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Abdominal and Pelvic Pain

Abdominal and Pelvic Pain. CAPT Mike Hughey, MC, USNR. Uncertainty of Diagnosis. “When I see a woman with abdominal or pelvic pain, I often haven't a clue as to what the problem is, even using ultrasound, a full lab, and countless consultants.”

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Abdominal and Pelvic Pain

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  1. Abdominal and Pelvic Pain CAPT Mike Hughey, MC, USNR

  2. Uncertainty of Diagnosis “When I see a woman with abdominal or pelvic pain, I often haven't a clue as to what the problem is, even using ultrasound, a full lab, and countless consultants.” “All I know is that the patient is sick with something.”

  3. The Point is: “In gynecology, the diagnosis is often obscure.” “You must frequently treat the patient before you know the correct diagnosis.”

  4. The Other Point is: “More important than knowing the correct diagnosis is doing the right thing for the patient.”

  5. Pain of Unknown Cause Bedrest for a few days is never the wrong thing to do.

  6. Pain and Fever • Give antibiotics to cover PID • Mild symptoms respond to PO drugs. • Severe symptoms respond to IVs.

  7. Chronic Pelvic Pain • Doxycycline • OCPs • Refer to GYN if pain persists

  8. Pregnancy Test Every patient complaining of lower abdominal pain should have a pregnancy test.

  9. BCPs and Pain • Most with chronic pain benefit from BCPs -dysmenorrhea -ovarian cysts -endometriosis -adenomyosis • Monophasic better • Cyclic vs. Continuous

  10. Dysmenorrhea • Painful Periods • Back ache • Pelvic cramps • NSAIDs • BCPs • If persistent and severe, laparoscopy to rule out endometriosis

  11. SUN MON TUE WED THU FRI SAT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Mittelschmerz • Mid-cycle pain • Unilateral • NSAIDs • BCPs P

  12. IUDs and Pain ALWAYS, remove the IUD

  13. IUDs and Pain •5% become infected•Pain, tenderness, fever•Remove IUD and begin ABx•Oral or IV, depending on high fever or severe symptoms.

  14. IUDs and Pain • Never push an IUD back in place if it is partway expelled. • Always remove an IUD if the patient complains of: -pelvic pain -tenderness -abnormal bleeding

  15. Ovarian Cysts • May be normal (<4 cm) • 95% disappear within 1-2 months • May cause problems: -delay menstruation -Rupture -Torsion -Pain

  16. Ovarian Cyst: Ruptured • May go unnoticed • May cause abdominal or shoulder pain • Usually resolves with rest alone • Sometimes requires surgery (bleeding)

  17. Ovarian Cyst: Unruptured • May go unnoticed • May cause pain • Usually resolve spontaneously • Sometimes requires surgery (pain) • Ultrasound scan of persistent cysts

  18. Ovarian Cyst: Torsioned • Severe unilateral pain • Marked rebound and rigidity • Surgery indicated within 24 hours • If surgery unavailable: -IVs, NPO, bedrest -Metabolic acidosis -20-50% Mortality

  19. Pelvic Inflammatory Disease (PID) • Bacterial inflammation of cervix, uterus, tubes and ovaries • Bilateral disease • 1st infection single agent • Repeat:multiple agents • Two categories: • Mild • Moderate to Severe

  20. PID: Mild • No fever • Bilateral pelvic pain • Cervical motion tenderness • WBC near normal • Doxy 100 BID #28, plus • Cefoxitin/Probenecid • Ceftriaxone • Ceftizoxime • Cefotaxime

  21. PID: Moderate to Severe • Fever > 100.4 • Bilateral pelvic pain • Cervical motion tenderness • WBC elevated • IV antibiotics

  22. PID Treatment : Moderate to Severe • Clinda/Gent • Ofloxacin/Flagyl • Amp/Sulbactam/Doxy • Cipro/Doxy/Flagyl • Doxy/Cefoxitin/Cefotetan

  23. Endometriosis • Progressive pelvic pain • Deep Dysparunia • Dysmenorrhea • Tender nodules in cul-du-sac

  24. Endometriosis: Treatment • Conservative Surgery • Radical Surgery • Danazol, Lupron • Continuous BCPs

  25. Degenerating Fibroid • Bulky, irregular, tender uterus • 40% of women >40 have them • Supportive treatment • Symptoms gradually resolve over ~3 weeks • Surgery for anemia, chronic pain, size >12 weeks

  26. Cystitis • Urgency, frequency, dysuria • Always treat • Push fluids (citric acid) • Any broad-spectrum ABx -Ampicillin (Amox) -Keflex -Bactrim DS -Doxycycline • Pyridium helps symptoms

  27. Pyelonephritis • Urgency, frequency, dysuria • Fever, flank pain/tenderness, chills • Push fluids (citric acid) • Any broad-spectrum Abx • Probably will need IV antibiotics

  28. Gastroenteritis • Diffuse, cramping pain • Nausea, vomiting, diarrhea • Fever, chills, distension • Pain moves from place to place • Supportive therapy • IV’s • Antibiotics • Cultures

  29. Functional Bowel Syndrome • Intermittent pain • Diarrhea/Constipation • Stress related • Moves from place to place • Supportive Rx: • Antispasmotics • No narcotics • No psychoactives

  30. Appendicitis • Progressive RLQ pain • Nausea/Anorexia • Guarding/Rigidity • Rebound • WBC variable

  31. Appendicitis: Treatment • Surgery • NPO/IVs • Antibiotics • Mefoxin/Gent • Flagyl/Gent • Amp/Sulbactam/Doxy • Clinda/Gent • Oflaxacin/Flagyl • Cipro/Doxy/Flagyl • Doxy/Cefoxitin/Cefotetan

  32. Bowel Obstruction • Cramping pain and distension • Hx: abdominal surgery • X-ray: distended loop • Most are partial obstructions • IV fluids • Decompression • Surgery

  33. Diverticular Disease • Variable presentation (mild to severe) • Cramping pain and distension • Blood streaked stool • Fever, WBC • IV fluids • Antibiotics • Sometimes Surgery

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