INTRODUCTION AND EPIDEMIOLOGY
This chapter reviews diagnosis and treatment of abdominal and pelvic pain in nonpregnant women, with a focus on gynecologic causes of pain. Even after the possibility of pregnancy is eliminated, abdominal pain in women remains a challenging diagnosis because of physical proximity and overlapping spinal segment innervation and similar symptoms of GI, urologic, and gynecologic organ systems. Discussion of the pregnant woman with abdominal/pelvic pain is found in Chapters 71, “Acute Abdominal Pain,” 100, “Maternal Emergencies After 20 Weeks of Pregnancy and in the Peripartum Period,” and 103, “Pelvic Inflammatory Disease.”
Define characteristics of the pain including onset, duration, location, quality, radiation, and exacerbating and alleviating factors. History should include questions about GI symptoms (nausea, vomiting, diarrhea, and constipation), urologic symptoms (dysuria, hematuria, frequency, and urgency), and gynecologic symptoms (vaginal bleeding, discharge, dyspareunia, and menstrual history). History of sexual activity and menstrual history should never be relied upon to exclude pregnancy. Obtain past medical, surgical, and family history, as well as details of prior pregnancies and outcomes. Active lactation and medication use, including specific methods of birth control, should be part of the history. Ask about infertility treatments because ovulation-inducing treatments increase risk of ovarian torsion, cysts, and ovarian hyperstimulation syndrome. When obtaining a sexual history and social history, it is wise to interview the patient alone, which may help patients feel more comfortable discussing potentially sensitive or embarrassing topics. Ask about pelvic inflammatory disease risk factors including unprotected intercourse, prior sexually transmitted infections, and multiple sexual partners. While the patient is alone, ask her about safety at home, and assess for any potential abusive situations. Patients with history of physical and sexual abuse may develop a variety of somatic complaints including abdominal and pelvic pain, and this pain is often chronic in nature. Social history should include living situation, occupation, and personal habits (use of tobacco, alcohol, and drugs).
A standard head-to-toe systematic approach beginning with vital signs is essential. The patient should be adequately undressed for a careful examination. In focusing on the examination of the abdomen, it is helpful to determine in what quadrant(s) of the abdomen the pain is located; this may help to narrow the differential diagnosis (see Figure 71-1).
In addition to palpating for tenderness or masses, evaluate for surgical scars, rashes, bruising, or ascites. Peritoneal signs may be less obvious in patients who are elderly, are obese, or have altered neurologic status. A digital rectal exam is helpful, if indicated, to evaluate complaints of rectal pain or bleeding.
A pelvic examination is usually a routine component of the exam of women with lower abdominal pain, but studies report a lack of accuracy and reproducibility of pelvic examination findings.1,2 Pelvic examination is useful for ...