{"paper_id":"b67434ef-ff97-4b16-8ad1-61c5cf1b8d48","body_text":"~ 152 ~ \nInternational Journal of Advanced Research in Medicine 2020; 2(2): 152-156 \n \n \n  \n \nE-ISSN: 2706-9575 \nP-ISSN: 2706-9567 \nIJARM 2020; 2(2): 152-156 \nReceived: 14-05-2020 \nAccepted: 22-06-2020 \n \nRawaa Abdulraheem Hasan \nMinistry of Health, Baghdad \nMedical office, Al-Russafa, \nFatima Al-Zahraa Maternity \nHospital for Women and \nChildren, Baghdad, Iraq \n \nZainab Naji Hashim \nMinistry of Health, Baghdad \nMedical office, Al-Russafa, \nFatima Al-Zahraa Maternity \nHospital for Women and \nChildren, Baghdad, Iraq \n \nSana Abd Al Hadi Abed \nMinistry of Health, Baghdad \nMedical office, Al-Russafa, \nFatima Al-Zahraa Maternity \nHospital for Women and \nChildren, Baghdad, Iraq \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nRawaa Abdulraheem Hasan \nMinistry of Health, Baghdad \nMedical office, Al-Russafa, \nFatima Al-Zahraa Maternity \nHospital for Women and \nChildren, Baghdad, Iraq \n \nAbdominal-pelvic pain in gynecology \n \nRawaa Abdulraheem Hasan , Zainab Naji Hashim  and Sana Abd Al \nHadi Abed \n \nDOI: https://doi.org/10.22271/27069567.2020.v2.i2c.60 \n \nAbstract \nAbdominal-pelvic pain is a complex entity, sometimes difficult to diagnose, which requires a thorough \nanalysis to determine its causes and the most appropriate treatment. It involves various  viscera, so \nfrequently the approach must be multidisciplinary and sometimes requires rapid action since the life of \nthe patient is at stake  only the causes of gynecological origin have been exposed in this work as we \nunderstand that the rest of the pathologies correspond to explain them to other specialties. \nA table of differential diagnosis is presented between the most frequent causes of pelvic pain of \ngynecological origin. \n \nKeywords: Pelvic pain, Ovarian torsion, Ectopic pregnancy, Pelvic inflammatory d isease, \nEndometriosis \n \nIntroduction \nAcute abdominopelvic pain is one of the most frequent causes of gynecological consultation \nand the most frequent cause of hospitalization. \nThe most important initial assessment to be performed is to determine if it is an  acute \nsurgical abdomen and if it requires immediate hospitalization. It is important to rule out \npregnancy when starting the evaluation of the patient (consider the possibility of a ruptured \nectopic pregnancy, which can become life-threatening). \nAmong the  possible diagnoses are: ectopic pregnancy, torsion of an ovarian cyst (the \nimportance of its early diagnosis lies in a rapid intervention to preserve the ovary and the \ntube), dysmenorrhea, endometriosis and fibroids. \nTimely diagnosis of acute pelvic pain is critically important because delay could increase \nmorbidity and mortality. The accurate history is key to establishing the correct diagnosis. It \nis necessary to verify the date and character of the last two menstrual periods and the \npresence of bleeding or abnormal discharge. \n  \nAcute pelvic pain \nThe onset, character, location and pattern of radiation of pain must be taken into account and \ncorrelated with changes (urination, defecation, intercourse, physical activity), the regularity \nof menstrual periods,  the possibility of of pregnancy, the presence of vaginal bleeding or \ndischarge, medical and surgical history. A recent history of dyspareunia or dysmenorrhea is \nsuggestive of pelvic pathology. The most common causes of acute pelvic pain in women \ninclude: pelvic inflammatory disease (PID), adnexal masses or cysts with torsion, rupture or \nbleeding, ectopic pregnancy, endometritis or myoma degeneration, infarction or torsion.  \nWhen presenting with a woman with an abdominopelvic pain, the most important initial  \nevaluation is to determine whether it is an acute surgical abdomen. The next two \nconsiderations are to find out if you are pregnant, (consider the possibility of ectopic \npregnancy) and if  requires immediate hospitalization. A rapid evaluation should be do ne to \nidentify patients who require urgent surgical intervention, including history, if possible, and \nphysical examination, including pelvic exam. There may be signs of severity that indicate the \nneed for urgent surgery (hemodynamic instability: hypotensio n, confusion, diaphoresis, \nclouding) \nIt is important to determine the history of the pain: how and when it started: the presence of \ngastrointestinal symptoms (eg anorexia, nausea, vomiting, relative or persistent constipation, \nflatulence); urinary symptoms (eg, urgent sensation to urinate, frequent urination, hematuria  \n\nInternational Journal of Advanced Research in Medicine http://www.medicinepaper.net \n~ 153 ~ \nand dysuria and signs of infection (fever, chills). \n  \nCauses of pelvic pain \nAcute pain: gynecological disease or dysfunction \nComplication of pregnancy  \n• Ectopic pregnancy (EE) ruptured  \n• Threatened abortion (AA) or incomplete abortion  \n• Degeneration of leiomyoma  \n- Acute infections  \n• Endometritis  \n• Pelvic inflammatory disease  \n• Tubo-ovarian abscess  \n- Adnexal disorders  \n• Ovarian Cyst functional hemorrhagic gico  \n• Attachment twist  \n• Torsion paraovarian cyst  \n• Ovarian cyst rupture (functional or neopl astic: dermoid / \nendometrioma) \n \nRecurrent pelvic pain \n- Periovulatory pain (Mittelschmerz)  \n- Primary / secondary dysmenorrhea  \n \nGastrointestinal causes \n- Gastroenteritis  \n- Appendicitis  \n- Intestinal obstruction  \n- Diverticu litis  \n- Inflammatory bowel disease  \n- Irritable bowel syndrome \n \nGeritourinary causes \n- Cystitis  \n- Pyelonephritis  \n- Ureteral lithiasis  \n \nMusculoskeletal causes \n- Abdominal wall hematoma  \n- Inguinal hernia  \n  \nGynecological causes (table 1) \n \nTable 1: Acute gynecological abdomen differential diagnosis table \n \nDiagnostic suspicion Clinic Confirmation Treatment \nEIP Fever, pain, flow vaginal abnormal Bacteriological Laparoscopy Antibiotherapy Surgery \nEctopic Amenorrhea, pain, vaginal bleeding, \nhemoperitoneum \nHemogram \nLaparoscopy pregnancy test Laparoscopy vs Laparotomy \nAdnexal cyst Adnexal mass Painful touch Ultrasound Laparoscopy vs Laparotomy \nMyoma Menometrorrhagia Irregular uterus Ultrasound Expectant vs Laparotomy \nUrine infection Fever, low back / suprapubic pain Urine culture Antibiotherapy \n  \nOvarian \n- Complicated ovarian cyst (hemorrhage, torsion, rupture)  \n- Follicular rupture  \n \nTubal \n- Ectopic pregnancy  \n- Adnexal torsion  \n- EIP  \n \nUterine \n- Interstitial or horn EE  \n- Complicated fibroid  \n- Adenomyosis  \n- Abortion in progress  \n \nOther causes \n- Acute porphyria  \n- Pelvic thrombophlebitis  \n- Aneurysm  \n- Abdominal angina  \n  \nDiagnosis of acute pelvic pain \nFor a correct diagnosis, the clinical history, type of pain, \ndata, complete clinical, analytical and  diagnostic tests. It \ndetermines your relationship with the menstruation and ovul\nation or intercourse. \n- History and physical examination  \n- Hemogram and coagulation  \n- Urine, sediment  \n- Pregnancy test (urine / serum)  \n- Cervical culture (Gonococcus / Chlamydia)  \n- Pelvic ultrasound  \n• If pregnancy test +: rule out EE  \n• Pelvic tumor of uncertain diagnosis  \n- Abdominal X - ray of the digestive tube if digestive \nsymptoms predominate  \n- CT: assess retroperitoneal tumor, o r abscesses of the \ndigestive tract  \n- Diagnostic laparoscopy :  \n• Acute abdomen of unknown cause  \n• Clarify the nature of a tumoral tion of a dubious anejo  \n• Define whether a pregnancy is intra or extrauterine  \n• Improve diagnostic accuracy if salpingoophoritis is \nsuspected  \n- Laparotomy \n(laparoscopy relatively mind Contrain dicado)  \n• Peritonitis  \n• Severe ileus  \n• Bowel obstruction  \n  \nEctopic pregnancy \nEctopic pregnancy is one of the most frequent gynecological \nemergencies, constituting the first cause o f maternal death \ndue to hemorrhagic shock. \nThe incidence is 1%, increasing (PID, intrauterine device –\nIUD-, assisted reproductive treatment (ART), conservative \nsurgery, older age). Heterotopic pregnancy (1 / 30,000). \n \nClinical manifestations \nThey usually a ppear with 6 or 7 weeks of amenorrhea, \nalthough it can occur later. It can present from \nasymptomatic to hypovolemic shock and death. \nThe classic symptoms are (full EE or no rupture) 1,2: \n- Abdominal pain: it is the most important symptom, in 99% \nof cases  \n- Amenorrhea in 75%  \n\nInternational Journal of Advanced Research in Medicine http://www.medicinepaper.net \n~ 154 ~ \n- Bleeding vaginal (low amount, in- mittent, dark) at 56%  \nAn EE should be suspected in any head -WANT woman in \nage reproductive with these symptoms, especially with \nfactors of risk, to try to form less aggressive (about the half \npass unnoticed on the first visit). \n \nRisk factors 3 \n- High risk  \n• Previous EE  \n• Previous tubal surgery (increases risk by 5-10%)  \n• Ligation of tubes (x 20 times)  \n• Tubal pathology / endometriosis.  \n• Intrauterine diethylstilbestrol  \n• IUD (more common in \"hormone releaser\")  \n- Moderate risk  \n• Infertility. In vitro fertilization  \n(IVF): (incidence 1-3%) 4 \n• Previous cervicitis  \n• History of PID (Chlamydia, risk x6) 5  \n• Multiple sexual partners  \n• Tobacco  \n- Low risk  \n• Previous abdominopelvic surgery (adhesions)  \n• Start early in relationships sexual  \nIt is important to perform a pregnancy test  in women with \nabdominal pain or vaginal bleeding to focus the subsequent \nevaluation. \nAmenorrhea plus abdominal pain with the presence or \nabsence of vaginal bleeding ar e complicating symptoms of \nearly pregnancy (threatened abortion, rupture or torsion  of \nthe corpus luteum, degeneration of uterine leiomyoma, \nUSA). \n  \nRecommended diagnostic test \nTransvaginal ultrasound \nThe transvaginal Echo test is the most useful to determ ine \nthe location of the sac. It has high sensitivity and specificity. \nIf there is a break, free liquid appears in the abdomen. \nIt detects the presence or absence of a gestational sac inside \nor outside the uterus and thus establishes the diagnosis. A \ncomplex adnexal mass + positive pregnancy test and an \nempty uterus is highly suggestive of an EE and is the most \ncommon ultrasound alteration (E: 99.9%, PPV 96.7%, NPV \n99.4%) [6]. \n  \nß hCG \nThe combination of transvaginal Echo and chorionic \ngonadotropin ßh allows a definitive diagnosis in almost all \ncases, very early, allowing less invasive treatments than \nsurgical excision7. \nIt can be detected in serum and urine 8 weeks after the \nappearance of the LH surge. Rises more slowly in most, but \nnot always (EE and non -viable pregnancies8 or sometimes \nsimilar). Measuring ßhCG every 72 hours instead of every \n48 hours is more practical9. A normal increase in ßhCG \nshould be evaluated with ultrasound (if ßhCG greater than \n1,500) and can be diagnosed intrauterine or ectopic. If the \nßhCG does not double after 72 hours, it is possible to affirm \nthat it is a norm evolutionary intrauterine pregnancy (an \nembryonal, tubal abortion, abortion, spontaneously resolved \nEE). A decrease in ßhCG is more consistent with a failed \npregnancy; the decline is slower with an EE, measured \nweekly up to ßhCG (-). \nFrom 1,500 (2,000 IU / l) of ßhCG it should be possible to \nvisualize the sac with echo10 (ultrasound is not sensitive to \ndetermine the location when ßhCG is lower). The absence \nof an intrauterine sac with this level of ßhCG suggests EE or \nnot viable or it may represent a multiple gestation for which \nultrasound and ßhCG are repeated in 48 hours. \nAn EE can be diagnosed if the concentration of ßhCG is \nelevated or \"plateau\" and not visualized by ultrasound. \nOther diagnostic tests are: serum progesterone level, echo -\nDoppler, laparoscopy, MRI, culdocentesis, but they do not \nadd useful additional clinical information.  \nTreatment can be oriented from a medical or surgical point \nof view. If tubal rupture o r hemodynamic instability is \nsuspected, the treatment of choice is laparoscopy with \nsalpingectomy. If there is no tube rupture, a more \nconservative treatment with salpingostomy (opening of the \ntube) and extraction of the sac can be considered; \nSubsequently, ßhCG controls should be carried out until it is \nnegative. But if the patient is symptomatic, the ßhCG is less \nthan 5,000 IU and the tube is smaller than 3 cm, medical \ntreatment with 50 mg of methotrexate in a single dose i.m. \nand subsequent control of ßhCG until its denial. \nAlthough the most important factor for the prognosis of \nfuture fertility is early diagnosis, it is important to know the \nstatus of the contralateral tube and the history of tubal \nsurgery. \n \nBroken ovarian cyst \nThis situation is frequent in reproductive age; more frequent \nin the right annex. It can be asymptomatic or associated with \nthe sudden onset of unilateral abdominal pain, which begins \nduring physical activity or intercourse. It may be \naccompanied by slight vaginal bleeding. Dependi ng on the \nnature of the cyst, it may remain asymptomatic (serous or \nmucinous) or produce severe pain (dermoid: chemical \nperitonitis). \nThe most important thing is to exclude ruptured EE \n(hemoperitoneum) due to the need for urgent surgery. \nIt is necessary to  carry out a pregnancy test, hemogram, \ngroup and Rh, urinalysis; ultrasound: (sensitivity: 85 -100%) \n11; an adnexal mass with fluid in the pelvis suggests \nrupture, but is not diagnostic. Avoid culdocentesis, \nparacentesis, and tumor markers. \nIf the rupture i s not complicated, do outpatient management \nand oral analgesia on demand. The fluid is reabsorbed \nwithin 24 hours and symptoms improve within a few days \n(possible subsequent surgery if persistent cyst, or it grows, \nor malignancy is suspected). \nIf it is complicated by hemoperitoneum, hospitalization with \nfluid replacement, vital signs, a serum hematocrit, and \nrepeat ultrasound are required. Once it stops, it takes several \nweeks to be reabsorbed. If the patient is unstable, \nlaparoscopy (laparotomy) will be evaluated. \nIf there is a ruptured dermoid cyst (rare), chemical \nperitonitis will occur, which develops adhesions formation \nand chronic pelvic pain. \n \nPelvic inflammatory disease \nIt is an acute infection of the upper genital tract (uterus -\ntubes-ovaries). It is  often accompanied by involvement of \nneighboring pelvic organs (endometritis, salpingitis, \noophoritis, peritonitis, perihepatitis, and Tubo -ovarian \nabscess); the endometrium and ovary are less susceptible to \ninfection than the tube, but may be the focus of infection. \nIt is a sexually acquired infection in most cases and less \n\nInternational Journal of Advanced Research in Medicine http://www.medicinepaper.net \n~ 155 ~ \nfrequently it is caused by medical procedures, pregnancy \nand other primary abdominal processes. It represents a \nspectrum within the infection. There is no single “gold \nstandard” diagnosis and the value of the clinical diagnosis is \nof the utmost importance. \n \nSymptoms \nLower abdominal pain is the main presenting symptom, \nalthough the pain characteristic can be quite subtle. The \nrecent onset of pain that worsens during intercourse may be \nthe only symptom and the onset during or just after \nmenstruation is particularly suggestive18. Abdominal pain \nis usually bilateral and rarely more than 2 weeks in duration. \nIn a third of cases, abnormal uterine bleeding is added19. \nVaginal discharge, urethrit is and fever appear that may be \nassociated, but are neither sensitive nor specific for the \ndiagnosis. PID is less likely if there are symptoms related to \nthe urinary or digestive tract. \nRisk factors for sexually transmitted diseases are: age \nyounger than 25 years, sexual precocity, no barrier methods, \nnew or multiple or symptomatic sexual partners, oral \ncontraceptives and cervical ectopia. \nThe patient should be evaluated and the risk factors that \nincrease the probability of PID such as: previous episodes of  \nPID, sexual intercourse during menstruation, vaginal \ndouching, bacterial vaginosis and IUD. \nOn physical examination, only half have fever and diffuse \nabdominal pain. Endocervical purulent flow and / or pain on \ncervical mobilization and adnexal pain on bim anual \nexamination is highly suggestive of PID. Uterus and adnexa: \npoint of maximum pain. Lateralization of adnexal pain is \nrare in PID; the existence of a palpable adnexal mass may \nrepresent a Tubo-ovarian abscess and other processes. \n \nDiagnostic considerations \nPID represents a spectrum of clinical disease from \nendometritis to sepsis intra -abdominal. Although \nlaparoscopy has substantial value in confirming the \ndiagnosis of PID, it is not sufficiently sensitive to be \nconsidered a “gold standard” in the diagnosis. \n \nDiagnostic criteria \nThe degree of suspicion should be high, especially in \nadolescent women, even if they deny sexual intercourse. A \nminimum of criteria for empirical treatment has been \nrecommended by the CDC to reduce the possibility of losing \nor delaying the diagnosis20. \nEmpirical treatment is advised in women with abdominal \npain who have at least one of the following criteria: \n- Painful cervical mobilization or uterine / adnexal pain \n- Temperature greater than 38.3 ºC \n- Leukocytosis with left deviation \n- Abnormal mucopurulent cervical or vaginal discharge \n- Leukocytes in vaginal smear \n- Increase in the speed of globular sedimentation \n- Increased C-reactive protein \n \nDiagnostic test \nIt includes a complete analysis looking for signs of \ninflammation, sm ears of vaginal or cervical secretions, \ncultures and imaging studies. \nAlways start with a pregnancy test to rule out EE The blood \ncount is of little use since only half have leukocytosis21. \nMicroscopic examination of flow can offer useful \ninformation. If t he Gram is + for diplococci, the probability \nof PID is very high; if it is negative it is of little use. \nChlamydia and gonococcus test, urine sediment, PCR. \nUltrasound is a test that offers a definitive diagnosis of PID \naccording to the CDC. \n \nRecommendation \nThere should be a low threshold for the diagnosis of PID, \nand young women sexually active patients with the \ncombination of lower abdominal pain, pain on cervical or \nadnexal mobilization should receive empirical treatment. \nThe specificity of these criteri a may be increased by the \npresence of fever, abnormal vaginal / cervical discharge, \nincreased ESR and / or CRP, and the demonstration of \ngonococcal / chlamydia infection. \nEven women with minimal findings should be treated. \nDifferential diagnosis is extensi ve, however, antibiotic \ntreatment should not be delayed when suspicion is high. \n \nReferences  \n1. Schwartz SM. 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