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Adolescent gynaecology - lower abdominal pain

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    PIC Endorsed

  • See also

    Adolescent gynaecology - abnormal uterine bleeding
    Abdominal pain - acute
    Engaging with and assessing the adolescent patient
    Urinary tract infection
    Gastroenteritis

    Key points

    1. Pregnancy related causes of acute pelvic pain (ectopic pregnancy, miscarriage, placental abruption and uterine rupture) should always be considered
    2. Other surgical and medical causes for acute abdominal pain must be considered
    3. Gynaecological causes for abdominal pain increase after puberty

    Background

    • Abdominal pain is one of the most common symptoms reported in childhood and adolescence
    • This guideline focuses on gynaecological causes of abdominal and pelvic pain
    • The pain characteristics and associated symptoms may help differentiate between the various gynaecologic causes of lower abdominal pain
    • For non-specific, episodic abdominal pain, consider chronic conditions such as constipation, abdominal migraine and functional abdominal pain

    Assessment

    Red flag features in red

    History

    • Menstrual history (menarche, last menstrual period, frequency, duration, flow)
    • Pain characteristics and associated symptoms (bowel, bladder, fever, nausea, vomiting)
    • Sexual history and contraception. If sexually active discuss safe sex and contraception
    • Systemic features: fever, weight loss, vomiting, headache
    • Adolescent assessment 

    Examination

    • Pallor, hypotension, tachycardia
    • Palpation of the abdomen for uterine or ovarian mass
    • Vaginal examination is rarely indicated in a child. Perineal inspection and vaginal examination should be discussed with a senior clinician, and if needed should only be performed once

    Gynaecological causes of acute abdominal pain

    Cause

    Clinical features

    Critical

    Ectopic pregnancy

    Abdominal pain, missed period with subsequent vaginal bleeding

    Ovarian torsion

    Acute, sharp pelvic pain (moderate to severe), adnexal mass, often with nausea and vomiting

    Acute placental abruption

    Vaginal bleeding, abdominal and/or back pain, and uterine contractions, in severe cases with disseminated intravascular coagulation (DIC). Any gestation (peak between 24–26 week)

    Uterine rupture

    Uterine tenderness, peritoneal irritation, vaginal bleeding and abnormal foetal heart rate

    Molar Pregnancy

    Vaginal bleeding, pelvic pain, an enlarged uterus and severe vomiting

    Infection

    Pelvic inflammatory disease (PID)

    Unprotected sex, post coital bleeding, mucopurulent discharge, lower abdominal or pelvic pain, fever

    Other

    Pregnancy

    Early signs & symptoms can include: breast tenderness, vomiting, bleeding, pelvic discomfort

    Dysmenorrhoea

    Crampy and intermittent lower abdominal, suprapubic or back pain, can have associated nausea, vomiting, headache, dizziness or fainting

    Mittelschmerz

    Mild unilateral recurrent midcycle pain, caused by normal follicular enlargement

    Ruptured ovarian cyst

    Sudden, severe, unilateral pelvic pain, can be precipitated by strenuous physical activity

    Spontaneous miscarriage

    Early pregnancy crampy pelvic pain, vaginal bleeding, and passage of some or all of the products of conception

    Endometriosis

    Crampy pelvic pain associated with menses. Depending on its location can be associated with pain on passing stool, urine or during sexual intercourse

    Functional abdominal pain

    Periumbilical or diffuse, variable location, exacerbated by stress, functional impairment out of proportion, chronic duration

    Management

    Investigations

    • Many non-gynaecological causes of acute abdominal pain do not require investigation
    • If there is any concern for pregnancy perform (with consent) a ßhCG (urine and/or blood if need a quantitative result)
    • For significant bleeding: FBE, blood group and antibody screen ± coagulation screen
    • Transabdominal (with full bladder) or transvaginal (in sexually active adolescents with consent) pelvic ultrasound
    • For infective causes
      • Urine MCS to exclude UTI
      • Perform first pass urine (nucleic acid amplification tests) for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas or an endocervical swab for gonorrhoea, chlamydia and MCS
      • If high degree of concern for pelvic inflammatory disease perform FBE, CRP ± blood culture if septic
    • Education about contraception and STI prevention, as well as STI screening, should be offered opportunistically to all sexually active adolescents. This may include serology for blood borne viruses depending on their sexual history and risk behaviour

    Treatment

    Treatment is targeted to the underlying cause

    Adolescent_gynaecology

    Consultation with local paediatric team when

    Managing patients with hemodynamically instability, marked pain or unclear underlying cause

    Consider transfer when

    Needing advice regarding escalation of care, if beyond the local centre capabilities

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when

    Stable and a review is scheduled with the GP

    Note: if there are concerning or persistent symptoms refer to paediatrician or local gynaecologist 

    Updated July 2020

  • Reference List

    1. Brown J et al, 2014, Endometriosis: An overview of Cochrane Reviews, Cochrane Database Systematic Reviews, Issue 3
    2. Brown, K et al 2019, Evaluation of acute pelvic pain in adolescent female. Retrieved from UpToDate,  https://www.uptodate.com/contents/evaluation-of-acute-pelvic-pain-in-the-adolescent-female (viewed June 2020)
    3. Brown R et al, 2015, Pelvic pain, British Medical Journal, vol. 5637 pp. 1–2
    4. Burnett M et al 2017, Primary Dysmenorrhea Consensus Guideline, Journal of Obstetrics and Gynaecology Canada, vol. 39(7) pp. 585–95.
    5. Fishman, MB et al, 2019, Chronic abdominal pain in children and adolescents: Approach to the evaluation. Retrieved from UpToDate, https://www.uptodate.com/contents/chronic-abdominal-pain-in-children-and-adolescents-approach-to-the-evaluation (viewed June 2020)
    6. Hertweck P, 2010, Common problems in pediatric and adolescent gynecology, Expert Review of Obstetrics and Gynecology vol. 5 pp. 311–28
    7. Irani S 2005, Paediatric and Adolescent Gynaecology - A Multidisciplinary Approac, Obstetrics and Gynaecology, vol. 7(3) pp. 218–218
    8. Jarrell JF, et al 2018, Consensus Guidelines for the Management of Chronic Pelvic Pain, Journal of Obstetrics and Gynaecology Canada vol. 40(11) pp.747–87
    9. Kives S, et al 2017, Diagnosis and Management of Adnexal Torsion in Children, Adolescents, and Adults, Journal of Obstetrics and Gynaecology Canada, vol. 39(2) pp. 82–905.
    10. Neuman, M 2019, Causes of acute abdominal pain in children and adolescents. Retrieved from UpToDate, https://www.uptodate.com/contents/causes-of-acute-abdominal-pain-in-children-and-adolescents (viewed June 2020)
    11. Peacock A et al, 2012, Period problems: Disorders of menstruation in adolescents, Archives of Disease in Childhood vol. 97 pp. 554–60.
    12. Robert CB et al, 2015, Pelvic Inflammatory Disease, New England Journal of Medicine, vol. 372 pp. 2039–48
    13. Smorgick N et al, 2018, Pelvic Pain in Adolescents, Seminars in Reproductive Medicine, vol. 36 pp. 116–22
    14. Solnik MJ, 2006, Chronic pelvic pain and endometriosis in adolescents, Current Opinions in Obstetrics and Gynecology, vol. 18(5) pp. 511–8
    15. Stuparich MA et al, 2017, Endometriosis in the Adolescent Patient, Seminars in  Reproductive Medicine, vol. 35(1) pp. 102–9