adnexal pathology seen commonly in adults is becoming much more prevalent in adolescents. The sonographer should keep in mind the possibility of pregnancy (ectopic or otherwise), tubo-ovarian abscess as a complication of pelvic inflammatory disease and endometrioma in the differential of pelvic pain or adnexal mass lesion in the adolescent. These topics are covered in detail in the relevant adult chapters (see Chapters 35 and 39Chapter 35Chapter 39).

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Chlamydia trachomatis (Trachoma and Urogenital Infections)

John E. Bennett MD, in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 2020

Epididymitis and Prostatitis

C. trachomatis279 andN. gonorrhoeae are the most frequent causes of epididymitis in men younger than 35 years, whereas Enterobacteriaceae (primarilyE. coli) are the usual pathogens in men older than 35 years.280 In younger men, urethritis is usually also present but may be asymptomatic and only noted on examination. The absence of urethritis does not exclude chlamydial infection or gonorrhea as the cause of epididymitis. Most men withE. coli epididymitis have other risk factors for urinary tract infection, including recent catheterization, urologic surgery, or rectal insertive intercourse. Chlamydial epididymitis is often associated with oligospermia during the acute phase,281 but there are no data indicating that future fertility is impaired. In addition, epididymitis is usually unilateral, and attempts to correlate chlamydial infections with male factor infertility have been unsuccessful.282 A presumptive diagnosis of epididymitis in the setting of NGU can be confirmed as chlamydial in etiology by a NAAT on first-void urine sample (Table 180.3).

Typically, acute epididymitis presents with unilateral testicular pain and tenderness, hydrocele, and palpable swelling of the epididymis.209,280 Patients also have dysuria, fever, and, in some cases, shaking chills. Many patients can be managed in the outpatient setting, but others require hospitalization for parenteral antibiotics, scrotal elevation, analgesia, and observation. An alternative diagnosis of testicular torsion should always be considered in a young man with acute onset of severe unilateral scrotal pain and should be ruled out with ultrasound.

The role ofChlamydia in prostatic infection remains controversial. From available data, this bacterium does not appear to play a role in acute prostatitis, which is mainly caused byE. coli, other gram-negative rods, or enterococci. Its role in chronic nonbacterial prostatitis remains more controversial. Although some investigators have recoveredC. trachomatis from prostatic expressate or biopsies, convincing evidence thatChlamydia plays an etiologic role in chronic nonbacterial prostatitis has yet to be developed and antibiotic therapy is not recommended.283

Disorders of the Female Pelvis

Lesley L. Breech MD, in Adolescent Medicine, 2008

Lower Abdominal Pain

Pelvic and lower abdominal pain peaks in prevalence during adolescence and is three times more common in females than males. The differential diagnoses for acute and chronic, recurrent pain are shown in Boxes 24–1 and 24–2, respectively.

The evaluation of acute pelvic pain in a female of reproductive age must include pregnancy testing. Ectopic pregnancy, which typically presents with pain and bleeding, remains a leading cause of maternal mortality in the United States. If ectopic pregnancy is diagnosed or strongly suspected, emergency surgery is indicated. Clinical suspicion should always be high in a patient with pelvic pain, bleeding, positive urine or serum testing for beta-human chorionic gonadotropin (beta-HCG), and the absence of an intrauterine gestational sac on transvaginal ultrasonography. Other factors that support the diagnosis include history of prior ectopic pregnancy, PID, pelvic surgery, or intrauterine device; missed menstrual periods; symptoms of pregnancy; and fullness in the cul-de-sac or adnexa.

Chronic or recurrent abdominal pain affects up to 5% of adolescent females. The difficulty establishing a diagnosis often leads to anxiety and frustration for patients, families, and clinicians. Although the differential diagnosis is extensive and the evaluation can be lengthy, 95% of cases in one series had no identifiable organic pathology (i.e., functional pain). Factors associated with functional pain include environmental stress, absence of pain during sleep, variable location or description of the pain, family history of unexplained abdominal pain, and absence of weight loss.

The evaluation of an adolescent with acute or chronic pelvic pain should include a menstrual and sexual history; evaluation of growth and weight change; skin and mucosal examinations for rash or ulceration; joint examination for arthritis (e.g., inflammatory bowel disease); abdominal examination; rectal examination with testing for occult blood; and pelvic examination as tolerated. At a minimum, the patency of the reproductive outflow tract should be verified by inserting a cotton-swabbed applicator into the vagina. Whenever possible, a vaginal-abdominal or recto-abdominal examination should be performed to palpate the cervix, uterus, and adnexae. However, the pelvic examination should not be considered mandatory in the young, virginal adolescent. If the bimanual examination is inadequate or indeterminate, pelvic ultrasonography is indicated to help define the pelvic anatomy.

Laboratory evaluation should be guided by the findings on history and physical examination but generally should include urine testing for beta-HCG, complete blood cell count, erythrocyte sedimentation rate or serum C-reactive protein, and urinalysis.

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Pediatric and Adolescent Gynecology

Basil J. Zitelli MD, in Zitelli and Davis' Atlas of Pediatric Physical Diagnosis, 2018

Pelvic Inflammatory Disease

PID is an important complication of lower genital tract infection in the postmenarchal female, resulting from ascending spread of cervical infection that may or may not have been symptomatic. AlthoughN. gonorrhoeae andC. trachomatis often play a critical initiating role, PID often occurs without evidence of either of these infections, and this does not alter treatment recommendations. The majority of cases involve a mixture of aerobic and anaerobic organisms, including those which are considered normal vaginal or enteric flora, but are pathogenic in the upper genital tract (seeBox 19.7). Women who are immunocompromised or from areas where tuberculosis is endemic can develop tuberculosis-associated PID.

Risk factors for developing PID include adolescent age, multiple sexual partners, and previous PID. Because menstruation facilitates ascent of pathogenic organisms from the cervix to the uterus and fallopian tubes, symptoms often begin during or shortly after a menstrual period. Long-term morbidity includes an increased incidence of ectopic pregnancy, decreased fertility, and chronic pelvic pain resulting from tubal occlusion and scarring of pelvic structures. Adverse sequelae may be more severe among patients withChlamydia-positive or non-GC/C. trachomatis infection, delayed diagnosis and treatment, and repeated infection.

The “textbook” picture of acute PID includes abrupt onset of high fever and shaking chills in association with intense lower abdominal pain, nausea, and vomiting. The patient appears acutely ill and may walk with a shuffling gait. On examination, there is prominent lower abdominal tenderness and guarding, and mucopurulent cervical discharge. Bimanual palpation of the uterus, adnexa, and cervix reveals marked tenderness. Adnexal fullness, if present, suggests abscess formation. The erythrocyte sedimentation rate is markedly elevated, and there is a pronounced leukocytosis with a left shift on complete blood count (CBC) and differential. However this “classic” picture is not the most typical. More commonly, the onset of symptoms is insidious and the clinical picture more subtle. Fever may be absent or low grade; abdominal pain, mild; and blood work, normal. In such cases, diagnosis can be difficult, requiring considerable suspicion and a low threshold for obtaining specimens. Lower abdominal, pelvic, and/or cervical motion tenderness and some evidence of lower genital tract inflammation usually are present even in clinically mild cases.

Acute salpingitis may mimic a number of other disorders (Box 19.9) and is particularly challenging when the presentation includes right lower quadrant abdominal pain (Fig. 19.36).Table 19.7 summarizes clinical findings that may aid in distinguishing among some common causes. Ultrasonography is normal in most cases of PID. Optimal imaging is achieved with a transvaginal probe; however, this may be particularly painful in women with PID. Most of the time, transabdominal ultrasound will be sufficient to evaluate for other causes or the presence of a tubo-ovarian complex. Given the variable clinical picture in PID, minimal diagnostic criteria have been developed. These include lower abdominal or pelvic pain, and cervical motion or uterine or adnexal tenderness. Treatment should follow current CDC recommendations. It should be noted that beyond the first 3 weeks after insertion, intrauterine devices (IUDs) do not confer an increased risk of PID. Removal of an IUD during PID treatment should only be considered if symptoms do not respond to treatment in 72 hours.

APPENDICITIS

Shawn D. St. Peter MD, in Ashcraft's Pediatric Surgery (Fifth Edition), 2010

DIFFERENTIAL DIAGNOSIS

In the patients with lower abdominal pain, the workup toward a diagnosis of appendicitis must also consider the alternative possible causes. Causes of acute right lower quadrant pain that is indistinguishable from appendicitis without laboratory or imaging studies include a tubo-ovarian pathologic process, Crohn’s disease, mesenteric adenitis, cecal diverticulitis, Meckel’s diverticulitis, constipation, viral gastroenteritis, and regional bacterial enteritis (Yersinia and Campylobacter, particularly). Lower abdominal pain or vague nonfocal pain can result from a urinary tract infection, kidney stone, ureteropelvic junction obstruction, uterine pathologic process, right lower lobe pneumonia, sigmoid diverticulitis, cholecystitis, pancreatitis, gastroenteritis, vasculitis, bowel obstruction, and malignancy (lymphoma). The most common diagnosis made in the presence of missed appendicitis has been reported to be gastroenteritis.17 Although many of these conditions may seem easily distinguished from appendicitis, they all possess a spectrum of presentation that overlaps the possible symptoms of appendicitis.

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Sexually Transmitted and Urinary Tract Infections

Arlene C. Seña, ... Myron S. Cohen, in Tropical Infectious Diseases (Third Edition), 2011

Clinical Manifestations

A patient presenting with lower abdominal pain accompanied by an abnormal vaginal discharge should be suspected of having PID. Other symptoms suggestive of PID include abnormal uterine bleeding, dysuria, dyspareunia, menometrorrhagia, pain associated with menses, nausea, vomiting, and fever. Physical examination may reveal a purulent cervical discharge, cervical motion, and adnexal tenderness. A patient presenting with symptoms of PID and pleuritic upper abdominal pain should raise suspicion for perihepatitis and peritonitis due to extension of the infection to the subphrenic and subdiaphragmatic space, a condition known as the Fitz-Hugh–Curtis syndrome.

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Gynecologic and Obstetric Emergencies

Paul S. Auerbach MD, MS, FACEP, FAWM, ... Eric A. Weiss MD, FACEP, in Field Guide to Wilderness Medicine (Third Edition), 2008

Septic

1.

Associated with lower abdominal pain, tenderness, and fever

2.

Endometritis or parametritis after a spontaneous or therapeutic abortion

3.

Can lead to septic shock

Signs and Symptoms

1.

History suggestive of early pregnancy including late or missed period and breast tenderness

2.

Positive urine pregnancy test with above signs and symptoms

3.

Spontaneous abortion presents as abnormal vaginal bleeding, followed by uterine cramping.

4.

Bleeding can vary from dark red spotting to bright red clots.

5.

Consistency may be gritty, with passage of products of conception.

6.

Cervix may be dilated or closed.

Treatment

1.

Unless a pretrip ultrasound has verified an intrauterine pregnancy, immediately evacuate the victim to rule out ectopic pregnancy.

2.

Keep the victim at “bed rest.”

3.

Direct all field treatment to volume replacement.

4.

Evacuation of uterus to prevent further hemorrhage or infection will be necessary once transported to medical facility.

5.

Treatment of septic abortion will involve broad-spectrum intravenous antibiotics.

6.

Treatment of shock until evacuated.

7.

Under wilderness conditions, control of significant maternal hemorrhage accompanying miscarriage may be difficult. Once the uterus is empty, uterine involution, spontaneous or aided by uterine massage, is usually sufficient to impede bleeding from the implantation site. In the absence of the ability to perform curettage, treatment with methylergonovine, 0.2 mg PO or IM, can enhance uterine contractions, accelerate expulsion of products of conception, and promote uterine involution to maintain hemostasis while plans are being made for evacuation of the victim. Methylergonovine should not be used in persons with hypertensive disorders or vascular disease unless the benefits outweigh the risks of generalized vasoconstriction. As an alternative, carboprost tromethamine 250 micrograms IM, or misoprostol 100 micrograms PO or vaginally, can be administered to stop uterine bleeding with less risk for cardiovascular compromise.

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Nonlimb Nerve Compressions or Entrapments

Aaron G. Filler, in Nerves and Nerve Injuries, 2015

Nerve Entrapments of the Anterior Pelvis

Evaluation of groin and lower abdominal pain involves a wide array of medical specialists, including general surgeons concerned with hernias, gastroenterologists, and urologists; however, once the specialists have eliminated the presence of an inguinal hernia, radiating pain from the hip joint, and dysfunction of the bladder or intestines, they can consider the possibility of a purely neural basis for the symptoms in this region. In addition, because of the very large number of hernia surgeries and other low abdominal incisions, postsurgical pains in the distribution of anterior abdominal nerve courses may become a clinical concern.

The clinician can consider the iliohypogastric, ilioinguinal, and genitofemoral nerves in a peripheral nerve evaluation of the lower abdomen (Jansen, Mens, Backx, Kolfschoten, & Stam, 2008). There is individual variation and overlap involving both the nerve courses and the distal nerve distributions, as well as considerable structural complexity, so that various differently innervated tissue layers overlap and may be difficult to distinguish based on physical exam.

As with ovarian tissue, testicular tissue has minimal somatic innervation so that direct sensation is dominated by sympathetics. However, the testes, like the spermatic cord, carry a number of closely applied layers that do have body wall somatic innervation. As a result, the most anterior innervated midline structure in the male anatomy is the penis, with the dorsal nerve of the penis being pudendal in origin (S2, S3, and S4). For female anatomy, it is the dorsal nerve of the clitoris. Immediately posterior to the dorsal nerve of the penis is the anterior wall of the scrotum, which has innervation from the genital branch of the genitofemoral nerve (L2), but immediately deep to this are the body wall layers of the spermatic cord carrying ilioinguinal nerve branches (L1). The sympathetic fibers innervating the testes can refer pain as high as T10. The posterior wall of the scrotum is innervated by perineal branches of the pudendal nerve so that it is abruptly back down to S3 for innervation.

Nerve impingements can present with local pain at the site of impingement, referred pain in the distal distribution of the nerve, and referred pain proximally in the nerve’s segment of origin. Impingement of the ilioinguinal and genitofemoral nerves therefore produces direct sensitivity in the groin upon physical exam. Deep palpation affects the obturator nerve medial to the femoral artery and the femoral nerve lateral to the femoral artery, as well as the obturator internus by transmission of the effects of palpation through the obturator window.

Because of these complexities of segmental origin and overlapping layers and courses, the peripheral nerve specialist needs to rely on several helpful methodical principles in diagnosing and treating problems in this area. An injury in the area of the medial groin or spermatic cord can simultaneously involve all of the nerves and structures mentioned in the preceding three paragraphs, but it is likely that only a single nerve is responsible for problem that has brought the patient to the nerve specialist.

As an initial method of evaluation, an injection block approach can be helpful when directed at the inguinal ligament and fold beginning a few centimeters distal to the anterior superior iliac spine (ASIS) along the inguinal ligament. From this point, it is possible to block the ilioinguinal and genitofemoral nerves and sometimes the iliohypogastric nerve as well. When a block of this type produces significant inguinal and genital numbness (proving an effective block), while at the same time blocking the patient’s pain, the clinicians has ruled out the femoral nerve, obturator nerve, pudendal nerve, and sympathetic or enteric sources, thus proving a likely treatable peripheral nerve issue.

The iliohypogastric is the more superiorly arising L1 nerve, and it is most likely to be involved uniquely in lower abdominal pain involving the area of the pubis and even the inferior portions of the rectus abdmonis. The ilioinguinal nerve is the more inferior L1-originating nerve of the inguinal region, and it is most likely to be involved in the spermatic cord, testicular wall, and the skin of inguinal crease. The genitofemoral nerve is L2 in origin, and it descends on the anterior surface of the psoas, but its genital branches can pass through the inguinal ring so that they travel distally along with ilioinguinal nerve into the scrotum, while the femoral branches may overlap with ilioinguinal innervation of the inguinal crease and uppermost thigh.

The most important surgical issues typically involve the use of neuroplasty to release the ilioinguinal, genitofemoral, and/or iliohypogastric nerves in the inguinal crease. Very often, the peripheral nerve surgeon is called on to deal with these nerves after entrapment or injury has resulted from prior surgery in this area. In many cases, after proving the involvement of these nerves by injection block, the surgeon can enter the inguinal crease through a small incision and then methodically separate layers, identifying these small nerve elements to the best extent possible and then accomplishing the neuroplasty. Intraoperative stimulation may help the surgeon locate the nerve elements because the genitofemoral nerve innervates the cremaster muscle, including its smaller female version. Neuroplasty for the iliohypogastric nerve may involve extension into the subcutaneous tissues of the lower anterior abdominal wall where the nerve could be entrapped in fibrosis associated with any of a variety of lower abdominal surgical incisions.

Inguinal hernia surgery is an extraordinarily common surgery, and some estimates suggest more than 10 million operations per year globally, including more than a million per year in the United States alone. So, it is not surprising that some will lead to persistent nerve pain in the inguinal region. Such iatrogenic pain may result from general fibrosis, either from the closure line or from a tissue reaction to surgical retraction, entrapment or compression by surgical meshes that stiffen after implantation, or the capture of the nerve element in a stitch or a small spiral fixator device “screwed” into place to secure a mesh to the body wall for endoscopic abdominal work. It is not necessarily imperative to work with a hernia surgeon, although overly aggressive decompression could weaken the abdominal wall, requiring repair.

Many hernia surgeons assume that the appropriate treatment for a painful posthernia inguinal nerve entrapment syndrome should involve severing these nerves. This type of aggressive neurectomy is actually a full time specialty for some general surgeons. This procedure may indeed resolve the pain in some patients, but the neurectomy often either fails to locate the actual involved nerve or, worse, succeeds initially but causes a painful neuroma that is very difficult to manage. When called to treat such a neuroma, the surgeon might be most successful by mobilizing, resecting, and revising the nerve and then trying to drop it into the abdomen where it is not subject to the mechanical pressures affecting the inguinal region during sitting and walking. Overall, a neuroplasty should be the first approach to the posthernia nerve pain problem because it is often very effective, and it would still be possible for the patient to find a surgeon to perform a neurectomy as a second measure if the neuroplasty fails. The use of neurectomy to treat any nerve pain remains controversial because of the difficulty of managing the adverse outcomes of a painful neuroma when it arises.

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Cervical and Uterine Cancers

Tai Lahans L.AC., M.TCM, M.Ed., in Integrating Conventional and Chinese Medicine in Cancer Care, 2007

Accumulation of damp heat

Symptoms: odorous leukorrhea, lower abdominal pain, dark urine, possibly constipation, bitter taste, foul breath.

Tongue: dark red with possible greasy yellow coat.

Pulse: fast and wiry/slippery.

Treatment principle: clear heat, drain dampness, clear toxin, antineoplasm.

Formula:23

chong lou (Paridis Rhizoma; Paris)15 g
bai hua she she cao (Hedyotis diffusae Herba; Oldenlandia)25 g
ban zhi lian (Scutellariae barbatae Herba; Scutellaria barbata)30 g
tu fu ling (Smilacis glabrae Rhizoma; Smilax glabra)25 g
yi ren (Coicis Semen; Coix lacryma-jobi)25 g
jiao gu lan (Herba Gynostemmatis; Gynostemma)20 g
zhu ling (Polyporus; Polyporus – Grifola)15 g
fu ling (Poria; Poria cocos)15 g
bai zhu (Atractylodis macrocephalae Rhizoma; Atractylodes macrocephala)15 g
huang qin (Scutellariae Radix; Scutellaria baicalensis)10 g
jin yin hua (Lonicerae Flos; Lonicera)15 g
tai zi shen (Pseudostellariae Radix; Pseudostellaria heterophylla)15 g
shan yao (Dioscoreae Rhizoma; Dioscorea opposita)15 g
yu jin (Curcumae Radix; Curcuma longa rhizome)15 g
gan cao (Glycyrrhizae Radix; Glycyrrhiza; licorice root)5 g

This is a strong formula for an aggressive tumor at a later stage. There are several antineoplastic herbs, including chong lou, bai hau she she cao, ban zhi lian, jiao gu lan, huang qin, jin yin hua. They all clear heat and toxin. The herbs that drain damp are yi ren, zhu ling and fu ling. These herbs are also antineoplastic by improving NK cell activity, increasing WBCs and phagocytosis, and they are also radiosensitising herbs. Tu fu ling reduces inflammation, clears damp heat toxins and is also antineoplastic. Tai zi shen tonifies qi while generating fluids, which is important in draining dampness and clearing heat. Shan yao tonifies the qi of the spleen and kidneys. Yu jin moves blood and circulates the liver qi in order to provide better access to the tumor for the herbs in the formula and cytotoxic agents like radiation or chemotherapy.

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