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HYPOGASTRIC PAIN

HYPOGASTRIC PAIN: Excerpt from Differential Diagnosis in Primary Care

Anatomy is the basic science that will open the door to this differential diagnosis. Visualizing the structures in the hypogastrium, one sees the abdominal wall, the bladder and urinary tract, the female genital tract, the sigmoid colon and rectum, the iliac vessels, the aorta and vena cava, and the lumbosacral spine. Occasionally, other organs fall into the hypogastrium, thus they must be considered too. A pelvic kidney, visceroptosis of the transverse colon, and a pelvic appendix all may occur.

ABDOMINAL PAIN, HYPOGASTRIC

Now that one has the organs in mind it is necessary only to apply the mnemonic MINT to recall the causes of hypogastric pain.

In the abdominal wall,

1. M—Malformations bring to mind the ventral hernias and urachal cysts or sinuses with associated cellulitis.
2. I—Inflammation includes cellulitis, carbuncle, and other skin infections.
3. N—Neoplasms of the abdominal wall do not usually present with pain.
4. T—Trauma suggests contusion of the rectus abdominus muscles or stab wound.

In the urinary tract, one recalls

1. M—Malformations such as diverticulum, cystocele, ureterocele, bladder neck obstruction from stricture and calculus, and phimosis and paraphimosis.
2. I—Inflammation suggests cystitis, prostatitis and urethritis, and Hunner ulcers.
3. N—Neoplasms suggest transitional cell papilloma and carcinoma and prostate carcinoma.
4. T—Trauma recalls ruptured bladder.

In the female genital tract,

1. M—Malformations that may cause pain include a retroverted uterus, an ectopic pregnancy, and various congenital cysts (e.g., hydatid cyst of Morgagni) that may twist on their pedicles.
2. I—Inflammation of the vagina and cervix is not usually painful except on intercourse, but endometritis and tubo-ovarian abscesses are associated with pain and fever.
3. N—Neoplasms such as carcinoma of the cervix and uterus do not cause pain unless they extend beyond the uterus or obstruct the menstrual flow. However, fibroids often cause dysmenorrhea and severe pain if they twist on their pedicles, and endometriosis may spread throughout the pelvis and cause chronic or acute pain.
4. T—Trauma such as perforation of the uterus during a dilatation and curettage (D & C), delivery, or by the introduction of a foreign body during sexual relations may cause abdominal pain.

The sigmoid colon and rectum may be the site of pain in

1. M—Malformations such as diverticulitis.
2. I—Inflammations such as ulcerative colitis with perforation, granulomatous colitis with perforation, amebic colitis, and ischemic colitis.
3. N—Neoplasms that spread beyond the lumen of the bowel or cause obstruction.
4. T—Trauma from introduction of instruments or foreign bodies.

Pain in the hypogastrium may also be caused by a dissecting aneurysm of the aorta or phlebitis of the iliac veins or the inferior vena cava. The lumbosacral spine may be the site of pain in

1. M—Malformations such as spondylolisthesis and scoliosis, but these are usually associated with back pain.
2. I—Inflammatory conditions of the spine such as tuberculosis and rheumatoid spondylitis are much more likely to cause hypogastric pain.
3. N—Neoplasms, particularly metastatic carcinoma, multiple myeloma, and Hodgkin disease may cause hypogastric pain.
4. T—Trauma of the spine may cause a herniated disc fracture or hematoma of the spine and surrounding muscles, producing hypogastric pain from a distended bladder or paralytic ileus, among other things.

The appendix and small intestine may occasionally end up in the pelvis; therefore, appendicitis and regional ileitis should not be forgotten as possible causes of hypogastric pain.

Approach to the Diagnosis

In cases of hypogastric pain, it is most important to do a good pelvic and rectal examination. Because the most common cause of hypogastric pain is cystitis or other urinary tract infection, it is essential to examine the urine (personally) and to do a culture sensitivity and colony count regardless of the findings on routine urinalysis. A vaginal culture should also be done in females on special media for Chlamydia and gonococcus to help rule out PID. Urethral smear and culture is done if there is a urethral discharge. Acute hypogastric pain may require a flat plate of the abdomen, CBC, chemistry panel, and amylase level depending in the seriousness of the patient’s condition. A general surgeon may need to be consulted. Ultrasonography may be ordered to further evaluate any suspicious pelvic mass. A pregnancy test should be ordered in women of childbearing age. Three conditions that must be ruled out in the female patient are ruptured ectopic pregnancy, PID, and endometriosis. That is why a gynecologist should be consulted early if these conditions are suspected in the acute cases. Chronic cases may need an IVP and cystoscopy if a urinary tract infection, stone, or neoplasm is suspected. If a problem in the lower bowel is suspected, colonoscopy or barium enema may be necessary. If there is any question about a perforated bowel or mesenteric infarction, a CT scan of the abdomen and pelvis should be done first.

Other Useful Tests

1. Stool for occult blood (mesenteric infarct, diverticulitis, neoplasm)
2. Stool for ova and parasites
3. Stool culture
4. Urine porphobilinogen (porphyria)
5. Sedimentation rate (pelvic inflammatory disease)
6. Tuberculin test
7. Culdoscopy (ectopic pregnancy)
8. Laparoscopy (PID, endometriosis)
9. Exploratory laparotomy
10. Angiogram (mesenteric infarct)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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