Acute Lower Abdominal Pain

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Acute lower abdominal pain in a woman may have several causes. 

These include Pelvic Inflammatory Disease (PID), ruptured ectopic pregnancy and septic abortion. The latter two are surgical emergencies, which require extreme urgency in their management.(Refer to full Ghana STG)

PID is caused by organisms which may be Sexually Transmitted Infection (STI)-related or other bacteria that ascend from the lower genital tract and produce inflammation of the uterus, fallopian tubes and other structures in the pelvis. However, after excluding ectopic pregnancy,  STI-related organisms are the most likely cause of lower abdominal pain in a sexually active woman who has not recently delivered a baby, or has no  past or recent history of uterine instrumentation.

The presence of intrauterine contraceptive devices (IUCD) favours the development of PID particularly in the month following insertion.

Cause

  • Ectopic pregnancy
  • Appendicitis 
  • Ovarian torsion
  • STI-related 
  • Non STI-related (e.g urinary tract infection)
  • Septic abortion
  • Post partum sepsis
  • Foreign body including IUCD

Symptoms

  • Fever 
  • Lower abdominal pain 
  • Pain with sexual intercourse (dyspareunia) 
  • Offensive vaginal discharge 
  • Dysuria or urethral discomfort

Signs

  • Abnormal vaginal discharge
  • Tenderness on moving the cervix (cervical excitation) on bimanual vaginal examination
  • Lower abdominal tenderness
  • Adnexal tenderness
  • Adnexal masses

Investigations

  • Pelvic ultrasound
  • Pregnancy test (if sexually active and amenorrhoea present)
  • High vaginal swab culture and sensitivity

TreatmentTreatment Objectives

  • To identify and manage potential life threatening causes e.g. ectopic
  • To treat any underlying bacterial infection
  • To relieve pain and inflammation

Non-pharmacological treatment

  • Surgery where indicated
  • Remove IUD, if present, 3 days after initiation of drug therapy

Pharmacological treatment 

For Pelvic inflammatory Disease (mild cases)

1st Line Treatment

Evidence Rating: [B]

  • Ciprofloxacin, oral, 500 mg 12 hourly for 3 days

And

  • Doxycycline, oral, 100 mg 12 hourly for 14 days

And 

  • Metronidazole, oral, 400 mg 12 hourly for 14 days 

Consider hospitalization or referral in the following cases:

  • Where surgical emergencies e.g. ectopic, appendicitis cannot be excluded.
  • The patient is pregnant (PID is uncommon in pregnancy, especially after the first trimester).
  • The patient does not respond clinically to oral antimicrobial therapy.
  • The patient is unable to follow or tolerate an outpatient oral regimen.
  • The patient has severe illness, associated with nausea and vomiting, or high fever.
  • The patient has a tubo-ovarian abscess.
  • HIV infection
  • Youth/adolescents (particularly if compliance is an issue)

For Pelvic inflammatory Disease (severe cases) 

  • Ceftriaxone, IM, 250 mg daily for 3 days 

And

  • Doxycycline, oral, 100 mg 12 hourly for 3 days 

And

  • Metronidazole, IV, 500 mg 8 hourly for 3 days 

Then

  • Doxycycline, oral, 100 mg 12 hourly for 14 days 

And 

  • Metronidazole, oral, 400 mg 12 hourly for 14 days

Note: The use of ciprofloxacin and doxycycline is contraindicated in pregnant and lactating women. 

 

Referral Criteria

  • Refer to a gynaecologist or general surgeon if there is no improvement  or if a pelvic abscess is suspected.