Presentation on theme: "Evaluation of Abdominal and Pelvic Pain in Women"— Presentation transcript:
1 Evaluation of Abdominal and Pelvic Pain in Women Setul Pardanani, MDAssistant Professor, OB/GYN & Women’s HealthAssistant Residency Program DirectorAlbert Einstein College of MedicineMontefiore Medical Center
2 Objectives Review the common etiologies of abdominal and pelvic pain Review the evaluation of patients presenting with abdominal and pelvic painReview treatment options
3 Milestone Abdominal/Pelvic Pain Level 1: Demonstrates a basic understanding of patients presenting with abdominal/pelvic pain regarding: Risk factors and Signs/SymptomsLevel 2: Demonstrates the ability to formulate a differential diagnosis and an understanding of the initial evaluation and treatment optionsLevel 3: Demonstrates the ability to utilize focused diagnostic approaches and formulate a comprehensive management planLevel 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 comorbiditiesLevel 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 evidenceThe Milestones are a product of the Obstetrics and Gynecology Milestone Project, a Joint Initiative of the ACGME, ABOG, and ACOG
5 Case 1 28 yo P1 presenting for acute onset of lower abdominal pain. How do you evaluate her?
6 EvaluationHistoryIdentify life threatening condition requiring emergent interventionPain characteristics: Location, Quality, Timing, Alleviating or Exacerbating factors, Associated symptomsSignificant past historyPhysicalGeneral: Vital signs, AppearanceAbdominal ExamPelvic ExamLaboratoryPregnancy test and Type and ScreenCBCUrinalysis, Urine cultureEvaluation for Gonorrhea and ChlamydiaInitiate the evaluation with a thorough history, first and foremost to identify life threatening conditions requiring emergent interventions. Then, establishing characteristics of the pain including location, quality, timing, associated factors and symptoms to help focus your differential diagnosis. A patients past history can also help to identify risk such as a infections, previous surgeries, abuse.The next step is to perform a physical exam. The vital signs can help to identify acute issues. Once noted to be stable, an assessment of the general appearance of the patient can be helpful. Is she lying comfortably or appears in distress. A focused abdominal exam to localize the pain and assess for guarding and rebound to identify signs of peritoneal irritation. The pelvic exam can help to assess for discharge, bleeding, masses and localization of the pain.
7 Evaluation Imaging Ultrasound CT abdomen/Pelvis X-ray MRI Surgical LaparoscopyIn regards to imaging, ultrasound is considered first line due to absence of radiation exposure and low cost. It is also is usually readiliy available and easy to utilize.
8 EndometriosisDefinition - extra uterine endometrial tissue “glands and stromal”Incidence7-10% women35% infertile women75% women with chronic pelvic painEtiology- leading theories:Retrograde menstruationHematogenous or lymphogenous spreadCoelomic metaplasia
9 Endometriosis Symptoms and signs variable and unpredictable Common presenting complaintsDysmenorrheaDyspareuniaInfertilityPhysical exam findingsUterorsacral nodularityAdnexal massDiagnosisVisualizations of lesions on laparoscopyPathology of biopsy
12 Endometriosis Treatment Depends on the symptoms complaintsMedicalNSAID’sCombined oral contraceptive pillsProgestinsGnRH agonistsSurgicalSurgical ablation or removal of lesionsLUNAPresacral NeurectomyTAH/BSO
13 Leiomyomata Benign smooth muscle tumors of uterus Prevalence - 1/3 of womenEvaluationHistoryIncreased bleedingDysmenorrheaPelvic PainPelvic pressurePhysical exam findingsEnlarged uterusPelvic or Adnexal massDiagnostic ImagingUltrasound
20 Chronic Pelvic Pain Evaluation Treatment Focused on identification of underlying etiologyHistoryFocus on pain history and associated symptomsPhysical ExamLaboratoryImagingTreatmentFocused on treatment of underlying etiology
21 Gynecologic Endometriosis Leiomyomata Infections-PID, TOA Benign and Malignant TumorsVulvar and Vestibular Pain
22 Non Gynecologic Gastrointestinal Genitourinary Irritable Bowel syndromeInflammatory Bowel DiseaseConstipationDiverticular DiseaseGenitourinaryUTI-acute, recurrent, chronicCystitis-Infectious and interstitialUrolithiasisMalignancy
23 Non Gynecologic Psychological Musculoskeletal Abuse Depression Abdominal Wall and Pelvic Floor myofascial painHerniaDegenerative and Herniated Disc DiseaseFibromyalgia
24 Summary Wide range of causes of pelvic pain in women Evaluation focused on identification of underlying etiologyTreatment aimed at treating pain and underlying cause