Basildon EM Handbook 2018

Other gynaecological causes of abdominal pain

March 2018 | by EMauthor

Endometriosis

Endometriosis is the presence of endometrial tissue outside the uterus. The disease may consist of only a few lesions, to large cystic lesions causing fi brosis and formation of adhesions. Symptoms include:

•Severe dysmenorrhoea.

•Deep dyspareunia.

•Chronic pelvic pain.

•Ovulation pain.

•Infertility.

•Cyclical, premenstrual symptoms

ED treatment consists of symptomatic relief with NSAIDs and exclusion of an ectopic pregnancy. Patients should be referred to the gynaecology team as an outpatient. Diagnosis is made via laparoscopy and direct visualisation of the pelvis with positive histology.

Ovarian cyst rupture/torsion

•Ruptured cysts

oPatients may develop abdominal pain when ovarian cysts rupture because the contents can cause peritoneal irritation and localized tenderness. Treatment is symptomatic and referral to the gynaecology team.

•Ovarian torsion

oSudden, unilateral, lower abdominal pain. The ovary is usually enlarged from a cyst or neoplasm and torts around the pedicle. Abdominal and adnexal tenderness may be present. The torsion may resolve spontaneously or progress to ovarian infarction.

oDiagnosis is difficult and may be made by transvaginal ultrasound or laparoscopy.

oPatients with a suspected ovarian torsion should be managed symptomatically (e.g. analgesia, fluids, etc) and referred to gynaecology as an inpatient.

Dysmenorrhoea

Dysmenorrhoea (pain during menstruation) may be primary, without underlying organ pathology, or secondary to uterine pathologies such as endometriosis, PID, or fibroids. Primary dysmenorrhoea is worse in the first few days of menstruation. Excess prostaglandins cause painful uterine contractions. Treatment with prostaglandin inhibitors, such as mefenamic acid or NSAIDs, helps control symptoms. Patients should be referred to their GP for further management.

Fibroids

Fibroids are nodules of smooth muscle cells and fibrous connective tissue that develop within the wall of the uterus. Symptoms include menorrhagia, dysmenorrhoea, and deep dyspareunia. Fibroids may undergo torsion resulting in sudden, severe, colicky pain, or they may infarct (‘red degeneration’), particularly during pregnancy. Patients require referral to gynaecology for further investigation.

Corpus luteum cyst rupture

The corpus luteum is formed when a mature ovarian follicle ruptures and releases an ovum. Rupture of a corpus luteum cyst may cause frank haemorrhage into the peritoneum. Patients present during the second-half of their menstrual cycle with abdominal pain and occasionally syncope. Fluid resuscitation and admission may be required if significant haemorrhage has occurred.

Mittelschmerz

This is mid-cycle pain due to the leakage of prostaglandin-containing follicular fluid at the time of ovulation. Treatment is symptomatic and patients can usually be discharged from the ED.

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