What is the proper management of abdominal pain in a gynecology (GYN) outpatient department (OPD)?

Management of Abdominal Pain in Gynecology Outpatient Department

Begin with a pregnancy test (β-hCG) in all reproductive-age women, followed by transvaginal ultrasound as the initial imaging modality for suspected gynecological causes, reserving CT for non-gynecological etiologies or when ultrasound is inconclusive. 1, 2

Initial Clinical Assessment

Critical First Steps

• Obtain serum or urine β-hCG immediately in all women of reproductive age to differentiate pregnancy-related from non-pregnancy-related causes 1, 2
• Assess for emergency red flags: fever (suggesting infection/PID), vaginal bleeding (ectopic pregnancy, placental abruption if pregnant), hemodynamic instability 1, 2
• Identify high-risk populations: sexually active young women and adolescents have higher likelihood of PID; postmenopausal women more commonly have ovarian cysts, fibroids, or malignancy 1

Focused History Elements

• Pain characteristics: Duration (acute <3 months vs chronic), location (unilateral suggests torsion/ectopic; bilateral suggests PID), timing in menstrual cycle (mid-cycle suggests mittelschmerz) 1, 3
• Associated symptoms: Abnormal vaginal discharge (PID), dyspareunia, abnormal bleeding, urinary symptoms (UTI, interstitial cystitis), GI symptoms 1, 4
• Risk factors: Sexual activity, multiple partners, history of STDs, recent instrumentation/surgery (iatrogenic PID), IUD presence 1

Physical Examination Findings

• Minimum diagnostic criteria for PID: Uterine tenderness AND adnexal tenderness AND cervical motion tenderness—all three must be present to initiate empiric treatment 1
• Additional supportive findings for PID: Oral temperature >38.3°C, mucopurulent cervical discharge, presence of WBCs on saline microscopy of vaginal secretions 1
• Critical caveat: If cervical discharge appears normal and no WBCs are found on wet prep, PID is unlikely and alternative diagnoses should be pursued 1

Diagnostic Imaging Algorithm

If β-hCG Positive (Pregnancy Confirmed)

• First-line: Transvaginal AND transabdominal ultrasound to evaluate for intrauterine pregnancy, ectopic pregnancy, or pregnancy complications 1, 2
• Ultrasound findings: Adnexal mass without intrauterine pregnancy has positive likelihood ratio of 111 for ectopic pregnancy; lack of adnexal abnormalities has negative likelihood ratio of 0.12 1
• Endometrial thickness: <8mm virtually excludes normal intrauterine pregnancy; ≥25mm virtually excludes ectopic pregnancy 1
• If ultrasound inconclusive and non-gynecological cause suspected: MRI abdomen/pelvis without contrast (100% sensitivity, 93.6% specificity for appendicitis in pregnancy) 2
• CT with IV contrast only if: Life-threatening diagnosis suspected AND ultrasound/MRI unavailable or inconclusive—risk to fetus from single CT is very low but informed consent required 1, 2

If β-hCG Negative (Gynecological Etiology Suspected)

• First-line: Transvaginal ultrasound with Doppler imaging as standard component 1, 2
• Ultrasound sensitivity/specificity: 93% sensitive and 98% specific for tubo-ovarian abscess; 98% sensitive and 100% specific for rectosigmoid endometriosis 1
• Ovarian torsion findings: Asymmetrically enlarged ovary, twisted pedicle (best seen with Doppler), absent/decreased blood flow, deviation of uterus to affected side 1
• TOA findings: Thick-walled complex adnexal mass with debris, septations, irregular margins, pyosalpinx, loculated echogenic cul-de-sac fluid 1

If β-hCG Negative (Non-Gynecological Etiology Suspected)

• First-line: CT abdomen/pelvis with IV contrast for suspected appendicitis, diverticulitis, bowel obstruction, urinary calculi 1
• CT sensitivity for appendicitis: 92% sensitivity, 99% specificity, 99% NPV 1
• Ultrasound has limited role for non-gynecological causes (rated 4/9 appropriateness) 1

Postmenopausal Women

• Different diagnostic considerations: Ovarian cysts (33% of cases), uterine fibroids (second most common), pelvic infection (20%), ovarian neoplasm (8%) 1
• Imaging approach: Similar algorithm but maintain higher suspicion for malignancy; ultrasound remains first-line for gynecological causes 1

Management by Diagnosis

Pelvic Inflammatory Disease

• Initiate empiric broad-spectrum antibiotics immediately when minimum criteria met (uterine + adnexal + cervical motion tenderness), even before culture results 1
• Coverage must include: N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, streptococci 1
• Low threshold for treatment: Better to overtreat than miss PID given risk of infertility, ectopic pregnancy, chronic pain 1
• Obtain cervical cultures for gonorrhea/chlamydia to guide partner treatment, but do not delay antibiotics 1

Ovarian Torsion

• Urgent surgical consultation if ultrasound shows enlarged ovary with decreased/absent Doppler flow 1
• Time-sensitive emergency: Delay risks ovarian necrosis and loss 1

Ectopic Pregnancy

• Immediate obstetric consultation for methotrexate vs surgical management 1
• Serial β-hCG monitoring if diagnosis uncertain and patient hemodynamically stable 1

Functional/Mittelschmerz Pain

• NSAIDs for symptomatic relief (ibuprofen, naproxen) 3
• Non-pharmacological measures: Heating pads, ice packs, moderate exercise 3
• Reassurance and patient education about benign nature 3

Common Pitfalls to Avoid

• Do not require multiple criteria before treating suspected PID—requiring two or more findings reduces sensitivity and misses cases that can cause permanent reproductive damage 1
• Do not dismiss mild or atypical symptoms—many PID cases present with nonspecific symptoms like abnormal bleeding or dyspareunia 1
• Do not overlook bladder as pain source—interstitial cystitis frequently masquerades as gynecological pain with urgency, frequency, nocturia 4
• Do not use CT as first-line for gynecological causes—ultrasound has equivalent or superior diagnostic accuracy without radiation exposure 1
• Do not forget pregnancy testing—failure to obtain β-hCG can lead to missed ectopic pregnancy or inappropriate radiation exposure 1, 2
• Do not assume postmenopausal pain is benign—maintain higher suspicion for malignancy in this population 1

Special Populations

Nulliparous, Postmenopausal, or Anxious Patients

• Expect higher pain levels during procedures and examinations 5
• Consider multimodal pain management: Oral analgesics, emotional support person, visual/auditory distraction 5

Patients with Chronic Pelvic Pain

• Multisystem evaluation required: Consider endometriosis, adenomyosis, vulvodynia, pelvic floor dysfunction, interstitial cystitis 4, 6
• Multidisciplinary approach: May require urology, gastroenterology, pain management, physical therapy referrals 6