Lower Left Quadrant Abdominal Pain. 

Essentials of Diagnosis Lower Left Quadrant Abdominal Pain.

 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

Symptoms and Signs

Pain Characteristics

Characteristics of the pain may aid in determining the diagnosis. Important characteristics include timing of onset, location, quality, and severity.

Onset

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.

Location

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.

Quality and Severity

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

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.

Aggravating and Alleviating Factors

Depending on the etiology, changes in pain may occur in relation to menses, coitus, activity, diet, bowel movements, or voiding.

Vital Signs

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.

Abdominal Examination

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.

Pelvic Examination

The pelvic examination is most easily organized to proceed from external to internal structures.

External 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.

Internal Structures

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 Findings

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, P < .01). It is important to note, however, that the CBC has a low sensitivity and specificity. The hematocrit is low in roughly one third of patients with ectopic pregnancy but normal in the remainder. In studies, a normal WBC count has been found in over half of patients with PID and in one third of patients with acute appendicitis, whereas an elevated WBC count is commonly seen in patients with ectopic pregnancies and bleeding corpus luteum cysts. The erythrocyte sedimentation rate is another nonspecific sign of inflammation. It is classically elevated in PID, but can be normal in up to 25% of patients.

A urinalysis should be performed on every patient with acute pelvic pain to rule out the presence of a urinary tract infection or kidney stone. Care must be taken with specimen collection to avoid contamination by vaginal or cervical discharge. Cervical specimens should be obtained to test for Neisseria gonorrhoeae and Chlamydia trachomatis. Vaginal fluid should be collected for saline (wet mount) and potassium hydroxide (KOH) preparation, for the diagnosis of bacterial vaginosis, Trichomonas vaginalis, and yeast infection. The finding of leukocytes on wet mount is very useful for making the diagnosis of PID, and the presence of 3 or more leukocytes per high-power field has a high sensitivity. Furthermore, the absence of leukocytes has a high negative predictive value for excluding PID as a diagnosis.

Imaging Studies

Imaging studies, especially ultrasound, may be very useful in making the diagnosis. Ultrasound is invaluable in the evaluation of ovarian cysts and their complications. Ultrasound, especially when performed transvaginally, is often the most useful imaging modality for the gynecologic organs. Nonetheless, computed tomography and magnetic resonance imaging scanning may also be helpful in the evaluation of women presenting with lower abdominal pain, especially when a nongynecologic cause is higher up on the differential diagnosis.

Special Tests

Diagnostic laparoscopy is perhaps the most definitive way to arrive at a diagnosis in a patient with acute pelvic pain. It is the best and most reliable method to achieve a complete evaluation of the pelvic structures, and allows direct visual access to the peritoneal cavity. It must be remembered, however, that although laparoscopy is minimally invasive, it carries with it some risks. Vascular injuries, as well as injuries to the gastrointestinal and urinary tracts, have been reported. The overall risk of injury to a vital structure has been estimated at between 2 and 3 per 1000. The high cost associated with diagnostic laparoscopy limits its utility in many cases of abdominal pain. Finally, although laparoscopy can be helpful, it requires the involvement of a gynecologist. Consultation may be useful in cases where the diagnosis remains unclear after investigation, or where the chosen treatment regimen is not resulting in the patient's improvement.

Differential Diagnosis

To assist in the diagnosis of acute pelvic pain, it is convenient to divide the causes into pregnancy-related, gynecologic, and nongynecologic. The gynecologic causes can be further subdivided into infectious and noninfectious. This classification is presented in Table 5–2.

When considering the diagnosis in a female patient with lower abdominal or pelvic pain, it is important to remember that this is a nonspecific symptom, with a wide variety of causes. Although lower abdominal pain is the most consistent symptom in patients with confirmed PID, it is seen with many other conditions as well. Similarly, pain on abdominal, pelvic, or bimanual examination can be a result of many conditions. Movement of the pelvic organs during examination will be painful if peritoneal irritation is present, regardless of the cause. Cervical motion tenderness can be found in up to 97% of patients with PID but is also commonly found in those with other disorders, such as ectopic pregnancy and appendicitis.

Of particular importance is the patient who presents with pelvic pain following an episode of domestic violence or sexual assault. It is estimated that up to 44% of all women have been the victims of an actual or attempted assault at some time in their lives. Women who have suffered abuse may account for 22–35% of women seeking care for any reason in an emergency department. Finally, it has been estimated that two million cases of domestic violence occur each year in the United States. The patient may present with vague symptoms and pain that is not well localized, and may not volunteer that she has been the victim of assault. Abuse may not be raised by the patient, and probing may be necessary. If a woman presenting with pain seems extremely nervous, anxious, or uneasy during the evaluation, it is appropriate to ask if she has been the victim of any unwanted sexual activity or physical violence. These patients need to be evaluated by clinicians familiar with the appropriate counseling and specimen collection techniques. Most hospitals have an assault or crisis team with a protocol for evaluating and managing these patients. Physical examination is tailored to a systematic search for injuries and to the collection of samples. Appropriate workup includes screening for sexually transmitted diseases (STDs), and pregnancy and HIV testing. Consideration must also be given to emergency contraception and prophylaxis for HIV and other infections.

Certain patient characteristics may assist in narrowing the differential diagnosis. The age of the patient can be useful, as infectious causes of pain such as PID and appendicitis are more common in younger women (adolescents and women younger than 30 years of age), whereas disorders such as diverticulitis are more commonly seen in women older than 40. The differential diagnosis of pain grouped by patient age is presented in Table 5–3. The menstrual history, including last normal menstrual period, can also be helpful. If the patient has missed any menstrual periods or if the last period was atypical, the diagnosis of pregnancy must be considered. If the patient is at midcycle, her pain may be related to ovulation (mittelschmerz). If the patient is menstruating, she may be suffering from dysmenorrhea. The results of some studies have suggested that PID is more likely to occur in the first half of the menstrual cycle, whereas appendicitis is randomly distributed.

A contraceptive history is also of diagnostic value. Women not using reliable contraception are at risk for pregnancy. Women not using barrier methods of contraception are at increased risk for STDs and PID, whereas those using barrier methods or combined oral contraceptives have a reduction in the risk of PID of approximately 50%. The presence of an intrauterine contraceptive device (IUD) increases the risk for developing acute PID, particularly around the time of insertion. Historically, IUD users were at an overall increased risk for PID, but with currently available IUDs this risk is limited to the time of insertion. IUD use does not increase the absolute risk for developing an ectopic pregnancy. However, an IUD is more effective at preventing intrauterine versus extrauterine gestation, so a pregnancy that occurs with an IUD in place has a 10-fold increased risk of being ectopic.

Finally, a sexual history is important. Information about sexual habits and risky behavior, current partners, and number of lifetime partners helps the clinician to estimate the patient's risk of STDs and PID.

A complete medical and surgical history may assist with the differential diagnosis. A history of urinary or gastrointestinal tract disorders may be a clue to the current problem. The surgical history may help to rule out certain disorders (eg, appendicitis) or heighten awareness of the possibility of other problems (eg, ectopic pregnancy in a patient with previous pelvic or tubal surgery).

To establish a working diagnosis in the woman of reproductive age with acute pelvic pain, the clinician must use all tools available. Clinical history, physical examination, laboratory tests, and imaging procedures are useful in providing diagnostic clues, but they may lack adequate sensitivity or specificity to make a final diagnosis. For example, abnormal uterine bleeding is part of the classic triad of symptoms for ectopic pregnancy but is absent in up to 50% of patients with this diagnosis. Similarly, up to 50% of patients with ectopic pregnancy have no palpable mass, and 43% have cervical motion tenderness. Despite a comprehensive history and physical examination, a significant proportion of patients with acute pelvic pain will continue to have an unclear diagnosis.

Complications

Many causes of lower abdominal pain in women are not associated with long-term complications, provided they are managed quickly and effectively. However, some of these conditions may lead to sequelae. Spontaneous abortion is common and usually not associated with long-term problems. Ectopic pregnancy may result in tubal damage or loss of the fallopian tube if rupture occurs. Endometritis can progress to myometritis, parametritis, or peritonitis.

PID may lead to both short-term and long-term consequences as a result of upper genital tract infection. Short-term sequelae include perihepatitis or Fitz-Hugh-Curtis syndrome (occurring in 15–30% of women with acute PID), tubo-ovarian abscess (occurring in 15–34% of women with acute PID), and death (occurring very rarely). Long-term sequelae include infertility (with the risk increasing with the number and severity of episodes of PID), ectopic pregnancy (with the risk 7- to 10-fold higher compared with women who have no history of PID), and chronic pelvic pain (occurring in 17–24% of women after acute PID). Chronic pelvic pain after PID is usually a result of pelvic adhesions caused by the inflammatory response to the infection. Similar to other sequelae after PID, the rate of chronic pelvic pain is proportional to the number and severity of episodes of PID. Pain can sometimes be severe enough to require analgesia, and may lead to the need for surgery.

Endometriosis may lead to pelvic adhesive disease, chronic pelvic pain, and infertility.

Treatment

The management of lower abdominal or pelvic pain in the female patient depends on the cause. The first step in management is, in fact, narrowing the wide differential diagnosis to come to a working diagnosis, using the previously described tools (history, physical examination, and laboratory tests). The differential should first be narrowed by system. That is, the clinician should first determine whether the pain has a gynecologic or non-gynecologic cause. Determining whether the patient is pregnant is paramount in aiding with the diagnosis. Referral to a specialist is appropriate when the diagnosis is unclear.

Acute Pelvic Pain

The most common pregnancy-related causes of acute pelvic pain are abortion and ectopic pregnancy. Some spontaneous abortions require no treatment, but some women may require medical or surgical intervention to complete the process. Ectopic pregnancy is a condition that requires medical or surgical management depending on several factors, including the size of the ectopic gestation, stability of the patient, and patient reliability. Medical management is accomplished with methotrexate, and surgical options include salpingostomy or salpingectomy via either laparoscopy or laparotomy. Referral to a gynecologic specialist is essential.

Infectious Gynecologic Causes of Pain

Infectious gynecologic causes of acute pelvic pain include endometritis, PID, and tubo-ovarian abscess. Endometritis is a polymicrobial infection, and treatment must therefore be with an antibiotic regimen covering a broad spectrum of bacteria. PID can also be caused by a wide spectrum of bacteria, both sexually and nonsexually transmitted, and management by a gynecologist is essential. The treatment regimens currently recommended by the Centers for Disease Control and Prevention are discussed in Chapter 8. Tubo-ovarian abscess is usually associated with PID and requires broad-spectrum antibiotics with anaerobic coverage (eg, metronidazole) and, depending on the size of the abscess, surgical drainage.

Noninfectious Gynecologic Causes of Pain

There are many noninfectious gynecologic causes of acute pelvic pain, each requiring different treatment strategies. The typical treatment of dysmenorrhea is with prostaglandin synthase inhibitors such as nonsteroidal anti-inflammatory drugs (NSAIDs) or combined oral contraceptives. Management of uterine fibroids is either medical (ie, NSAIDs or hormonal suppression) or surgical (ie, myomectomy or hysterectomy). Treatment of endometriosis is either medical or surgical. Medical therapy includes oral contraceptives, progestins, danazol, or gonadotropin-releasing hormone agonists. The objective of surgical therapy is to restore normal anatomy and to remove or ablate as much abnormal tissue as possible; this can be accomplished with laparoscopy or laparotomy.

For physiologic cysts of the ovary such as follicular and corpus luteum cysts, management should be expectant as they usually resolve spontaneously within 4 to 8 weeks. Complications such as rupture, hemorrhage, or torsion may require surgical intervention. Rupture of a follicular cyst leads to release of fluid, which may irritate the peritoneum and cause pain. This pain is typically sudden in onset and may be severe but is self-limited and resolves without treatment. Corpus luteum cysts have an extensive vascular supply and rupture can lead to severe hemorrhage and pain that can be indistinguishable from that of a ruptured ectopic pregnancy. If the diagnosis of a ruptured corpus luteum cyst is confirmed and the patient is stable, expectant management may be appropriate. If significant hemorrhage is suspected or the patient is unstable, surgery is required.

Adnexal torsion is an acute surgical emergency because the blood supply to the adnexa is interrupted, and this can lead to necrosis and infarction. Surgical management is usually accomplished via laparoscopy. The current surgical approach involves untwisting the adnexa and assessing its viability, and removing the ovary if it is not viable. If an ovarian cyst is present, a cystectomy should be done to obtain a histologic diagnosis.

Nongynecologic Causes of Pain

Nongynecologic causes of acute pelvic pain include disorders of the gastrointestinal, urinary, and musculoskeletal systems. Treatment should be directed to the cause. Acute appendicitis is managed surgically with appendectomy, either laparoscopically or through an incision over McBurney's point. The treatment of gastroenteritis is usually supportive care with fluids and bowel rest. Diverticulitis, inflammatory bowel disease, and bowel obstruction may all be managed medically or surgically depending on the severity. Treatment of lower urinary tract infections can usually be accomplished with oral antibiotics. Pyelonephritis may require hospital admission and parenteral antibiotics, as these patients are typically unwell and may have high fevers with chills. Management of nephrolithiasis is usually expectant and involves analgesia and hydration; surgical treatment is occasionally required. For musculoskeletal causes of lower abdominal, pelvic, or back pain, management is usually medical, with muscle relaxants or NSAIDs.

When to Refer to a Specialist

Because the diagnosis of lower abdominal pain in women has such a wide variety of causes, it is helpful to narrow the differential diagnosis before referral to a specialist is made. Once the diagnosis has been categorized by organ system (gynecologic, gastrointestinal, urinary, or musculoskeletal), referral may be considered.

Another circumstance that warrants referral occurs when the practitioner has made a diagnosis and begun treatment, but the treatment regimen does not seem to be resulting in cure. In complicated cases such as these, consultation with a specialist may be helpful.

Practice Points

 The finding of leukocytes on wet mount is very useful for making the diagnosis of PID, and the presence of 3 or more leukocytes per high-power field has a high sensitivity. Furthermore, the absence of leukocytes has a high negative predictive value for excluding PID as a diagnosis.