Evaluation of Abdominal and Pelvic Pain in Women

1. 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

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

3. MilestoneAbdominal/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

4. Etiology • 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

5. Case 1 • 28 yo P1 presenting for acute onset of lower abdominal pain. • How do you evaluate her?

6. Evaluation • History • Identify life threatening condition requiring emergent intervention • Paincharacteristics: 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

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

8. 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

9. 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

10. Endometriosis

11. Endometriosis

12. 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

13. 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

14. Leiomyomata

15. Leiomyomata

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

17. 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

18. Case 2 • 37 yo P2 presenting for her well woman visit reports pelvic pain for the past year. • How do you evaluate her?

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

20. Chronic Pelvic Pain • Evaluation • 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

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

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

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

24. 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

25. Questions?

26. Good Luck! • Welcome to the amazing world of Obstetrics and Gynecology