Abdominal-pelvic pain in gynecology

Abdominal-pelvic pain is a complex entity, sometimes difficult to diagnose, which requires a thorough analysis to determine its causes and the most appropriate treatment. It involves various viscera, so frequently the approach must be multidisciplinary and sometimes requires rapid action since the life of the patient is at stake only the causes of gynecological origin have been exposed in this work as we understand that the rest of the pathologies correspond to explain them to other specialties. A table of differential diagnosis is presented between the most frequent causes of pelvic pain of gynecological origin.

Pelvic pain, Ovarian torsion, Ectopic pregnancy, Pelvic inflammatory d isease, Endometriosis

Acute abdominopelvic pain is one of the most frequent causes of gynecological consultation and the most frequent cause of hospitalization. The most important initial assessment to be performed is to determine if it is an acute surgical abdomen and if it requires immediate hospitalization. It is important to rule out pregnancy when starting the evaluation of the patient (consider the possibility of a ruptured ectopic pregnancy, which can become life-threatening). Among the possible diagnoses are: ectopic pregnancy, torsion of an ovarian cyst (the importance of its early diagnosis lies in a rapid intervention to preserve the ovary and the tube), dysmenorrhea, endometriosis and fibroids. Timely diagnosis of acute pelvic pain is critically important because delay could increase morbidity and mortality. The accurate history is key to establishing the correct diagnosis. It is necessary to verify the date and character of the last two menstrual periods and the presence of bleeding or abnormal discharge. Acute pelvic pain The onset, character, location and pattern of radiation of pain must be taken into account and correlated with changes (urination, defecation, intercourse, physical activity), the regularity of menstrual periods, the possibility of of pregnancy, the presence of vaginal bleeding or discharge, medical and surgical history. A recent history of dyspareunia or dysmenorrhea is suggestive of pelvic pathology. The most common causes of acute pelvic pain in women include: pelvic inflammatory disease (PID), adnexal masses or cysts with torsion, rupture or bleeding, ectopic pregnancy, endometritis or myoma degeneration, infarction or torsion. When presenting with a woman with an abdominopelvic pain, the most important initial evaluation is to determine whether it is an acute surgical abdomen. The next two considerations are to find out if you are pregnant, (consider the possibility of ectopic pregnancy) and if requires immediate hospitalization. A rapid evaluation should be do ne to identify patients who require urgent surgical intervention, including history, if possible, and physical examination, including pelvic exam. There may be signs of severity that indicate the need for urgent surgery (hemodynamic instability: hypotensio n, confusion, diaphoresis, clouding) It is important to determine the history of the pain: how and when it started: the presence of gastrointestinal symptoms (eg anorexia, nausea, vomiting, relative or persistent constipation, flatulence); urinary symptoms (eg, urgent sensation to urinate, frequent urination, hematuria International Journal of Advanced Research in Medicine http://www.medicinepaper.net ~ 153 ~ and dysuria and signs of infection (fever, chills). Causes of pelvic pain Acute pain: gynecological disease or dysfunction Complication of pregnancy • Ectopic pregnancy (EE) ruptured • Threatened abortion (AA) or incomplete abortion • Degeneration of leiomyoma - Acute infections • Endometritis • Pelvic inflammatory disease • Tubo-ovarian abscess - Adnexal disorders • Ovarian Cyst functional hemorrhagic gico • Attachment twist • Torsion paraovarian cyst • Ovarian cyst rupture (functional or neopl astic: dermoid / endometrioma) Recurrent pelvic pain - Periovulatory pain (Mittelschmerz) - Primary / secondary dysmenorrhea Gastrointestinal causes - Gastroenteritis - Appendicitis - Intestinal obstruction - Diverticu litis - Inflammatory bowel disease - Irritable bowel syndrome Geritourinary causes - Cystitis - Pyelonephritis - Ureteral lithiasis Musculoskeletal causes - Abdominal wall hematoma - Inguinal hernia Gynecological causes (table 1) Table 1: Acute gynecological abdomen differential diagnosis table Diagnostic suspicion Clinic Confirmation Treatment EIP Fever, pain, flow vaginal abnormal Bacteriological Laparoscopy Antibiotherapy Surgery Ectopic Amenorrhea, pain, vaginal bleeding, hemoperitoneum Hemogram Laparoscopy pregnancy test Laparoscopy vs Laparotomy Adnexal cyst Adnexal mass Painful touch Ultrasound Laparoscopy vs Laparotomy Myoma Menometrorrhagia Irregular uterus Ultrasound Expectant vs Laparotomy Urine infection Fever, low back / suprapubic pain Urine culture Antibiotherapy Ovarian - Complicated ovarian cyst (hemorrhage, torsion, rupture) - Follicular rupture Tubal - Ectopic pregnancy - Adnexal torsion - EIP Uterine - Interstitial or horn EE - Complicated fibroid - Adenomyosis - Abortion in progress Other causes - Acute porphyria - Pelvic thrombophlebitis - Aneurysm - Abdominal angina Diagnosis of acute pelvic pain For a correct diagnosis, the clinical history, type of pain, data, complete clinical, analytical and diagnostic tests. It determines your relationship with the menstruation and ovul ation or intercourse. - History and physical examination - Hemogram and coagulation - Urine, sediment - Pregnancy test (urine / serum) - Cervical culture (Gonococcus / Chlamydia) - Pelvic ultrasound • If pregnancy test +: rule out EE • Pelvic tumor of uncertain diagnosis - Abdominal X - ray of the digestive tube if digestive symptoms predominate - CT: assess retroperitoneal tumor, o r abscesses of the digestive tract - Diagnostic laparoscopy : • Acute abdomen of unknown cause • Clarify the nature of a tumoral tion of a dubious anejo • Define whether a pregnancy is intra or extrauterine • Improve diagnostic accuracy if salpingoophoritis is suspected - Laparotomy (laparoscopy relatively mind Contrain dicado) • Peritonitis • Severe ileus • Bowel obstruction Ectopic pregnancy Ectopic pregnancy is one of the most frequent gynecological emergencies, constituting the first cause o f maternal death due to hemorrhagic shock. The incidence is 1%, increasing (PID, intrauterine device – IUD-, assisted reproductive treatment (ART), conservative surgery, older age). Heterotopic pregnancy (1 / 30,000). Clinical manifestations They usually a ppear with 6 or 7 weeks of amenorrhea, although it can occur later. It can present from asymptomatic to hypovolemic shock and death. The classic symptoms are (full EE or no rupture) 1,2: - Abdominal pain: it is the most important symptom, in 99% of cases - Amenorrhea in 75% International Journal of Advanced Research in Medicine http://www.medicinepaper.net ~ 154 ~ - Bleeding vaginal (low amount, in- mittent, dark) at 56% An EE should be suspected in any head -WANT woman in age reproductive with these symptoms, especially with factors of risk, to try to form less aggressive (about the half pass unnoticed on the first visit). Risk factors 3 - High risk • Previous EE • Previous tubal surgery (increases risk by 5-10%) • Ligation of tubes (x 20 times) • Tubal pathology / endometriosis. • Intrauterine diethylstilbestrol • IUD (more common in "hormone releaser") - Moderate risk • Infertility. In vitro fertilization (IVF): (incidence 1-3%) 4 • Previous cervicitis • History of PID (Chlamydia, risk x6) 5 • Multiple sexual partners • Tobacco - Low risk • Previous abdominopelvic surgery (adhesions) • Start early in relationships sexual It is important to perform a pregnancy test in women with abdominal pain or vaginal bleeding to focus the subsequent evaluation. Amenorrhea plus abdominal pain with the presence or absence of vaginal bleeding ar e complicating symptoms of early pregnancy (threatened abortion, rupture or torsion of the corpus luteum, degeneration of uterine leiomyoma, USA). Recommended diagnostic test Transvaginal ultrasound The transvaginal Echo test is the most useful to determ ine the location of the sac. It has high sensitivity and specificity. If there is a break, free liquid appears in the abdomen. It detects the presence or absence of a gestational sac inside or outside the uterus and thus establishes the diagnosis. A complex adnexal mass + positive pregnancy test and an empty uterus is highly suggestive of an EE and is the most common ultrasound alteration (E: 99.9%, PPV 96.7%, NPV 99.4%) [6]. ß hCG The combination of transvaginal Echo and chorionic gonadotropin ßh allows a definitive diagnosis in almost all cases, very early, allowing less invasive treatments than surgical excision7. It can be detected in serum and urine 8 weeks after the appearance of the LH surge. Rises more slowly in most, but not always (EE and non -viable pregnancies8 or sometimes similar). Measuring ßhCG every 72 hours instead of every 48 hours is more practical9. A normal increase in ßhCG should be evaluated with ultrasound (if ßhCG greater than 1,500) and can be diagnosed intrauterine or ectopic. If the ßhCG does not double after 72 hours, it is possible to affirm that it is a norm evolutionary intrauterine pregnancy (an embryonal, tubal abortion, abortion, spontaneously resolved EE). A decrease in ßhCG is more consistent with a failed pregnancy; the decline is slower with an EE, measured weekly up to ßhCG (-). From 1,500 (2,000 IU / l) of ßhCG it should be possible to visualize the sac with echo10 (ultrasound is not sensitive to determine the location when ßhCG is lower). The absence of an intrauterine sac with this level of ßhCG suggests EE or not viable or it may represent a multiple gestation for which ultrasound and ßhCG are repeated in 48 hours. An EE can be diagnosed if the concentration of ßhCG is elevated or "plateau" and not visualized by ultrasound. Other diagnostic tests are: serum progesterone level, echo - Doppler, laparoscopy, MRI, culdocentesis, but they do not add useful additional clinical information. Treatment can be oriented from a medical or surgical point of view. If tubal rupture o r hemodynamic instability is suspected, the treatment of choice is laparoscopy with salpingectomy. If there is no tube rupture, a more conservative treatment with salpingostomy (opening of the tube) and extraction of the sac can be considered; Subsequently, ßhCG controls should be carried out until it is negative. But if the patient is symptomatic, the ßhCG is less than 5,000 IU and the tube is smaller than 3 cm, medical treatment with 50 mg of methotrexate in a single dose i.m. and subsequent control of ßhCG until its denial. Although the most important factor for the prognosis of future fertility is early diagnosis, it is important to know the status of the contralateral tube and the history of tubal surgery. Broken ovarian cyst This situation is frequent in reproductive age; more frequent in the right annex. It can be asymptomatic or associated with the sudden onset of unilateral abdominal pain, which begins during physical activity or intercourse. It may be accompanied by slight vaginal bleeding. Dependi ng on the nature of the cyst, it may remain asymptomatic (serous or mucinous) or produce severe pain (dermoid: chemical peritonitis). The most important thing is to exclude ruptured EE (hemoperitoneum) due to the need for urgent surgery. It is necessary to carry out a pregnancy test, hemogram, group and Rh, urinalysis; ultrasound: (sensitivity: 85 -100%) 11; an adnexal mass with fluid in the pelvis suggests rupture, but is not diagnostic. Avoid culdocentesis, paracentesis, and tumor markers. If the rupture i s not complicated, do outpatient management and oral analgesia on demand. The fluid is reabsorbed within 24 hours and symptoms improve within a few days (possible subsequent surgery if persistent cyst, or it grows, or malignancy is suspected). If it is complicated by hemoperitoneum, hospitalization with fluid replacement, vital signs, a serum hematocrit, and repeat ultrasound are required. Once it stops, it takes several weeks to be reabsorbed. If the patient is unstable, laparoscopy (laparotomy) will be evaluated. If there is a ruptured dermoid cyst (rare), chemical peritonitis will occur, which develops adhesions formation and chronic pelvic pain. Pelvic inflammatory disease It is an acute infection of the upper genital tract (uterus - tubes-ovaries). It is often accompanied by involvement of neighboring pelvic organs (endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and Tubo -ovarian abscess); the endometrium and ovary are less susceptible to infection than the tube, but may be the focus of infection. It is a sexually acquired infection in most cases and less International Journal of Advanced Research in Medicine http://www.medicinepaper.net ~ 155 ~ frequently it is caused by medical procedures, pregnancy and other primary abdominal processes. It represents a spectrum within the infection. There is no single “gold standard” diagnosis and the value of the clinical diagnosis is of the utmost importance. Symptoms Lower abdominal pain is the main presenting symptom, although the pain characteristic can be quite subtle. The recent onset of pain that worsens during intercourse may be the only symptom and the onset during or just after menstruation is particularly suggestive18. Abdominal pain is usually bilateral and rarely more than 2 weeks in duration. In a third of cases, abnormal uterine bleeding is added19. Vaginal discharge, urethrit is and fever appear that may be associated, but are neither sensitive nor specific for the diagnosis. PID is less likely if there are symptoms related to the urinary or digestive tract. Risk factors for sexually transmitted diseases are: age younger than 25 years, sexual precocity, no barrier methods, new or multiple or symptomatic sexual partners, oral contraceptives and cervical ectopia. The patient should be evaluated and the risk factors that increase the probability of PID such as: previous episodes of PID, sexual intercourse during menstruation, vaginal douching, bacterial vaginosis and IUD. On physical examination, only half have fever and diffuse abdominal pain. Endocervical purulent flow and / or pain on cervical mobilization and adnexal pain on bim anual examination is highly suggestive of PID. Uterus and adnexa: point of maximum pain. Lateralization of adnexal pain is rare in PID; the existence of a palpable adnexal mass may represent a Tubo-ovarian abscess and other processes. Diagnostic considerations PID represents a spectrum of clinical disease from endometritis to sepsis intra -abdominal. Although laparoscopy has substantial value in confirming the diagnosis of PID, it is not sufficiently sensitive to be considered a “gold standard” in the diagnosis. Diagnostic criteria The degree of suspicion should be high, especially in adolescent women, even if they deny sexual intercourse. A minimum of criteria for empirical treatment has been recommended by the CDC to reduce the possibility of losing or delaying the diagnosis20. Empirical treatment is advised in women with abdominal pain who have at least one of the following criteria: - Painful cervical mobilization or uterine / adnexal pain - Temperature greater than 38.3 ºC - Leukocytosis with left deviation - Abnormal mucopurulent cervical or vaginal discharge - Leukocytes in vaginal smear - Increase in the speed of globular sedimentation - Increased C-reactive protein Diagnostic test It includes a complete analysis looking for signs of inflammation, sm ears of vaginal or cervical secretions, cultures and imaging studies. Always start with a pregnancy test to rule out EE The blood count is of little use since only half have leukocytosis21. Microscopic examination of flow can offer useful information. If t he Gram is + for diplococci, the probability of PID is very high; if it is negative it is of little use. Chlamydia and gonococcus test, urine sediment, PCR. Ultrasound is a test that offers a definitive diagnosis of PID according to the CDC. Recommendation There should be a low threshold for the diagnosis of PID, and young women sexually active patients with the combination of lower abdominal pain, pain on cervical or adnexal mobilization should receive empirical treatment. The specificity of these criteri a may be increased by the presence of fever, abnormal vaginal / cervical discharge, increased ESR and / or CRP, and the demonstration of gonococcal / chlamydia infection. Even women with minimal findings should be treated. Differential diagnosis is extensi ve, however, antibiotic treatment should not be delayed when suspicion is high.

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