What is the best treatment for abdominal wall pain caused by coughing?

Treatment for Abdominal Wall Pain Due to Coughing

For abdominal wall pain caused by coughing, the most effective first-line treatment is a local anesthetic injection (such as 0.5% bupivacaine 2mL, 2% lidocaine 3mL, and betamethasone 4mg) at the trigger point, which can provide complete pain resolution in up to 95% of patients. 1

Diagnosis and Assessment

• Abdominal wall pain is characterized by strictly localized pain in the anterior abdominal wall that worsens with coughing 2
• Carnett's sign (increased pain when tensing the abdominal muscles) helps differentiate abdominal wall pain from visceral pain 3
• Trigger points can be identified by applying pressure to the abdominal wall, which elicits sharp shooting pain during compression 1
• Despite being present in up to 30% of patients with chronic abdominal pain without demonstrable pathology, abdominal wall pain is frequently overlooked 2

Treatment Algorithm

First-Line Treatments:

1. Local Anesthetic Injection

   • Injection of local anesthetics with steroids into the painful area provides pain relief for at least 4 weeks in 95% of patients 2
   • A mixture of 0.5% bupivacaine 2mL, 2% lidocaine 3mL, and betamethasone 4mg 1mL is effective 1
   • Lidocaine alone can bring improvement in 83-91% of patients 2

2. Antitussives to Reduce Cough-Induced Pain

   • Dextromethorphan (30-60mg) is the preferred antitussive due to its superior safety profile compared to opioid alternatives 4
   • Maximum cough reflex suppression occurs at 60mg doses of dextromethorphan 4
   • For nighttime cough disrupting sleep, first-generation antihistamines with sedative properties may be beneficial 4

3. Non-Pharmacological Approaches

   • Simple home remedies like honey and lemon mixtures may help reduce cough frequency 4
   • Voluntary cough suppression techniques can reduce cough frequency 4
   • Menthol inhalation provides quick but temporary relief of cough 4

Second-Line Treatments:

1. Repeated Injections

   • Long-term pain relief occurs after a single lidocaine injection in 20-30% of patients 2
   • Repeated injections provide relief in 40-50% of patients 2
   • Combined lidocaine and steroid injections provide long-term relief in up to 80% of patients 2

2. Alternative Antitussives

   • Benzonatate (100-200mg qid) can be considered as an alternative to dextromethorphan when opioids are contraindicated 5, 6
   • Peripherally-acting antitussives like levodropropizine (75mg tid) may be tried if central antitussives fail 6

Refractory Cases:

1. Surgical Options

   • Neurectomy can be considered for persistent pain despite conservative treatments 2
   • Peripheral nerve stimulation in the transversus abdominis plane may be an alternative for refractory cases 7

2. Advanced Antitussive Approaches

   • For severe, persistent cough, nebulized local anesthetics (lidocaine 5mL of 0.2% tid) may be considered, though aspiration risk should be assessed 6
   • Short-course oral corticosteroids (prednisolone 30mg daily for 2 weeks) may help with severe paroxysms of cough 6, 4

Common Pitfalls and Caveats

• Abdominal wall pain is frequently misdiagnosed as visceral pain, leading to unnecessary invasive procedures and tests 8
• Using subtherapeutic doses of dextromethorphan may not provide adequate cough suppression 4
• Codeine-based antitussives should be avoided due to their poor benefit-to-risk ratio and greater side effect profile (drowsiness, nausea, constipation) 4
• Local anesthetics can increase the risk of aspiration when used for cough suppression, particularly in frail patients 6
• When using local injections, careful identification of the trigger point is essential for treatment success 1

Follow-Up

• Patients should be examined on a weekly basis after trigger point injection and undergo reinjection if symptoms recur 1
• After successful treatment, approximately 86.5% of patients remain free of abdominal pain at 3-month follow-up 1