Acute pain due to ischemia or injury to a viscus is accompanied by autonomic reflex responses such as nausea, vomiting, restlessness, and sweating. The following is a discussion of some of the important gynecologic causes of acute abdominal pain.

Culdocentesis is a very useful diagnostic aid for differentiating the cause of acute gynecologic pain. In the absence of a positive pregnancy test result, fresh blood suggests a corpus luteum hemorrhage, old blood suggests a ruptured endometrioma (chocolate cyst), purulent fluid suggests acute pelvic inflammatory disease (PID), and sebaceous fluid indicates a dermoid cyst.

Ectopic pregnancy
An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients.

Abdominal examination findings include tenderness and guarding in the lower quadrants. Once hemoperitoneum has occurred, distension, rebound tenderness, and sluggish bowel sounds may develop.

Pelvic examination may reveal cervical motion tenderness that is exaggerated on the side of the tubal ectopia.

Initially, a sensitive serum or urine pregnancy test should be performed. Transvaginal ultrasonography should be performed. If an intrauterine gestational sac with a fetal pole is identified, the chances of a coexisting ectopic pregnancy are remote. Such a heterotopic gestation should be considered in patients taking ovulation-inducing drugs. Serial serum beta-human chorionic gonadotropin (hCG) estimations are often helpful in making the diagnosis. In early intrauterine gestations, the doubling time for hCG is usually 48 hours. Only 15% of cases are exceptions to this rule. In the absence of the availability of ultrasonography or in an emergency setting, culdocentesis can be of value to detect unclotted blood. A hematocrit of less than 16% (in the peritoneal blood) excludes hemoperitoneum.

Laparoscopy should be attempted if the patient is hemodynamically stable, a high index of suspicion remains, or the patient complains of increasing pain despite adequate analgesia.

Treatment options for an unruptured ectopic pregnancy include salpingostomy and salpingectomy. These may be performed laparoscopically or by open procedure. Methotrexate, a folic acid antagonist, is also used for the treatment of unruptured ectopic pregnancy. A ruptured ectopic pregnancy requires a laparotomy with removal of blood clots.

Adnexal masses
Corpus luteum hematoma

This condition develops in the luteal phase of the menstrual cycle. Slow leakage produces minimal pain. Frank hemorrhage can lead to hemoperitoneum and hypovolemic shock. Generalized abdominal pain and syncope are features of such a presentation. Treatment includes laparoscopy or laparotomy, evacuation of clots, and control of ovarian bleeding.

Ruptured ovarian cyst
The most common causes are dermoid cyst, cystadenoma, and endometrioma. Because the amount of blood loss is minimal, hypovolemia does not supervene. Peritoneal irritation due to leakage of cyst fluid can lead to significant tenderness, rebound tenderness, abdominal distension, and hypoperistalsis. Treatment involves cyst removal.

Ovarian torsion
Changes in ovarian axial morphology, which are typically secondary to ovarian cysts (most commonly dermoids), can undergo torsion around the pedicle. Frequently, torsion resolves spontaneously, and the only presenting symptom is lower abdominal pain. Persistent torsion progresses to occlusion of the venous drainage of the ovary, which leads to congestion, ovarian enlargement, thickening of the ovarian capsule, and subsequent infarction. Pain eventually becomes severe and is accompanied by nausea, vomiting, and restlessness. Infarction also leads to fever and mild leukocytosis.

If the ovary appears viable based on laparoscopic examination findings, the pedicle may be untwisted and the cyst removed. An infarcted ovary must be removed.

Acute pelvic inflammatory disease
Acute salpingo-oophoritis is a polymicrobial infection that is transmitted sexually. Neisseria gonorrhoeae and Chlamydia trachomatis are usually identified in patients with PID, and both organisms often coexist in the same patient. Gonococcal disease tends to have a rapid onset, while chlamydial infection has a more insidious onset. The US Centers for Disease Control and Prevention (CDC) has recommended strict diagnostic and management guidelines for the treatment of PID in an effort to reduce serious preventable sequelae such as adhesions and infertility.

Diagnostic criteria for PID
All of the following criteria must be present:

•   Lower abdominal tenderness
•   Cervical motion tenderness
•   Adnexal tenderness

Diagnosis may also be supported by any of the following criteria:

•   Temperature greater than 101°F (38.3°C)
•   Abnormal cervical or vaginal discharge
•   Laboratory evidence of C trachomatis or N gonorrhoeae
•   Elevated erythrocyte sedimentation rate or elevated C-reactive protein value

Definitive criteria for diagnosis include the following:

•   Positive findings on transvaginal ultrasound or other imaging technique demonstrating thickened fluid-filled tubes with or without tubo-ovarian abscess or free pelvic fluid
•   Positive endometrial biopsy findings
•   Positive laparoscopy findings

Outpatient management of PID

•   Regimen B includes ceftriaxone at 250 mg IM, cefoxitin at 2 g IM plus probenecid at 1 g PO, or another parenteral third-generation cephalosporin. Add doxycycline at 100 mg PO bid for 14 days to whichever of the above is chosen.
•   Quinolones are no longer recommended for treatment of infections possibly related to gonococcal infections because of the emergence of resistant strains.

Inpatient management of PID

•   Regimen A includes cefotetan at 2 g IV q12h or cefoxitin at 2 g IV q6h. Add doxycycline at 100 mg IV/PO q12h to the above choice.
•   Regimen B includes clindamycin at 900 mg IV q8h plus gentamicin at 2 mg/kg IV/IM loading dose followed by 1.5 mg/kg q8h as a maintenance dose.

Admission criteria for PID

•   Pregnancy
•   Inability to exclude surgical emergencies such as appendicitis
•   Immunosuppression (including HIV infection with low CD4 count)
•   Confirmed or possible pelvic abscess
•   Intrauterine device in situ
•   High fever or severe nausea and vomiting
•   Inability to comply with an outpatient regimen
•   Failed outpatient therapy
•   Adolescence
•   Significant fertility issues

Tubo-ovarian abscess

A ruptured abscess can lead to gram-negative endotoxic shock; therefore, this condition is a surgical emergency. The most common presentation is bilateral, palpable, fixed, tender masses. Patients often present with generalized abdominal pain and rebound tenderness caused by peritoneal inflammation. In such cases, the infected tissue must be surgically removed under broad-spectrum antibiotic coverage. Preoperative antibiotic coverage for 24-48 hours is recommended if the patient is stable.

Fibroids
Degenerating fibroid
This may occur during pregnancy when rapid growth of the tumor outstrips its blood supply. This condition is conservatively managed as much as possible.

Twisted subserous fibroid
A pedunculated subserous fibroid may twist and undergo necrosis, causing acute abdominal pain. It may be removed by laparoscopy or an open procedure.

Submucous fibroid
A pedunculated submucous fibroid may present with cramping pain and vaginal bleeding. Hysteroscopic resection is the treatment of choice.

Author: Dharmesh Kapoor, MD, MBBS, MRCOG, Subspecialty Fellow, Department of Gynecology, Derriford Hospital

Coauthor(s): Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida; Willy Davila, MD, Head, Section of Urogynecology and Reconstructive Pelvic Surgery, Chairman, Department of Gynecology, Cleveland Clinic Florida

Editors: Jordan G Pritzker, MD, Assistant Professor of Obstetrics, Gynecology, and Women’s Health, Women’s Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Dept of Obstetrics and Gynecology, Long Island Jewish Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine