Evaluation of Abdominal and Pelvic Pain in Women Setul Pardanani, MD Assistant Professor, OB/GYN & Women’s Health Assistant Residency Program Director Albert Einstein College of Medicine Montefiore Medical Center

Objectives Review the common etiologies of abdominal and pelvic pain Review the evaluation of patients presenting with abdominal and pelvic pain Review treatment options

Milestone Abdominal/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 Obstetric Non 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 Initiate 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.

Evaluation Imaging Ultrasound CT abdomen/Pelvis X-ray MRI Surgical Laparoscopy In 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.

Endometriosis Definition - extra uterine endometrial tissue “glands and stromal” Incidence 7-10% women 35% infertile women 75% women with chronic pelvic pain Etiology- leading theories: Retrograde menstruation Hematogenous or lymphogenous spread Coelomic metaplasia

Endometriosis Symptoms 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 Treatment Depends 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

Leiomyomata Benign smooth muscle tumors of uterus Prevalence - 1/3 of women Evaluation History Increased bleeding Dysmenorrhea Pelvic Pain Pelvic pressure Physical exam findings Enlarged uterus Pelvic or Adnexal mass Diagnostic Imaging Ultrasound

Leiomyomata

Leiomyomata

Leiomyomata Treatment Medical Interventional Surgical NSAIDS Combined Oral Contraceptive Pills GnRH Agonist Interventional Uterine Artery Embolization Ultrasound/MRI guided ablation Surgical Myomectomy Hysterectomy

Dysmenorrhea Definitions: 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 2 37 yo P2 presenting for her well woman visit reports pelvic pain for the past year. How do you evaluate her?

Chronic Pelvic Pain Definition - lasting > 6 months, causing functional disability Incidence - 15% women Etiologies GYN GI GU Neurogenic Psychological Musculoskeletal

Chronic Pelvic Pain Evaluation Treatment Focused on identification of underlying etiology History Focus on pain history and associated symptoms Physical Exam Laboratory Imaging Treatment Focused on treatment of underlying etiology

Gynecologic Endometriosis Leiomyomata Infections-PID, TOA Benign and Malignant Tumors Vulvar and Vestibular Pain

Non Gynecologic Gastrointestinal Genitourinary Irritable Bowel syndrome Inflammatory Bowel Disease Constipation Diverticular Disease Genitourinary UTI-acute, recurrent, chronic Cystitis-Infectious and interstitial Urolithiasis Malignancy

Non Gynecologic Psychological Musculoskeletal Abuse Depression Abdominal Wall and Pelvic Floor myofascial pain Hernia Degenerative and Herniated Disc Disease Fibromyalgia

Summary Wide range of causes of pelvic pain in women Evaluation focused on identification of underlying etiology Treatment aimed at treating pain and underlying cause

Questions?

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