28/06/2019
LOWER ABDOMINAL PAIN IN WOMEN
The abdomen(abdominal cavity) is a large hollow space that houses most of the important organs in the human body.It extends from the underside of the chest wall to the groin.It is bounded posteriorly by the spinal cindica the back muscles and laterally by the flank muscles..It is euphemistically referred to as the stomach but in actual fact the stomach is only one of the many organs accommodated in the abdominal space.Several organs are housed in the abdominal cavity. Each organs occupies a specific space . Understanding the specific location of each organ greatly assists the doctor in confirming where a complaint is emanating from.
The UMBILICUS serves as a midpoint of the abdomen.The space above it is referred to as the UPPER ABDOMEN and the one below as the LOWER ABDOMEN.Today’s writeup is about the lower abdomen.Organs from different systems of the body are located in the lower abdomen..The presence of the reproductive organs in the pelvis is the major difference between the male and the female lower abdomen.These systems include the musculoskeletal-skeletal, renal- urinary, cardiovascular, gastrointestinal, and reproductive. Pain can arise from any of the organs in these systems.Each pain has specific features and implications and requires specific management.
PAIN FROM THE MUSCULOSKELETAL SYSTEM
1. MUSCLE STRAIN: There are two big muscle ,the re**us muscles , covering the lower abdomen from the front. Any portion of any of these muscles can get strained in the course of your routine daily activities. This could happen slowly over time( chronic strain) or suddenly( whilst lifting a heavy object, injury from sporting activities, from a fall, blow to the tummy,etc). Pain is usually localised, could be very severe( depending on the severity of the injury) and is exacerbated by any movement/activity involving that part of the body.The patient is otherwise well with no other signs of ill health like fever or vomiting.Cold and hot compresses( ice packs, hot water bottle etc) could be quite helpful.
2. SACRO-ILIAC JOINT DYSFUNCTION
This joint is located between the sacrum and ilium bones of the pelvis. The sacrum supports the spine and is supported by the ileum on either side. this joint is a common source of leg,groin,butt,lower back(waist) and hip pain in women especially during pregnancy due to the softening of the connective tissue by the hormones of pregnancy. Treatment in the non pregnant is as described above. Management is a bit more complicated in pregnancy as most of the analgesics may not be safe.Addition of physiotherapy has been found to be quite useful during pregnancy
3. HERNIAS
Hernia is an abnormal protrusion of an internal organ, most commonly the intestine, through a weakened/damaged part of the musculoskeletal wall.The typical sign of hernia is an abnormal swelling over the area which is usually painless and can easily be pushed back..But once the swelling becomes large, painful and refuses to go back, urgent medical attention is required. There is no medical treatment for hernia.Treatment is usually surgical.The operation entails pushing back the organ and closure of the hole/space through which the hernia appeared. Common hernias in women include inguinal( above the groin), femoral((below the groin),umbilical( common in children and pregnant women)
Surgical (incisional) hernia can occur in women,more commonly in the obese, as a consequence of poor wound healing following an abdominal operation.
HERNIAS HARDLY EVER CAUSE ANY OTHER SYMPTOMS AND SHOULD NOT BE BLAMED FOR ANY OTHER PROBLEMS WITHOUT THOROUGH INVESTIGATIONS
PAIN FROM THE GASTROINTESTINAL SYSTEM
The gastrointestinal system comprises of the mouth, throat, stomach, small and large intestines.The system is responsible for the digestion of the food you eat, the absorption of water and nutrients and the processing of the waste which is stored in the re**um and passed out as faeces. Any disruption in the smooth functioning of this system can cause pain and discomfort in the lower abdomen. This is because the small intestines, which is about 23 ft long and the large intestines, 3 cm in diameter and 5 ft long are all coiled up in the lower abdominal space. The common problems include:
1. INDIGESTION (DYSPEPSIA)
Gas in the intestines is caused by food that is not completely broken down until it reaches the large intestines (colon).The more the undigested food the more gas that is produced. The build up of gas can cause abdominal pain,bloating and a “knotted” feeling in the abdomen. Burping and farting usually provide relief.It is not unusual for such a person to fart in excess of twenty times in a day.other causes of intestinal gas include overeating,chewing gum,smoking. Treatment for indigestion includes the use of antacids, avoiding heavily spiced food and fries, consuming frequent but small portions,avoiding overeating,smoking and eating late.
2. IRRITABLE BOWEL SYNDROME (IBS)
IBS is a chronic condition the cause of which is not known.The symptoms include bouts of severe generalised colicky abdominal pain,bloating, gas, alternation of diarrhoea and constipation . The sufferer might have long spells without pain. The onset of any attack is usually sudden and unexplained.The condition is not life-threatening , does not cause any damage to the bowels and does not lead to anything more serious. Pain is usually relieved by an antispasmodic like buscopan.
3. DIVERTICULITIS
Diverticulitis develops when small pouches called diverticuli occur in weak areas in the large intestines. and become inflamed. These pouches can swell ,tear, and become infected causing severe low abdominal pain,nausea ,malaise.
In severe cases urgent surgical treatment may be required
4. CONSTIPATION
Severe constipation is a common cause of severe low abdominal pain which is readily overlooked.. sometimes the symptoms may include nausea, bloating and headache. It is better to prevent than to treat constipation. That can be easily achieved by daily consumption of items with high fibre content, fruits ,vegetables and generous consumption of water(at least 2 litres per day) and not forgetting to empty your bowels every day
5. OBSTRUCTION
Obstruction occurs when a portion of the small or large intestines is blocked interfering with the free passage of food products. This leads to abdominal distension, severe generalised abdominal pain, vomiting, no passage of stool. This is a serious life-threatening condition that requires immediate hospital admission, stabilisation and surgery
6. APPENDIDITIS
Appendicitis is a common cause of low abdominal pain. The appendix is a redundant organ that is located on the right lower edge of the abdominal wall. The pain from appendicitis usually starts in the middle of the abdomen and gradually shifts to the right side.Acute appendicitis is a serious condition associated with severe pain, fever, vomiting and malaise and requires urgent surgery .A delay could lead to rupture of the appendix and the spillage of its purulent contents into the abdominal caving causing peritonitis, a severe life-threatening complication. Unfortunately there is a high incidence of over diagnosis of “acute appendicitis “ and many unnecessary operations are being carried out.careful choice of reputable health facilities and providers will go a long way in reducing the incidence of this malpractice.
PAIN FROM THE RENAL-URINARY SYSTEM
Urine is manufactured in the two kidneys and transported to the bladder via two tubes( ureters) that connect the kidneys to the bladder which lies in the pelvis.Certain conditions arising from any of these organs can cause severe abdominal pain. They include:
1. PYELONEPHRITIS (INFLAMMATION OF THE KIDNEY)
The kidney lies just under the rib age, on its back side and very close to the edge of the abdominal wall.Acute kidney infection causes severe pain over the kidney and this pain is usually referred to edge of the low abdominal wall.. The patient is usually very ill with fever, vomiting, loss of appetite. The urine could cloudy and bloodstained. The patient,advisedly, should be seen by a doctor.In less severe cases admission may not be necessary. An ultrasound scan is a useful tool in confirming the diagnosis and the causative organism could be isolated from a urine culture
2. KIDNEY STONES (NEPHROLITHIASIS)
Kidney stones are hard deposits made of minerals and salts that form inside the kidney..kidney stones can affect any part of the urinary tract from the kidney to the bladder. Kidney stones can cause severe illness with severe pain ,fever, nausea vomiting and blood in the urine.. The size of the kidney stone can range from a speck of sand to that of a corn seed..Passing the kidney stone( when the stone starts moving from the kidney through the ureter towards the bladder)could be associated with excruciating pain( RENAL COLIC)The pain travels along the route of the ureter,over the front edge of the abdominal wall. Once the stone is delivered into the bladder the pain suddenly stops. But if the stone gets trapped in the ureter causing unrelenting pain associated with urine infection urgent surgery- to dissolve and flush out the stone- may become necessary
3. CYSTITIS(BLADDER INFECTION)
Cystitis is more common in women than in men because of the proximity of the bladder to the v***a due to the shortness of the female urethra. Symptoms include frequency of micturition, pain passing urine, severe low abdominal pain,blood in the urine and incomplete emptying of the bladder. Diagnosis could easily be made by urine microscopy and culture..
PAIN ARISING FROM ORGANS OF THE REPRODUCTIVE SYSTEM
The reproductive organs consist of the va**na, the womb, ovaries and Fallopian tubes..The womb, ovaries and tubes are otherwise called the pelvic organs. Conditions arising from each of the pelvic organs are associated with severe low abdominal pain
THE UTERUS
1.DYSMENORRHEA (MENSTRUAL PAIN)
Most females experience cramp like low abdominal pain during the monthly period..The pain that starts once a young girl starts menstruating for the first time is called primary dysmenorrhea.The pain usually starts on the first day of the period .The pain could last till the end of the period but in most cases stops before the end of the bleeding. In most cases the pain is mild and bearable.But in a few cases it could be very severe and debilitating. The cause of primary dysmenorrhea is the prostaglandin which is released with the shedding of the lining of the womb during menstruation. The higher the prostaglandin level the more severe the pain...The intensity of the pain tends to reduce with age.The pain could disappear completely after the first va**nal delivery. Menstrual pain occurring in someone who never used to have it is called secondary dysmenorrhea.The pain develops as a result of other ailments in the pelvis like endometriosis,pelvic infection, fibroids,etc and will only subside once the problems are successfully dealt with.
2. ENDOMETRIOSIS- endometriosis occurs when part of the inner lining of the womb shed during menstruation travels upwards( instead of downwards to the va**na) , passes through the Fallopian tubes and is deposited on the pelvic wall and other pelvic organs. The lining keeps growing and shedding (as in the womb), causes adhesions between the organs of the pelvis and within a short period of time such a woman would start experiencing severe persistent low abdominal pain. There is no blood test that would confirm the presence of endometriosis..Ultrasound would not show endometriosis. The only reliable diagnostic tool is laparoscopy. Treatment could be medical,surgical or both
3. FIBROIDS
Fibroids are lumps that grow in the womb.It is more common in black women. Most of them cause no symptoms.The large ones can cause severe menstrual pain,and pressure pain in neighbouring organs like the bladder and re**um. Bleeding into a fibroid can cause excruciating low abdominal pain that may sometimes require hospitalisation. Pain usually subsides with analgesic and rest
4. PREGNANCY
A normal intrauterine pregnancy can cause severe pain due to stretching and distension of the uterine muscles early in pregnancy. Severe pain may also occur when a pregnancy is located outside the womb ( ectopic). A positive urine pregnancy test should be followed by an urgent pelvic (. Transva**nal)ultrasound to confirm the pregnancy’s location and viability and plan the appropriate management.
Severe low abdominal pain associated with va**nal bleeding in early pregnancy is termed threatened miscarriage. Such a pregnancy should be followed up with an ultrasound scan to rule out an incomplete or complete miscarriage.
THE O***Y
1. OVULATION PAIN
some women experience severe low abdominal pain during the ovulation window. The pain starts on the day of ovulation and can last for two or three days. The typical feature of the pain is that it always occurs about two weeks before the next period.A woman trying to conceive is strongly advised to brave the pain, take adequate analgesic and have sexual contact with her partner on the first day of the pain as that is the most likely day for conception
2. OVARIAN TORSION
A large ovary,or the one containing an ovarian cyst could tort( twist several times on its stalk) cutting out the blood supply to the ovary.The pain is of sudden onset, usually one-sided and is associated with vomiting.The condition requires immediate diagnosis, ( based mostly on a high index of suspicion from the history and findings from clinical examination as an ultrasound scan may not show much) and an emergency operation to untwist the ovary,restore blood supply and prevent its necrosis
3. OVARIAN CYST
An ovarian cyst is a ballon- like swelling arising from one or both ovaries.The content of the cyst could be fluid, solid, and some ,the dermoid cyst contain remnants of certain body organs like hair,teeth..An ovarian cyst can vary in size from the size of a small grape to that of a large melon or bigger.Large ovarian cysts tend to cause a persistent one sided pain.The severity of the pain depends on the size of the cyst and its location.
Any woman presenting with abdominal pain should have a pelvic/abdominal ultrasound scan.If a small cyst is detected in a young person and she is symptom free, 3-monthly ultrasound scans should be carried out for follow-up.Surgery may be considered if there is marked increase in size or if it becomes symptomatic. The approach is different in the older woman.Surgery should be strongly considered in a woman over 40 with ovarian cyst with or without symptoms and the specimen sent for histological examination to rule out malignancy. Surgery may be withheld when the cyst is small and if there is facility to carry out a Ca 125 blood test and if the level is within normal limits
4. OVARIAN CYST RUPTURE
An ovarian cyst may suddenly rupture releasing its contents into the pelvic cavity. This causes severe low abdominal pain very suggestive of a ruptured ectopic pregnancy ..The only difference is that the pregnancy test is negative and the patient is usually haemodynamically stable.
PELVIC INFLAMMATORY DISEASE (PID)
PID implies an infection in any or all of the pelvic organs( womb, Fallopian tubes, ovaries and surrounding tissues). In most cases PID results from an ascending sexually transmitted infection from the va**na.other instances of PID could result after a septic abortion/miscarriage or from a postoperative infection.The major symptom is severe low abdominal pain, pain during washing up and painful in*******se. In some cases there is fever,nausea and vomiting. There could be an offensive va**nal discharge.Pelvic infection should treated aggressively with appropriate antibiotics to prevent damage to the pelvic organs,in particular the Fallopian tubes the damage to which could lead to infertility
BOTTOMLINE
Pain in the lower abdomen is common in women of reproductive age. Contrary to the general belief amongst many women and some health care providers the incidence of PID is not as high as is being diagnosed and treated. There are numerous other causes of low abdominal pain.. and most of them do not require antibiotic treatment.Careful choice of good healthcare providers by women will go a long way in ensuring that the proper investigations are carried out, the correct diagnoses are made , the right treatment is prescribed and the woman’s reproductive health is .maintained......