Aboubakr Elnashar

Gynecological causes of acute abdominal pain

Prof. Aboubakr Elnashar, Egyptelnashar53@hotmail.com

Aboubakr Elnashar

CONTENTSINTRODUCTIONCAUSESSYSTEMATIC APPROACHALGORITHM CONCLUSION

Aboubakr Elnashar

INTRODUCTIONChallenging clinical scenario:History and physical examination findings: often nonspecificEarly diagnosis important to prevent sequelae of delayed diagnosisPID and ovarian torsion: infertilityEctopic pregnancy: hemoperitoneum

Aboubakr Elnashar

Types of painAcute pain: Chronic pain: Recurrent pain:Cyclic episodic pain rather than acute or chronic pain. MittelschmerzDysmenorrheaEndometriosis

Aboubakr Elnashar

Organic pain: Pain with an identifiable specific causeFunctional pain: without a clearly identifiable cause that is exacerbated by psychosocial factors

Aboubakr Elnashar

Typical sites of various causes of acute abdominal pain

Aboubakr Elnashar

Typical sites of various causes of chronic or recurrent abdominal pain

Aboubakr Elnashar

CAUSESA. Women of reproductive age

I. Pregnancy relatedEctopicSeptic abortionEndometritis: post-partum or post-abortionII. InfectionPIDTOAIII. Complicated ovarian cystTorsion, rupture, hemorrhage, OHSSIV. Complicated fibroidDegeneratingTorsion

Aboubakr Elnashar

B. Adolescents Similar + imperforate hymen and transverse vaginal septum

C. Postmenopausal womenSimilar –ectopic pregnancy and ovarian torsion

Aboubakr Elnashar

Most common causes of acute lower abdominal pain1. PID2. Ruptured ovarian cysts3. Appendicitis

Aboubakr Elnashar

CDC Criteria for Diagnosis of PID. (2006)At least one of the following criteria:1. Adnexal tenderness2. Cervical motion tenderness3. Uterine tendernessAdditional diagnostic criteria (enhances specificity if present):

1. Cervical or vaginal mucopurulent discharge2. Elevated CRP3. Elevated ESR4. Lab documentation of cervical infection with N gonorrhoeae

or C trachomatis5. Tem >38.3° C6. Saline microscopy of vaginal secretions: abundant

numbers of WBC

Aboubakr Elnashar

The most specific criteria for diagnosing PID:1. Endometrial biopsy: histopathologic

evidence of endometritis2. Laparoscopy: abnormalities consistent with

PID3. TVS or MRI: thickened, fluid-filled tubes with

or without free pelvic fluid or tubo-ovarian complex, or

Doppler studies suggesting pelvic infection (e.g., tubal hyperemia)

Aboubakr Elnashar

Adenxal torsion Pain: Twisting Lateral lower quadrant sudden onset Peritonism Fever, leucocytosis, N/VUS colour Doppler: no flow

Right adnexal torsion at the utero-ovarian pedicle.

Aboubakr Elnashar

EndometriosisPain:Acute Abdominal Pain {Rupture of an endometrioma}usually at menstruationMost commonly between 30 and 45 yUsually preceded by premenstrual lower abdominal pain Diagnosis: confirmed at laparoscopy

Aboubakr Elnashar

SYSTEMATIC APPROACH

Objective:To rule out: urgent life-threatening conditions : ectopic pregnancy, ruptured ovarian cyst, appendicitisfertility-threatening conditions: PID, ovarian torsion

Aboubakr Elnashar

I. HISTORY1. Personal: Age:AdolescentsWomen of reproductive agePostmenopausal women.

Aboubakr Elnashar

2. Present: LocationRadiationTime of onsetDurationRelation to menstrual cycleFrequency: constant, intermittentType: severe, crampy, achy, dullExacerbating and relieving factorsAssociated symptoms Treatment tried

Aboubakr Elnashar

Minutes Minute to hours to few

days

Days to weeks

Weeks to months

Ov cyst rupture Dysmenorrhea PID Endometriosis

Ov torsion Mittelschmerz Fibroids

TO abscess rupture

OHSS Sexual abuse

Appendicitis Diverticulitis Cystitis IBS

Ureterolithiasis GE PNP Inflammatory BD

Neoplasm

Ab wall myositis

Time of onset

Aboubakr Elnashar

Fibroids, Dysmenorhea, UTI Mid lowerJust above SP

Late appendicitisGE, IBS, IBD, diverticulitis

RLQ onlyLLQ only

Endometriosis, PID , Both sidesOvarian cyst, ovarian torsion, mittelschmerz, Endometriosis

On either one side or the other

Location

Aboubakr Elnashar

Right-sided pelvic painchallenging and can be confusing{close proximity of the appendix, uterus, right fallopian tube, and right ovary}. imaging to determine etiology.

Aboubakr Elnashar

3. Past:Surgery: abdominal and gynecologic. Gynecologic problems: 53% with ovarian torsion had a known history of ovarian cyst or mass (Houry D, Abbott,2001).

Aboubakr Elnashar

4. Sexual and STI history -Husband symptoms:Risks for PID and ectopic pregnancy. -Recent IUCD: PID risk 1st 3w: 6 times higher After that:similar to that in the general population (Farley et al, 1992)

Aboubakr Elnashar

II. PHYSICAL EXAMINATION1. Vital signs2. Abdominal3. Pelvic most important partrequired for any woman with abdominal or pelvic pain.

Aboubakr Elnashar

III. LABORATORY TESTING1. Urine analysis2. Pregnancy testSerum is more sensitive than urinaryβ-hCGSensitive to 25 mIU/mL3-4 days after implantation: positive7 days after implantation, or At time of the expected menses: 98% of the tests: positive.

Aboubakr Elnashar

3. Vaginal wet mountWBCs: support PID.4. Nucleic acid amplification tests (NAATs)Chlamydia and gonorrhea. Amplify and detect DNA and RNA sequences More sensitive than previous chlamydia and gonorrhea tests. Urine NAATs have sensitivities and specificities similar to those of cervical samples.

Aboubakr Elnashar

4. Other testsBased on the history and physical examination-Rh blood typing (if pregnant)-Urine culture-CBC-ESR: nonspecific marker of inflammation that can be associated with ectopic pregnancy .-Fecal occult blood test.

Aboubakr Elnashar

IV. IMAGINGGoal:Accurate diagnosis using the least amount of radiationTVS: imaging modality of choiceCT or MRI: negative or inconclusive TVS:most sensitive strategy{abdominal or pelvic CT: radiation dose 200 radiographs}

Aboubakr Elnashar

Ectopic pregnancyTVS should be conducted immediatelySerum β-hCG level o Discriminatory zone: β-hCG >1,500 mIU per mL

gestational sac should be visible if not, ectopic pregnancy should be suspected.However, one half of women presenting with ectopic pregnancy have β-

hCG levels less than 2,000 mIU per mL, which can make the distinction between early pregnancy and ectopic pregnancy difficult when an empty uterus is seen on TVS.

Aboubakr Elnashar

o Pseudo sac5 to 10% of ectopic pregnancies. Single echogenic ring. True sac: double echogenic rings (double decidual

sac sign).

Aboubakr Elnashar

o Heterotopic pregnancy:Ectopic pregnancy simultaneously with an

intrauterine pregnancy 1: 7,000 pregnanciesART: 1:100 pregnancies.

Aboubakr Elnashar

PID:Most common gynecologic cause of acute pelvic painEarly PID changes: ± not apparent on USlater changes: pyosalpinx and tubo-ovarian abscess, will be seen.

Aboubakr Elnashar

Tuboovarian abscess. (a) TVS: bilateral dilated folding tubular structures with thickened walls, internal echogenic fluid, and debris. (b) Axial contrast-enhanced CT: dilated tubular structures with thick enhancing walls. Inflammatory stranding of the surrounding fat is most demonstrable on the right (arrow).

Aboubakr Elnashar

Pelvic abscess. (a) TVS: a well-defined mass with thick walls and an internal fluid-

debris level. (b) Axial contrast-enhanced CT: left adnexal tuboovarian abscess

(arrow) with thick enhancing walls and complex internal fluid. The abscess resolved with conservative therapy.

Aboubakr Elnashar

Appendicitis:most common cause of nongynecologic painCan be diagnosed by USUS: sensitivity: 75 to 90%CT: sensitivity: 87 to 98%.Normal US: makes appendicitis less likely, but does not rule it out.

Aboubakr Elnashar

Other urgent conditionsUS: sensitiveHemorrhagic ovarian cystUterine fibroidsOvarian torsion.

Aboubakr Elnashar

TVS: Hemorrhagic ovarian cyst:with the characteristic lacelike echogenic pattern of fibrin strands that form as blood clots and retracts.

Aboubakr Elnashar

TVS: Adnexal torsion. an enlarged ovary (maximal diameter, >5 cm) with prominent peripheral nonovulatory follicles and a small amount of free fluid (arrow) around the inferior margin.

Aboubakr Elnashar

Color Doppler: Ovarian Torsion Red arrowheads shows absence of blood flow demonstrating ovarian torsion.diagnosis rests on ovarian enlargement with normal ovarian volume being up to approximately 15 cc.  Other suggestive findings are multiple peripherally based follicles.

Aboubakr Elnashar

TVS: Ruptured ovarian cyst.thick-walled ovarian cyst (corpus luteum) with surrounding anechoic free fluid, a finding indicative ofrupture.

Aboubakr Elnashar

TVS: Pedunculated fibroidheterogeneous, slightly hypoechoic mass (arrow) that is clearly attached to the anterior margin of the uterine fundus.

Aboubakr Elnashar

Degenerating fibroid. (a) Longitudinal TV color Dopplerinferior part of the uterus demonstrates a complex cystic mass with internal echogenicity and no internal vascularity. (b) Axial contrast-enhanced CT: an isoattenuating uterine mass with a well-defined complex cystic center (arrow) containing fluid and debris layering, a feature indicative of hemorrhagic degeneration.

Aboubakr Elnashar

TVS: Endometrioma large,well-defined, complex cystic mass with low-levelinternal echoes.

Aboubakr Elnashar

V. DIAGNOSTIC LAPAROSCOPY Rarely needed to make the diagnosis.

Aboubakr Elnashar

ALGORITHM

Aboubakr Elnashar

History, Examination, Pregnancy test

Pregnant

Yes: evaluate for ectopic: BHCG, TVS No

Right lower quadrant pain or pain migrating from umbilicus to RT lower quadrant

Yes: surgical consultation and laparotomy for appendicitis; if diagnosis in doubt: US or CT with IV contrast

No

Cervical motion, uterine, or adenxal tenderness

Yes: Consider PID: TVS for TOA No

Pelvic mass on examination

Yes: consider complicated ovarian cyst , complicated fibroid or endometriosis: TVS

No

Dysuria and WBC on urine analysis

Yes: Evaluate for UTI or PNP: urine culture No

Gross or microscopic hematuria

Yes: may be 2ndry to vaginal bleeding: consider stone kidney: stone protocol CT

No

TVS to evaluate for other diagnosis

Aboubakr Elnashar

CONCLUSIONThe most common urgent causes are ectopic pregnancy, ruptured or torsion ovarian cyst, PIDEarly diagnosis is important to prevent sequelae of delayed diagnosis Most diagnosis can be made with History examination , pregnancy test and TVS

Aboubakr Elnashar

As the first priority, urgent life-threatening conditions and fertility-threatening conditions must be considered. A high index of suspicion should be maintained for PID when other etiologies are ruled out, because the presentation is variable and the prevalence is high.

Aboubakr Elnashar

Benha University Hospital, Egypt

Email: elnashar53@hotmail.com

Prof. Aboubakr Elnashar

Thank you