Significance of the Location of Lower Abdominal Pain

The location of the abdominal pain is important, as it can help narrow your differential diagnosis. For example, diffuse abdominal pain may represent gastroenteritis, whereas localized right lower quadrant pain is classic for but not limited to appendicitis. Think about what is in the various quadrants of the abdomen when considering the differential diagnosis of abdominal pain.

Red Flags of Life-Threatening Condition in Patient with Lower Abdominal/Pelvic Pain

There are many signs and symptoms of a life-threatening condition in a patient with abdominal or pelvic pain. Examples include: Abrupt onset of severe pain Shock with hypotension and tachycardia Distension Peritoneal irritation signs Rigid abdomen Pulsatile abdominal mass Absent bowel sounds Fever Vomiting Diarrhea Weight loss Menstrual changes Trauma, prior surgeries, or operative scars History/presence of blood in emesis History/presence of blood in stool Severity of the pain Ecchymoses/bruising Rebound tenderness Mass or ascites

Obstetrical History

G Gravida or number of pregnancies

T Number of Term pregnancies

P Number of Preterm infants

A Number of spontaneous or inducedAbortions

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L Number of Living children

Documenting Follow-Up and Lab Reporting

Documentation of attempts to schedule follow-up visits and inform patients of laboratory results is very important. Failure to reach a patient by phone or mail should also be documented. If a provider is unable to reach a patient about an important test result (e.g. an abnormal Pap smear), reaching out to emergency contacts and sending a certified letter should be done to document every effort to reach a patient.

Abdominal Pain History

Location Quality Severity Timing Aggravating factors and alleviating factors

Some Common Causes of Lower Abdominal Pain Presenting in Primary Care

Constipation: Patients may give a history of having small, hard pellets for stools, decreased frequency of stooling, harder stools than usual, or occasionally having loose stools, which may actually signify an impaction, where the patient has soft stool leaking around an impacted hard stool. This type of stooling pattern is more often associated with irritable bowel syndrome. Irritable bowel syndrome (IBS): Many patients will describe abdominal pains of varying location, associated with either soft, frequent, loose stools, or constipation, or an alternating stool pattern. They may also describe abdominal bloating, increased flatulence, and mucus in the stool. The symptoms of IBS are frequently worse when the patient is under stress, anxious, or depressed. Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, diet, and change in activity—and the symptoms are often unpredictable. Caffeine and dairy products can make symptoms worse. The diagnosis is based on clinical history, physical exam, and absence of alarming symptoms suggesting other pathology. The Rome IV criteria is often used to aid diagnosis of adult IBS: Recurrent abdominal pain, on average ≥ 1 day per week in past 3 months with two or more of following features:

1. Related to defecation 2. Associated with change in stool frequency 3. Associated with change in stool form (appearance)

Endometriosis: Patients with endometriosis may begin to notice increasingly more painful and heavier menstrual cycles as early as late adolescence. A patient with endometriosis might indeed have lower abdominal discomfort, often starting after ovulation during most cycles and continuing through their menstrual cycle. There may also be low back pain or painful stooling. It is not uncommon for a patient with endometriosis to experience pain with intercourse. Ultrasounds or MRIs may be needed in order to help diagnose the problem. Laparoscopy may be needed to definitively diagnose, treat, or alleviate symptoms. Hormonal contraception often stops the pain and the process, thus preserving the patient’s ability to become pregnant later. Genetic factors are often involved. Inflammatory bowel disease (IBD): Patients with IBD usually have some combination of abdominal pain, bloody diarrhea, and frequent stooling. The onset of symptoms frequently occurs in the late 20s or early 30s. The patient may ultimately be diagnosed with either ulcerative colitis or Crohn Disease. Diagnosis is made through specific radiological findings on barium enema, small bowel follow-through, and by colonoscopy. Muscular pain or musculoskeletal pain is generally reproducible. On exam, there is usually point tenderness to palpation of the affected muscles. The pain may recur during certain activities or when the offending position is (re)assumed. Psychosomatic pain: Symptoms from this type of pain are variable and can be associated with or aggravated by other etiologies such as IBS or gastritis. The pains can occur anywhere throughout the abdomen. They usually present as an atypical pain pattern, occur in a depressed or otherwise mentally ill patient, and may point toward a psychogenic cause. This is a diagnosis of exclusion. Stress: The patient’s symptoms and pains tend to be increased when the patient is under increased stress or is involved in other negative interactions. The patient may present with a whole constellation of other stress-related symptoms, such as headache, depression, anxiety, appetite changes, and sleep disorders. Stress can also aggravate other conditions, such as irritable bowel syndrome. This diagnosis, which is related to psychosomatic disease, is one of exclusion. Urinary tract infection (UTI): Symptoms may include lower abdominal or suprapubic pain, urinary frequency, burning with urination (dysuria) that is frequently worse at the end of the urinary stream (terminal dysuria) and which can also involve hematuria. There may even be lower back pain in severe infections that involve the kidney. Among patients with female genitalia, the onset of symptoms may be related to recent sexual intercourse. UTI is a common condition and should always be considered in patients with lower abdominal pain. Vaginitis: The patient’s symptoms and concerns will vary depending on the cause of the discharge. She can present with a vaginal discharge that is watery to pasty; it may be malodorous; discomfort can vary from itching to burning, and there may or may not be pain with intercourse (dyspareunia) and pelvic pain. Being at risk for sexually transmitted infections widens the differential, and the use, or lack thereof, and the type of contraceptive used impacts that risk. An expanded history is needed in this case. Examination of the discharge under the microscope, or sending a vaginal swab and cervical cultures to the lab, is generally required.

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Intimate Partner Violence: Screening Recommendations, Prevalence, and Complications

Screening recommendations:

The American College of Obstetrics and Gynecology suggests screening all patients who come to them (family planning patients, all ob-gyn patients, and all prenatal patients) at first visit, at each trimester, and at the postpartum visit. It may help to preface asking such questions with a statement such as: “Because intimate partner violence (IPV) is so common, I ask all of my patients about this…” The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for IPV, such as domestic violence, and provide or refer women who screen positive to intervention services. (Level of Evidence: B) This is routinely done at annual exams or when red flags are present. Here is a good resource regarding screening for intimate partner violence. Prevalence:

It is important to be aware of IPV when addressing our patients, as approximately 25% of women in the U.S. report being victimized by an intimate partner at some point in their lifetime. While the majority of IPV victims are women, they can be any gender, occur in both heterosexual and same-sex relationships, and across all socioeconomic, age, and ethnic divides. Complications:

In addition to the trauma incurred, the rates of chronic disease—including heart disease, diabetes, depression, and suicide—are significantly higher in victims as well as in adults who were victimized as children as a result of direct abuse and exposure to IPV.

Symptoms and Conditions Experienced More Frequently by Victims of IPV Red Flags for Intimate Partner Violence

Individuals who were victimized by their intimate partner are more likely to experience:

Migraines, frequent headaches Chronic pain syndrome Heart and blood pressure problems Arthritis Stomach ulcers, frequent indigestion, diarrhea, constipation, irritable bowel syndrome, spastic colon Pain during sex (dyspareunia), dysmenorrhea, vaginitis, pelvic inflammatory disease, chronic pelvic pain syndrome, and other gynecological diagnoses Invasive cervical cancer and preinvasive cervical neoplasia Depression, anxiety, and post-traumatic stress Unexplained or poorly explained findings on physical exam

Red flags for intimate partner violence include:

Delay in seeking medical care Non-compliance with treatment plan Partner insisting on staying close and answering questions directed to patient Hesitancy or not answering questions or inconsistent or incorrect answers given to questions Shyness or reticence in answering questions Explanation of problem or incident does not match severity of findings

Facilitating Discussion About Intimate Partner Violence

There are several nonjudgmental ways to ask about intimate partner violence. Examples include: “Do you feel safe at home?” “Because violence is so common, and there are so many forms of violence, I am asking all my patients about it. Is anyone now or has anyone in the past hurt you emotionally, physically, or sexually. Is anyone threatening you?” “All couples disagree at sometime. What happens when you disagree/fight/argue?” “Does your partner ever force you to do things you do not want to do or keep you from doing things you want to do?” “How do you handle money issues in your relationship?” “I often see the type of symptoms that you have in people who are being hurt at home or in a relationship. Do you think that this might be happening to you?”

There are lots of things you can do to facilitate discussion about IPV.

Ask screening questions

Many clinics will ask a screening question of all patients during the triage process. Asking the patient, “Do you feel safe at home?” follows the vital signs and questions about whether or not the patient is having any pain. This open-ended question allows the patient to share information they might have about feeling unsafe at home, in their neighborhood, or where they live, work, or shop, or feeling threatened or actually being abused by someone. This question is appropriate for any age, gender, or socioeconomic class. It may take several visits for the patient to feel comfortable enough with the provider to discuss such a sensitive issue.

Create a safe setting

Hang posters on the clinic walls and place brochures about safety, particularly in private areas like bathrooms and exam rooms. These should also contain information addressing cultural differences and acknowledging varied relationships and backgrounds.

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Interview the patient alone

Never interview with the suspected perpetrator present. In order to have the partner leave the room, you can cite protocols such as, “I always do this part of the exam just with the patient. You can join us again when we are done.” Or, “I begin the visit with the patient alone. If you have questions after, we can meet together.”

If the partner insists, then attempt to separate the two by taking the patient to obtain a urine sample or another test outside of the exam room.

Infants and toddlers three years old or younger can stay with the parent, but it is recommended that if the child/children accompanying the parent are older than three, you should meet with the patient alone.

Ensure confidentiality

Update and review HIPAA forms and make sure that all staff are aware of how to use them. Be sure to tell the patient that anything discussed in the room will not be shared with anyone not directly involved with their care, including their partner and family members.

Direct assessment

Interviewing can begin with indirect questions such as, “Tell me about your relationship,” but should include a direct assessment of safety, including questions regarding weapons in the house and danger or possible harm to the children or pets.

Know your local laws

All states require reporting of child abuse and some require reporting of intimate partner violence. Be open with your patient about your legal constraints.

Facilitate impartiality

Consider using a telephone service for interpretation if an appropriate professional interpreter is not present in the office. Do not use a friend or relative.

Listen nonjudgmentally Validate the patient’s concerns and the fact that abuse is not the fault of the victim.

Handling Children During a Sensitive History and Exam

It is generally preferred to have children outside the room during a pelvic or genital exam of the parent. Depending on the age of the child, some parents may prefer to have the child sit in the room in a corner and face away from the exam table, or keep a sleeping child in a stroller in the room with them. The clinician may have sensitive questions to ask; the parent-patient may not want the child to see them undressed and undergoing this exam. There is frequently someone on staff who will watch or entertain the child or children during this portion of the exam. Or the parent may have come to the clinic with a friend or relative with whom the child can stay in the waiting room during that portion of the visit. It is also important to have a chaperone in the room for the exam for legal reasons and for protection of the clinical staff. This person should be named in the chart note.

Symptoms of Exposure to Domestic Violence in Children and Adolescents

Obvious physical signs of physical or sexual abuse Behavioral or emotional problems, such as increased aggression, increased fear or anxiety, difficulty sleeping or eating, or other signs of emotional distress Chronic somatic concerns

30% to 60% of perpetrators of intimate partner violence also abuse children in the household.

Intimate Partner Violence Safety Assessment

1. Increasing severity of violence 2. Presence of gun in the house 3. Threats to kill or commit suicide by either victim or abuser 4. Use of drugs or alcohol by victim or abuser 5. Victim trying to leave or left recently 6. Harm to children

Increasing Severity of Intimate Partner Violence

1. Verbal abuse, insults, yelling 2. Throwing things, punching wall 3. Pushing victim or throwing things at victim 4. Slapping 5. Kicking, biting 6. Hitting with closed fist 7. Attempting strangulation 8. Beating up; punching with repeated blows

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9. Threatening with weapon 10. Assault with weapon

Escalating Cycle of Intimate Partner Violence

Intimate partner violence is a pattern of increasing episodes of violence in which one partner exerts control over another through intimidation, physical and/or emotional violence, and threats. It is common for there to be a tension-building phase, a crisis phase when overt violence is likely to occur, followed by a calmer phase when the abuser might ask for forgiveness and even be affectionate. Unfortunately, in most cases, the cycle begins again and often the violence is increasingly severe.

Documenting a Case of Suspected Intimate Partner Violence

When documenting a history of abusive behavior, use the patient’s own words in quotes and fill in names after pronouns are used. Example: “then he (John Smith)…”. Use neutral language. Example: “patient states”, not “patient alleges,” which may give a false impression of disbelief. Give a detailed description of the patient’s appearance, behavioral indicators, injuries and stages of healing, and health conditions. If the patient consents, use photos to document injuries; one with a face included in the photo, and then close-ups of the injury. If photos are not possible, draw and describe injuries on a body map in blue ink as this is difficult to alter/reproduce. Document recommendations for support and follow-up as well as materials given to the patient. Document abuse history as reported by patient in the subjective. The subjective section is meant to document the patient’s experience and verification is not applicable. Include any laboratory and radiology tests ordered with results to maintain a complete record for the patient. Document results of health and safety assessments and plans for follow-up as well as referrals and materials given to the patient. Document recommendations for support. If the patient was referred for a post-rape exam, document the referral site. Maintain strict confidentiality and safeguard the chart rather than limit the contents for best care practices.

Clinical Skills

Adequately Addressing Your Patient’s Needs Within Time Constraints

It is a common scenario to see a patient that is scheduled for an acute visit, but the situation requires more time to be adequately addressed. Prioritize the most acute or high risk issues raised during this visit and focus on these, and then emphasize the importance of follow-up and schedule a follow-up visit as soon as possible.

Management

The Role of the Health Care Provider in the Care of a Victim of Intimate Partner Violence

Acknowledge the abuse and health implications

It is important to acknowledge the abuse, recognize the health implications, and share this with your patient.

Support your patient’s decisions

While you may not always agree with the decisions your patient makes to stay or escape, it is important that you support their decisions. They have a greater understanding of the complexity of the problem, and have more information on which to base their actions.

Address safety issues

Address the level of risk and safety issues for your patient. Provide information for them to go to a safe haven if needed. As lack of a telephone or computer (or monitoring of their use) often make it unsafe or impossible for victims to contact IPV resources from home, it is important not only to give contact information to the patient, but also to offer a means for them to contact services while in your office. One should be aware that the person inflicting the violence might check the patient’s/victim’s phone and computer for recent phone calls, website visits, and emails.

Practice cultural sensitivity

Cultural differences can give the appearance of abuse, be accepting of practices some might consider abusive, and can inhibit the ability to interview or support a victim. Practicing sensitivity in caring for patients from different backgrounds is key to a supportive patient-clinician relationship.

Consider impact of abuse on children and other vulnerable

When children or other vulnerable persons who are less able to make decisions on their own behalf are in the home, consideration must be given to the impact of the abuse on them physically and mentally as well as their safety. Even in states where reporting abuse towards a domestic partner is not mandated, the impact or abuse on a child or other vulnerable person may be and will supersede the desires of the victim to not alert social services.

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parties

It is not possible for a clinician to solve the problem of IPV for an individual. Statistically, the most dangerous time for a victim is when they escape an abusive relationship. While it is hard to accept, sometimes it may be safer for a victim to stay with the perpetrator. Clinicians are not in a position to stop the abuse. You can make recommendations in terms of decreasing the victim’s level of risk by providing resources to the patient, limiting access to weapons, and developing an escape plan with a victim’s advocate. Safety planning takes time and expertise. While some clinicians will take the time to be trained to be effective at this, it is probably best to utilize experts who are associated with IPV agencies if available or to train a staff member to serve this role. Reporting

Reporting laws differ from state to state, so you need to know what the laws are where you are working. Whenever a child is abused as a result of IPV, either intentionally or unintentionally, state law requires health care providers to report this abuse to child protection services. Mandated reporters would also report any high-risk situation of IPV in which children are at risk. However, state laws are less clear about whether exposure to IPV in the absence of injury or serious risk of injury to the child would require a report to children’s protective services. In some states, stringent rules/laws require mandated reporters to notify child protection services whenever a child is in the home and has been exposed to a parent’s abuse, whether or not the child has been directly abused. Proponents of this definition point to the ample documentation of the overlap between adult IPV and child abuse and the adverse psychological effects on children who witness IPV. Opponents of this policy believe it penalizes women for abuse that they have no control over and may discourage women from seeking help. It also could elevate the level of risk for the victim. In other states, a child’s exposure to IPV does not automatically require a mandatory child protection report. The provider has wider discretion to assess whether a child has been directly involved and what other factors may exist to put the child at risk. In these states, a provider would take into account the existence of direct injury to a child, the potential danger of the situation, and the capacity of the mother to keep her children safe in deciding whether to notify Child Protective Services (CPS). The rules for victims who are adults and are not disabled vary dramatically from state to state, from mandatory reporting for evidence of abuse to reporting only if the victim asks the clinician to do so. Contact your local Domestic Violence helpline and ask what the rules are for the community in which you work. You can find out about your local resources by calling the National DV Hotline at (800) 799-SAFE, TTY (800) 787-3224.

Studies

Recommended Studies for Evaluation of Lower Abdominal Pain

Pap test— thin prep Recommended in the setting of previous abnormal results.

KOH/saline wet prep

This is a quick test which should be done as it could indicate inflammation (white blood cells) or diagnose trichomonas, bacterial vaginosis, or yeast vaginitis.

Chlamydia / gonorrhea DNA probe

Chlamydia and gonorrhea can present with a yellow discharge, abdominal pain, and dyspareunia. This is the preferred method for diagnosis of chlamydia and gonorrhea because both can be performed using the same sample, and the sample can be endocervical, urethral, vaginal, oral, or urine.

Urine dipstick Helpful to rule out a urinary tract infection (UTI).

Urine pregnancy test

Should be performed on any patient who is physically able to be pregnant.

RPR Should be done as part of the STI screen to rule out syphilis.

HIV Should be done as part of the STI screen.

HPV Consider ordering a reflex HPV. Reflex refers to the fact that an abnormal Pap will automatically be tested for HPV.If the Pap is normal, the HPV testing will not be done.

Pelvic ultrasound

The pelvic exam, urine pregnancy test, and STI testing will help guide the need for an ultrasound to evaluate a possible pelvic mass, the size of uterus and ovaries, to confirm the location of a pregnancy, or to rule out an inflammatory or infectious process.

Colposcopy Colposcopy is not indicated until the results of the Pap are back. If the Pap is abnormal, and/or if high-risk HPV ispositive, a colposcopy may be indicated. Follow the ASCCP guidelines for follow up of abnormal PAP

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Gonorrhea culture

While this is a good test for gonorrhea, a separate test needs to be done on vaginal or urine samples. However, this is still the preferred method for sexual assault tests, for tests of cure, and for oral and rectal specimen.

HCG beta sub This is generally not indicated because of the sensitivity of the urine pregnancy test. If the results of the urinepregnancy test were inconclusive, a blood test such as HCG Beta Sub would be needed.

Clinical Reasoning

Severe / Life-Threatening Causes of Abdominal Pain

Appendicitis Patients with appendicitis often start with visceral pain that is dull and in the periumbilical region; within a short time the pain classically localizes; presentation is usually of fairly acute onset with moderate to severe right lower quadrant pain. There is often a history of nausea and/or vomiting. There are usually some changes in the patient’s bowel movements.

Ectopic pregnancy

Ectopic pregnancy is a medical emergency. Early medical treatment reduces the need for surgery, but if the fallopian tube is in danger of rupture, surgical intervention may be necessary. Patients present with divergent symptoms ranging from no pain and normal menses to intense pain and irregular or absent menses. A good history, the physical exam and lab testing (always get a pregnancy test if the patient has a uterus) are crucial for this diagnosis. Imaging is also usually needed. You need the date of the patient’s last menstrual period (LMP), her menstrual history, most recent intercourse dates, the types of contraception used currently and used in the past /ever used, history of any vaginal or pelvic infections, and history of previous ectopic or normal pregnancies.

Endometriosis

While endometriosis is not typically life-threatening, it can be severe. The majority of patients are of reproductive age and present with cyclical pelvic pain, following the menstrual cycle in patients with regular menses. The location and pattern of the pain can vary widely, depending upon which organs have been affected. For example, those with bladder involvement may present with urinary frequency, urgency or dysuria. Endometriosis may also present as infertility in an otherwise asymptomatic patient or as an incidental finding during surgery.

Ovarian pathology

Patients with ovarian problems generally have lower abdominal or pelvic pain. Pain from ovarian torsion or ruptured cyst or ectopic pregnancy may be very severe and usually has a sudden onset. Patients often present to the emergency department due to the pain, and this is appropriate since imaging is usually necessary to determine the exact cause of the pain. In several cases, the pain from ovarian problems may persist for several weeks. It is often aggravated by intercourse or strenuous activity.

Pelvic inflammatory disease

Patients with pelvic inflammatory disease (PID) might have abdominal or pelvic pain, which is worse with sexual intercourse or with activities such as running or jumping, which cause jarring of the pelvic organs. This diagnosis has significant morbidity, which increases with the severity of the disease and with the length of time to diagnosis. Studies show that approximately one in four patients who had a single episode of PID later experienced tubal infertility, chronic pelvic pain, or an ectopic pregnancy, as a result of scarring and adhesions. Tubal adhesions leading to infertility have been reported to occur in 33% of patients after their first episode of PID, and up to 50% after the second pelvic infection.

Normal pregnancy

Patients who have normal pregnancies may experience some lower abdominal discomfort or pain as the uterus undergoes normal growth. This is more a diagnosis of exclusion, but you would not want to miss a pregnancy. Certain medications should not be given to patients who are pregnant. Fetuses should not be exposed to radiation.

Trauma A careful history is important in regard to trauma. Be aware of the patient’s body language and response to touch. Consider the consistency of the history with the exam. Have the patient undress and examine the patient thoroughly in a gown so that all areas can be visualized. Consider taking a photograph of any injuries and bruises if there is a way to appropriately attach them to the patient’s medical record, and if the patient gives consent.

References

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Futures Without Violence. The Facts on Domestic, Dating and Sexual Violence. Released 2009. Accessed February 8, 2020.

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Futures Without Violence. The Health Care Costs of Domestic and Sexual Violence. Updated March 2010. Accessed February 8, 2020.

Hatcher RA et al. Contraceptive Technology 19th edition, Ardent Media, 2007. http://www.contraceptivetechnology.org/table.html. Accessed February 8, 2020.

Institute for Clinical Systems Improvement (ICSI). Initial management of abnormal cervical cytology (Pap smear) and HPV testing. Algorithm. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); Oct 2008;32:63. Accessed February 8, 2020.

Katz VL et al, Infections of the Upper Genital Tract: Endometritis, Acute and Chronic Salpingitis In: Comprehensive Gynecology, 5th edition. Philadelphia, PA: Mosby; 2007.

Marsicano E, Vuong GM, Prather CM. Gastrointestinal causes of abdominal pain. Obstet Gynecol Clin North Am. 2014;41(3):465-89.

National Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care Settings. Produced by The Family Violence Prevention Fund, 383 Rhode Island Street, Suite 304, San Francisco, CA 94103-5133. (415) 252-8900. TTY (800) 595-4889. First Printing: September, 2002. Updated: February, 2004.

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