Essentials of Diagnosis
- • Lower abdominal pain in women is a common presenting complaint; pain characteristics (duration, location, quality, and severity) may be helpful in determining the diagnosis.
- • Pain may be caused by gynecologic disorders, but also by disorders of the gastrointestinal, urinary, and musculoskeletal systems.
- • Pain on abdominal or pelvic examination may signal peritoneal irritation.
- • History, physical examination, and laboratory tests should be used to arrive at a diagnosis.
- • Ultrasound may aid in the diagnosis; diagnostic laparoscopy can provide a definitive diagnosis and may be considered when the diagnosis is uncertain.
General Considerations
Lower abdominal pain is a common presenting complaint and one of the most difficult problems to evaluate in women. Arriving at the correct diagnosis when a woman of reproductive age presents with acute pelvic pain remains a challenge in clinical medicine—a fact that has been confirmed by numerous studies. A comprehensive evaluation leading to a timely diagnosis will reduce the morbidity associated with delayed diagnosis.
Pelvic pain is a common presenting symptom of many gynecologic disorders. However, it also may occur with disorders of the gastrointestinal, urinary, and musculoskeletal systems. To determine the etiology of the pain, the clinician must use the history, physical examination, and diagnostic tests as tools.
Clinical Findings
Characteristics of the pain may aid in determining the diagnosis. Important characteristics include timing of onset, location, quality, and severity.
Pain of sudden onset suggests an acute event such as hemorrhage, rupture, or torsion of an ovarian cyst, whereas pain that is more gradual may be present in subacute or progressive conditions. The differential diagnosis of lower abdominal pain grouped by time of onset is presented in Table 5–1.
| Acute onset (seconds to minutes) |
| Aortic dissection |
| Nephrolithiasis |
| Ovarian cysts |
| Rupture |
| Hemorrhage |
| Torsion |
| Rupture |
| Tubo-ovarian abscess |
| Abdominal aortic aneurysm |
| Ectopic pregnancy |
| Gradual onset (hours to days) |
| Abortion |
| Appendicitis |
| Diverticulitis |
| Ectopic pregnancy |
| Gastroenteritis |
| Herpes zoster |
| Mittelschmerz (midcycle ovulatory pain) |
| Pelvic inflammatory disease (PID) |
| Primary dysmenorrhea |
| Slow onset (days to weeks) |
| Abdominal aortic aneurysm |
| Abortion |
| Cystitis |
| Diverticulitis |
| Ectopic pregnancy |
| Neoplasms |
| PID |
| Pyelonephritis |
| Chronic onset (weeks to months) |
| Chronic pelvic pain |
| Diverticular disease |
| Domestic violence or sexual abuse |
| Endometriosis |
| Inflammatory bowel disease |
| Neoplasms |
| Irritable bowel syndrome |
The location of the pain may also be helpful, although different disease processes can lead to pain in the same region. The uterus, cervix, and adnexae share visceral innervation with the lower ileum, sigmoid, and rectum (T10–L1), and pain from any of these structures may be felt in the same place. This is one of the dilemmas when trying to distinguish acute appendicitis from pelvic inflammatory disease (PID), although typically the pain of appendicitis is localized in the right lower quadrant whereas that of PID is more diffuse. Diffuse and generalized pain should alert the clinician to the possibility of peritonitis, which may be seen following intra-abdominal hemorrhage or sepsis.
Although pain quality and severity are nonspecific symptoms, they may provide some clue to the etiology of the pain. Abrupt and severe pain is typically associated with perforation (ectopic pregnancy), strangulation (ovarian torsion), or hemorrhage (ovarian cysts). Crampy pain is often seen with dysmenorrhea or spontaneous abortion. Pain that is colicky in nature is typical of ovarian torsion or nephrolithiasis. Burning or aching pain often occurs with inflammatory processes such as appendicitis or PID.
Associated symptoms are often helpful when trying to narrow the diagnosis. Pain with fever suggests an infectious or inflammatory etiology, such as appendicitis, PID, or a tubo-ovarian abscess. Nausea, vomiting, and anorexia are nonspecific symptoms of peritoneal irritation that may be present in patients with inflammatory conditions and hemoperitoneum. Vaginal discharge can occur with infectious conditions of the female genital tract, such as cervicitis or PID. Vaginal bleeding may be associated with pregnancy-related disorders, abnormalities of the menstrual cycle, PID, or pathology of the uterus or cervix.
Depending on the etiology, changes in pain may occur in relation to menses, coitus, activity, diet, bowel movements, or voiding.
In women who present with lower abdominal pain, vital signs must be obtained as part of the evaluation. The presence of fever is a key feature that can help to identify an inflammatory process but may not help to specify which one. One study, for example, found no significant difference between oral temperatures in patients with PID and appendicitis. Women with acute PID or tubo-ovarian abscess may be afebrile; therefore, the absence of fever should not exclude these conditions. In conditions that raise suspicion of hemorrhage, such as ruptured ectopic pregnancy or hemorrhagic ovarian cysts, orthostatic pulse and blood pressure should be measured to evaluate for hypovolemia.
The important components of the abdominal examination include inspection, auscultation, percussion, and palpation. Bowel sounds may be decreased in the presence of peritoneal irritation. Percussion and palpation can help to identify masses and peritoneal irritation. Peritoneal irritation is confirmed by the presence of rebound tenderness, involuntary guarding, and increased pain with motion or cough.
The pelvic examination is most easily organized to proceed from external to internal structures.
The external genitalia should be carefully inspected for lesions. The presence of inguinal adenopathy is suggestive of a local infectious process such as genital ulcer disease. On speculum examination, the vagina and cervix should be visualized. Lesions, blood, or discharge should be noted. The presence of cervical discharge, erythema, or friability should alert the clinician to the possibility of cervicitis or PID. Grossly purulent cervical discharge (mucopus) reflects a high concentration of polymorphonuclear leukocytes in the mucus, but the presence of mucopus has not been shown to accurately predict PID.
On internal pelvic examination, the first step should be an assessment for cervical motion tenderness. Its presence is nonspecific and may indicate PID, ectopic pregnancy, endometriosis, or appendicitis. Next, a bimanual examination should be performed, with assessment of the uterus and adnexae. An enlarged uterus may indicate fibroids or pregnancy. A uterus that is fixed and immobile may occur as a result of adhesions from endometriosis or PID. Adnexal enlargement may be seen with ovarian cysts, torsion, tubo-ovarian abscess, or ectopic pregnancy. Pain on bimanual examination may occur with endometritis, degenerating uterine fibroids, endometriosis, PID, ovarian cysts or torsion, ectopic pregnancy, or appendicitis. Finally, digital rectal and rectovaginal examinations should be performed. These parts of the examination can be especially useful when abdominal examination is unremarkable. Nodularity in the cul-de-sac or on the uterosacral ligaments as a result of endometriosis may be appreciated this way. Also, a tender mass may be palpated in certain gastrointestinal disorders, such as appendicitis or diverticulitis.
When interpreting the pelvic examination, it is important to remember that movement of the pelvic organs will be painful if peritoneal irritation is present, regardless of the cause. Therefore, cervical motion tenderness and adnexal tenderness may be found with a variety of disorders, not only pelvic infection. In one study that compared findings in patients with PID and appendicitis, cervical motion tenderness was found significantly more often in patients with PID, but was still found in 28% of patients with appendicitis. Adnexal tenderness was found with equal frequency in both groups but was usually limited to the right side in patients with appendicitis and was usually, but not always, bilateral in patients with PID.
Laboratory and diagnostic imaging tests may help in the differential diagnosis of acute pelvic pain but should be interpreted cautiously. Baseline tests should include at least a complete blood count (CBC) and pregnancy test. The white blood cell (WBC) count may be elevated in inflammatory conditions, and the hematocrit may be low in the setting of hemorrhage. In one study, the total WBC count was significantly higher in patients with appendicitis than in those with PID (15.3 cells/ mm3 vs 12.7 cells/mm3
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