What is the next best step in managing a 77-year-old female with lower abdominal pain, history of uterine cancer, and pending urinalysis and urine culture results?

Management of Lower Abdominal Pain in a 77-Year-Old Female with History of Uterine Cancer

The next best step in managing this patient with lower abdominal pain and history of uterine cancer is to proceed with a CT scan of the abdomen and pelvis with and without IV contrast if the urinalysis and urine culture are negative, as planned by the physician. 1

Evaluation of Current Findings

Current Assessment:

• 77-year-old female with persistent lower abdominal pain for several weeks
• History of hysterectomy for uterine cancer
• Occasional right upper quadrant pain
• Renal sonogram: normal size kidneys, no hydronephrosis, no calculi, bilateral simple cysts
• Incidental finding: 1.3 cm gallstone
• Pelvic sonogram: normal bladder walls, prevoid 50 mL

Diagnostic Approach:

1. Rule out urinary tract infection first

   • The current plan to obtain urinalysis and urine culture is appropriate as the initial step
   • Urinalysis and urine culture are the basic laboratory tests for evaluating lower urinary tract symptoms 1
   • UTI can present with lower abdominal pain, especially in older patients who may not have typical symptoms

2. If urinalysis/urine culture negative:

   • Proceed with CT scan of abdomen and pelvis with and without IV contrast
   • This is appropriate to evaluate for:
     • Recurrent uterine cancer
     • Other pelvic pathology
     • Potential complications related to prior hysterectomy
     • Evaluation of the 1.3 cm gallstone and its potential contribution to symptoms

Rationale for CT Imaging

1. History of uterine cancer

   • Patients with history of uterine cancer require thorough evaluation of new abdominal/pelvic symptoms
   • Recurrence of uterine cancer can occur even years after initial treatment 1
   • Most recurrences of endometrial cancer occur within 3 years of initial treatment, but late recurrences are possible 1

2. Age and risk factors

   • At 77 years old with persistent lower abdominal pain, malignancy must be considered
   • Abnormal vaginal bleeding is the most common symptom of endometrial cancer recurrence, but abdominal pain can also be a presenting symptom 2
   • Even though the patient had a hysterectomy, recurrence can occur in the vaginal cuff or pelvic lymph nodes

3. Limitations of initial imaging

   • Ultrasound has already been performed but has limitations in evaluating deep pelvic structures
   • CT provides better visualization of potential masses, lymphadenopathy, or other pathology

Alternative Diagnoses to Consider

1. Symptomatic gallstone disease

   • The 1.3 cm gallstone found incidentally may be contributing to the right upper quadrant pain
   • CT can better characterize gallbladder pathology and evaluate for complications

2. Interstitial cystitis/bladder pain syndrome

   • Can present with lower abdominal pain and urinary symptoms
   • Diagnosis of exclusion after ruling out other causes 1
   • CT can help rule out other pathologies

3. Pelvic floor disorders

   • More common in gynecologic cancer survivors 1
   • May require specialized evaluation if other causes are ruled out

4. Gastrointestinal causes

   • Constipation, diverticulitis, or other GI pathology
   • CT is excellent for evaluating these conditions

Follow-up Plan

1. If urinalysis/urine culture positive:

   • Treat according to culture results and antibiotic sensitivities
   • Consider follow-up imaging if symptoms persist despite appropriate antibiotic therapy

2. If CT scan is negative:

   • Consider referral to gastroenterology or urogynecology for further evaluation
   • Evaluate for chronic pain syndromes which affect approximately one-third of cancer survivors 1

3. If CT scan shows concerning findings:

   • Prompt referral to gynecologic oncology for evaluation of potential recurrence
   • Consider biopsy of suspicious lesions if identified

Important Considerations

• Avoid premature closure of diagnosis: While UTI is a common cause of lower abdominal pain in elderly women, the history of uterine cancer warrants thorough investigation
• Recognize that cancer recurrence can present atypically: Abdominal pain without vaginal bleeding can still represent recurrent disease
• Consider the patient's age and comorbidities: Diabetes and hypertension may complicate the clinical picture and influence management decisions

The planned approach of ruling out UTI first, followed by CT imaging if negative, represents a logical, stepwise approach to evaluating this patient's concerning symptoms while considering her significant oncologic history.