What could be causing my lower abdominal pain, pelvic pressure when standing, and sharp cramp-like pains after having a hysterectomy and tubal removal?

Post-Hysterectomy Lower Abdominal and Pelvic Pain

You need CT abdomen and pelvis with IV contrast as the initial imaging study to evaluate your nonlocalized lower abdominal pain and pelvic pressure. 1

Why CT is the Appropriate First Step

Given your history of hysterectomy and tubal removal years ago, combined with nonspecific lower abdominal pain and positional pelvic pressure, the differential diagnosis is broad and requires comprehensive imaging that can evaluate multiple organ systems simultaneously. 1

CT abdomen and pelvis with IV contrast is the gold standard for evaluating nonlocalized abdominal pain because it:

• Changes the leading diagnosis in 51% of patients and alters admission decisions in 25% of cases 1
• Provides fast, definitive imaging across all abdominal and pelvic organ systems 1
• Has superior diagnostic yield compared to other modalities for nonspecific presentations 1

Most Likely Diagnostic Considerations in Your Case

Post-Surgical/Gynecologic Causes

• Adhesions from prior surgery - intraperitoneal adhesions may cause chronic pain, though the causal relationship remains unclear 2
• Ovarian pathology - ovarian cysts account for approximately one-third of gynecologic pain cases in women with prior hysterectomy 2, 3
• Pelvic congestion syndrome - characterized by engorged periuterine and periovarian veins causing positional pain 2
• Ovarian neoplasm - accounts for 8% of cases and must be excluded given malignancy risk 3

Non-Gynecologic Causes

• Gastrointestinal pathology - including diverticulitis, inflammatory bowel disease, or bowel obstruction 1, 3
• Urinary tract disorders - chronic cystitis, urethral pathology 3, 4
• Musculoskeletal pain - pelvic girdle pain, myofascial pain, or lower back disorders referring to pelvis 2, 3, 4

Critical Red Flags to Communicate

When you present for imaging, ensure your provider knows if you have:

• Any palpable abdominal or pelvic mass - requires urgent evaluation 3
• Vaginal bleeding (if you retained your cervix) - mandates immediate workup 3
• Fever - raises concern for abscess or infection requiring emergent attention 1
• Acute severe pain with lightheadedness - suggests ovarian torsion, ruptured cyst, or other surgical emergency 3

Common Diagnostic Pitfalls to Avoid

Do not assume your pain is gynecologic in origin simply because of your surgical history. The differential for lower abdominal pain after hysterectomy includes gastrointestinal (inflammatory bowel disease, diverticulitis), urologic (cystitis, urethral disorders), and musculoskeletal causes (pelvic floor dysfunction, nerve entrapment). 2, 3

Your positional component (worse when standing) suggests:

• Pelvic congestion syndrome with venous pooling 2
• Pelvic floor dysfunction or prolapse 4
• Adhesions creating traction on peritoneal surfaces 2

If CT is Inconclusive

Should CT imaging fail to identify a cause, MRI abdomen and pelvis without and with IV contrast is the next appropriate step, as it provides superior soft tissue characterization and can identify subtle gynecologic pathology, endometriosis, or pelvic floor disorders that CT may miss. 1

Ultrasound is NOT the appropriate initial test in your case because it has limited utility for nonlocalized abdominal pain and cannot adequately evaluate the full range of post-surgical, gastrointestinal, and urologic pathology that must be considered. 1

Next Steps After Imaging

Once imaging identifies (or excludes) structural pathology, management becomes targeted:

• If structural cause identified - treat the specific condition (surgical intervention for torsion/mass, antibiotics for infection, etc.) 3
• If imaging negative - consider functional disorders like irritable bowel syndrome, interstitial cystitis, or pelvic floor myofascial pain requiring multimodal therapy including physical therapy and potentially gabapentin or nonsteroidal anti-inflammatory drugs 4, 5, 6