Acute Pain in a Female Patient
INTRODUCTION
Large number of patients with abdominal and pelvic pain are reffered to both the gynecologists and surgeons . The vast majority of cases will be found to have no organic basic and will be categorized as irritable bowel syndrome, spastic colon, pelvic inflammatory disease or even "psychosomatic".
The current view is that pains are pains are real and that doctors should not adopt a dismissive attitude. Several factors including infections , endocrine disorders,pregnancy,childbirth,previous surgery could all be implicated. In addition there could be a psychological overlay with stress and social problems.
In the chapter we hope to address the differential diagnosis, discuss the recent investigative modalities and the most appropriate treatment for acute pain from reproductive and intestinal tract.
Most causes of pain fit into three categories :
1 . Causes that originate in the reproductive tract.
2. Causes that originate in the intestinal tract.
3. Causes that originate in the urinary tract.
THE ORIGINS OF PELVIC PAIN
THe rectum, lower colon , cecum, appendix, terminal ileum , bladder and gynecological organs are so closely related and the localization of visual pain so poor that it is not surprising that pelvic pain could be seen by a variety of specialists . Pain from these areas is largely perceived via the sympathetic nervous system and there is shared innervations of the vagina cervix inner third of fallopian tubes broad ligament , upper bladder , terminal ileum and large bowel. The pain travels via the hypogastric plexus and hypogastric nerve to the lower thoracic and lumbar sympathetic chain . The afferents enter the cord between T10 -L1. Pain from the colon also travels via the parasympathetics to the pelvic plexus , pelvic nerves and enters the cord at S 2-4. The outer third of the fallopian tube and urethra are innervated differently and the afferents enter the cord between T 9 and T10. The lower vagina , lower bladder and rectosigmoid junction are innervated by sacral afferents. The localization of pain is dependent upon convergence of visual and somatic nerves within the central nervous system in the anterior horn . Referred pain is thought to be due to the shared connections of the afferent nervous system in the posterior root ganglia. Reffered patterns may lead to quite unusual and unexpected sites of pain.
ECTOPIC GESTATION
· It is necessary to exclude an ectopic pregnancy in all women of reproductive age group married or otherwise. The patient's last menstrual period and sexual activity pattern are useful but do not eliminate the need to do a pregnancy test. A simple urine pregnancy test will detect BhCG of even 20 mIU/ml. If inconclusive a serum BhCG should be done . In subacute presentations when diagnosis is not obvious non- invasive tests namely high resolution transvaginal scan and serial BhCG estimations are useful. Normally developing intrauterine pregnancies will have a characterstic doubling rate of BhCG of 1.98 days . When the BhCG does not double it is suggestive of a falling intrauterine pregnancy or an ectopic gestation. If subsequent BhCG values show a declining trend,one can wait without surgery or medical treatment. Often several BhCG estimations and ultrasound have to be performed before a definitive diagnosis is made . Laparoscopy which used to be the gold standard for diagnosis is made. Laparoscopy which used to be the gold standard for diagnosis is seldom needed to diagnose an ectopic gestation . Generally , one should be able to see a gestational sac with a quant of 1000 miu/ mi. Identifying an intrauterine sac does not exclude a co-existing ectopic pregnancy , defined as heterotopic pregnancy . This is rare , 1 in 5000 pregnancy but is increasing with more women undergoing treatment with artifical reproductive techniques (ART) and pelvic inflammatory disease(PID) .
· Once an ectopic pregnancy is diagnosed further management depends on the level of BhCG and the size of the ectopic gestational mass.
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