Women often present with lower abdominal pain. The causes range from minor but uncomfortable problems such as constipation or period pain, to life-threatening problems such as a ruptured ectopic pregnancy or appendicitis.
Some simple rules to manage lower abdominal pain include:
- Always do a pregnancy test on women of child-bearing age.
- Think past an obvious cause of the pain, e.g. many women have an abnormal dipstick urine test, but urinary infection may not be the cause of the pain.
- Pelvic inflammatory disease (PID) is a common cause of lower abdominal pain in areas of high rates of gonorrhoea and chlamydia in WA. Always think about PID as a possible diagnosis and treat early to avoid complications especially if the patient is at risk of infertility (e.g. young, recent change of partner or multiple partners, recurrent STIs, past infertility, following termination of pregnancy or other instrumentation).
- Take a risk history.
If a patient complains of lower abdominal pain, take a medical history, examine and consider:
- urinary tract infections – dysuria (pain on passing urine) and frequency
- appendicitis – usually central abdominal pain moving to the right lower quadrant and accompanied by nausea, vomiting and poor appetite
- gastroenteritis or colitis – accompanied by bowel changes, diarrhoea and blood or mucus per rectum
Consider ectopic pregnancy or other gynaecological conditions, such as an ovarian cyst or endometritis, if the patient has also:
- missed a period or the last period is overdue
- had a recent delivery or abortion
- unexpected vaginal bleeding.
It is important to perform a pregnancy test and exclude an ectopic pregnancy, which needs urgent referral to a gynaecologist.
The term PID refers to infections of the female upper genital tract – uterus, fallopian tubes, ovaries or pelvic cavity. It can be caused by gonorrhoea, chlamydia or anaerobic bacteria, or a variety of bacteria commonly found in the vagina, such as the different bacteria that can cause bacterial vaginosis, especially post-instrumentation.
Symptoms include constant pain in the lower abdomen that worsens with movement such as running or going up and down stairs, or pain with intercourse (deep dyspareunia). There can be fever or raised temperature, malaise, irregular or heavy periods, or pain can start after a recent period.
Signs on pelvic examination include a cervical discharge and/or vaginal discharge, cervical excitation (pain on rocking the cervix), tenderness, heat or swelling in the fornices. Abdominal examination can show tenderness in the iliac fossae, guarding or rebound tenderness.
Clinical examination, investigations and specimen collection
If the patient has a temperature (>38 °C), rebound tenderness, guarding, pain during examination and/or vaginal discharge, consider PID in the differential diagnosis of an acute abdomen. The following investigations should be performed where PID is considered:
- Examine the urethra and vulva for redness and discharge.
- Pass a speculum and visualise the vagina and cervix.
- On examination any vaginal discharge should be noted as that may indicate an ascending infection.
- Collect a high vaginal swab using a charcoal swab – smear initially onto a glass slide for microscopy and then insert in a charcoal transport media tube for culture and sensitivity.
- Test vaginal pH on indicator paper (normal is pH < 4.5). Note if there is a fishy odour.
- On examination, the cervix should be observed carefully as any purulent discharge is significant.
- Take one endocervical swab for MC&S – smear initially onto a glass slide for microscopy and then insert in a charcoal transport media tube for culture and sensitivity. This specimen is suitable for culture of gonococci, anaerobes, Mycoplasma spp. and other endogenous flora.
- Take a second endocervical swab for chlamydia and gonorrhoea NAAT. Note that point-of-care testing for chlamydia and gonorrhoea is not indicated in patients with PID as it will not alter the treatment required.
- Perform a pelvic examination to check the pelvic area for masses, heat, tenderness, or fullness in the adnexa. An important sign is cervical excitation.
- Collect first void urine for gonorrhoea and chlamydia NAAT.
- If the patient has urinary frequency, take a mid-stream specimen for culture and sensitivity.
- Do a pregnancy test.
- Pelvic ultrasound may be required.
- Take a full blood picture and measure erythrocyte sedimentation rate (ESR) as well as C reactive protein.
- Assess disease severity and consider hospitalisation.
- If PID is considered, treat immediately.
- Ensure the patient understands that their condition is likely to be the result of an STI and that recent partners may be asymptomatically infected.
- Undertake contact tracing and treatment of partner(s).
- Advise return visit in three days to ensure improvement and test of cure.
- Patients should be advised not to have sex until they have been assessed.
- In all cases, educate the patient about safe sexual behaviour.