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His and Hers Abdominal Pain: Gender-specific factors
Ruling out the causes of abdominal pain remains the art of all medical diagnoses. Abdominal pain is frequently misdiagnosed or undiagnosed in both the hospital and prehospital settings. Gender issues complicate an already-difficult evaluation. Knowledge of possible problems, proper psychological first aid and excellent history-taking skills will lead to appropriate prehospital patient management.
His
Many disorders of the penis and scrotum can present with pain of the lower abdomen. The more common disorders of the male genitourinary system are scrotal abscesses, cysts, inguinal hernias, varicoceles (a swelling of veins in the scrotum) and epididymitis. Unless there is strangulation of an organ, these will probably not present in the prehospital setting. Careful history taking is important. If strangulation occurs, the more rapid the diagnosis, the less damage to the organ.
Epididymitis—The epididymis is a tube that carries sperm from the testicles to the seminal vesicle in the male reproductive tract. When inflamed from infection, it can cause pain and swelling of the scrotal area, with unilateral pain possibly radiating to the lower abdomen. The patient may be febrile. Pain may lessen when the scrotum is elevated. There is usually a mucus discharge and a history of urethral problems. Epididymitis occurs most often in sexually active men.1
Hernia—Although not truly a problem of the genitalia, inguinal hernias may present with scrotal pain.
Hydrocele—Hydrocele presents as a gradual event. It is an enlarged, painless scrotal cyst, which may indicate the presence of a tumor.
Testicular torsion—Testicular torsion in males presents with acute lower abdominal pain. There may be no sign of change in the scrotum if the torsion is intra-abdominal. Other signs and symptoms are that the patient or examiner has felt tenderness and a mass on palpation of the abdominal area. It is a rare finding. A delay of six hours in diagnosis may result in surgical excision of the testis (orchiectomy). Application of ice to the scrotum may delay tissue damage.2 Refer to your medical control for patient treatment.
Urethritis—While urological in origin, this condition can present with abdominal pain as well as a burning sensation and discharge.
Varicocele—A common occurrence in adolescent or young adult males, varicocele causes painless swelling of the left scrotum that enlarges with Valsalva’s maneuver. Untreated, this condition inhibits growth of the left or both testicles.
Hers
Gender-specific problems for female patients can, in many cases, be life-threatening emergencies. Do not dismiss abdominal pain lightly without a thorough history. Be on the alert for underlying causes.
Ectopic pregnancy—Females between the ages of 9–60 presenting with abdominal pain may be experiencing an ectopic pregnancy, which is a life-threatening condition if rupture occurs. Younger and older patients fall into a higher-risk category for ectopic pregnancies. While the diagnosis of ectopic pregnancy prior to rupture is difficult even in the hospital setting, the EMT must keep the possibility in mind.3
Scar tissue in the fallopian tube can lead to ectopic pregnancies. Sexually transmitted infections such as Chlamydia and gonorrhea are major culprits in these sequelae. Scarring causes the fertilized egg to move slowly through the tube. The ovum becomes blocked, unable to move into the uterus. A patient history of STDs is a red flag.
Obtain information regarding gynecological problems such as pelvic inflammatory disease, endometriosis, bleeding/discharge, ovarian cysts and any abnormal Pap test results.
Congenital abnormalities or endometriosis can factor into the picture by affecting the normal shape and structure of the fallopian tube. Be a competent and thorough medical detective. Surprising as it may seem, ectopic pregnancies can occur after tubal ligations. In addition, they are quite possible if a patient is taking oral contraceptives.4
Ovum may attach to fallopian tubes (uterine tubes), ovaries, abdominal walls or pelvic cavities. When the attachment is to the fallopian tube or ovaries, pain exhibits in the lower quadrants. Pain in other areas of the abdomen does not rule out ectopic pregnancy. Prior to a rupture of the organ of attachment, there is cramping pain, then steady, continuous pain. The patient may complain of cramping, or the pain may be generalized. If the organ ruptures, pain is diffuse and generalized, but the patient’s status deteriorates rapidly due to massive internal hemorrhage. In this event, your patient will be unable to give an adequate history.
While the likelihood of ectopic pregnancy is important to keep in mind, let’s explore further.
Ovarian cyst—An ovarian cyst may cause abdominal pain. The pain may be caused by inflammation and/or swelling of an ovary or ovaries. Pain is unilateral, usually in the lower quadrant, increasing in intensity during ovulation and accompanied by internal and/or external hemorrhage if rupture occurs. A ruptured ovary can cause significant internal bleeding.
Ovarian torsion—Ovarian torsion is an infrequent but significant cause of acute lower abdominal pain in women. The signs and symptoms may be nonspecific and easily misdiagnosed; however, it is the fifth-most common gynecological emergency surgery. It is not life threatening, but delayed diagnosis usually results in removal of the ovary (salpingo-oophorectomy), making it a true emergency.5 Presenting pain is sudden in onset in the lower abdomen, usually over the affected side, radiating to the back, pelvis and thigh. As with testicular torsion, it is a rare finding.
Uterine perforation—Uterine perforation can occur during a therapeutic abortion. This may occur more often in second-trimester abortions. With second-trimester procedures, perforation can result in injury to abdominal viscera from the perforating instruments or even from sharp fetal bony structures. The patient may not be aware of a problem for days following the procedure.6 A thorough medical history, past and present, is essential to ruling out certain abdominal problems. The patient’s chief complaint may be severe, diffuse abdominal pain with nausea and vomiting, and she may be febrile. Since these are the signs and symptoms of many abdominal disorders, the actual problem could easily be misdiagnosed. Obtain as detailed a history as possible.
Uterine rupture—Uterine rupture is rare before the second trimester of pregnancy. A history of cesarean section predisposes the patient to uterine rupture during labor. This is a true emergency and carries high mortality rates for both mother and fetus. There may be massive hemorrhage. Always treat the mother. As with any serious trauma patient, do not delay transport. This patient needs rapid surgical intervention.
His and Hers
These conditions affect both male and female patients.
Cystitis—Cystitis, inflammation of the bladder, presents with abdominal pain as well as other signs and symptoms such as dysuria. It can afflict male, female and pediatric patients. As well as lower abdominal pain, there may be pain on urination, defecation or, for the male, during or after ejaculation.7 Sudden onset is unlikely, and this condition is not life threatening. A patient experiencing signs and symptoms for the first time may become concerned and call 9-1-1.
Sexually transmitted diseases (STDs)—Significant to any condition presenting with abdominal pain is a history of sexually transmitted diseases (STDs). Chlamydia trachomatis and Neisseria gonorrhoeae are common sexually transmitted organisms. Women may be asymptomatic as carriers. Pelvic inflammatory disease (PID) with known serious sequelae—including chronic pelvic pain, infertility and ectopic pregnancy—may present in the active stage.8 PID usually has a component of lower abdominal pain. The primary complaint in almost 70% of the cases is vaginal bleeding and discharge accompanied by pain. The International Infectious Disease Society for Obstetrics and Gynecology has recommended the term upper genital tract infection (UGTI) be used, rather than the term PID, for a variety of clinical and therapeutic reasons.9 UGTI, while seen frequently in the ED, is infrequently encountered as the chief complaint in the prehospital setting. The link between UGTI and ectopic pregnancy must be kept in mind.
Pediatric patients—Do not overlook possible gender-related problems in pediatric patients. Pediatric patients who present with abdominal and/or pelvic pain should always be evaluated in the ED. Remember that pediatric patients of both genders are at risk for external and internal genitourinary trauma from sexual abuse. A pediatric patient may be reluctant or unable to explain their situation. Unless there is a life-threatening injury or illness, evaluation of the problem should be left to pediatric specialists. It is extremely important to report any unusual findings to ED staff.
Pediatric patients may have the same sexually transmitted infections as their adult counterparts. Persons with PID are significantly more likely to have been younger at first intercourse, have had older sex partners, have had involvement with child protection agencies, have had prior suicide attempt(s), have consumed alcohol before their last sexual encounter, and have a current Chlamydia trachomatis infection.10 This pertains to female pediatric patients who may be much younger than the prehospital caregiver expects to be sexually active. This patient may be hesitant to disclose information, especially in the presence of adult caregivers. Language and cultural barriers add difficulty to assessing patients with abdominal pain. Every attempt must be made to contact the proper translators for the patient, as this is vital to properly inform and treat them.11
Hers: Specific History
In the absence of trauma, the prehospital caregiver must address severe abdominal pain in women in light of a careful and complete medical history. Pertinent professional questioning is extremely important in assessing a patient presenting with abdominal pain. Is the patient pregnant? When was her last period? Has she had any pain previous to this episode? If so, what makes the pain different, or why did she call for an ambulance this time? Were there any previous pregnancies and/or complications? Ask about any abortions, spontaneous or therapeutic. Remember that these questions should be asked in a safe environment in order to obtain correct information. A patient may give false information if her parent or significant other is within hearing distance. Since this is a matter of life and death, these procedures must be adhered to with great attention.
General history and questions—Many medical conditions other than genitourinary conditions present with severe sudden-onset abdominal pain and must be ruled out as well. Question the patient regarding the duration of the pain. Has it occurred over hours, days, weeks, months or years? Was it a sudden onset? How long has the pain lasted? What is its severity? Where is the pain? Does the pain radiate or is it referred? Does anything relieve the pain, such as position or medication? Are there any other signs or symptoms possibly related to the pain?
Treatment—Treatment should be carried out according to your local protocol, which usually includes O2, large-bore IV, position of comfort and transport, with careful focused assessment and repeated monitoring of mental status and vital signs.
Summary
Abdominal pain should not be dismissed without proper evaluation. A patient presenting with acute, severe abdominal pain is best transported to the emergency room for treatment.
While gender issues remain a delicate subject, proper prehospital care prevents patient deterioration, tissue loss and loss of life. Prehospital information is invaluable. Due to unforeseen complications, including patient deterioration, the history you obtain on scene may be the only information available to the medical team at the hospital. Professional care begins in the prehospital setting. Knowledge, skill and experience will guide you.
References
1. Graber M, Martinez-Bianchi V. University of Iowa Family Practice Handbook 11:9–11, 1999.
2. Lewis RL, Roller MD, Parra BL, Cotlar AM. Torsion of an intra-abdominal testis. Curr Surg 1;57(5):497–499, Sept. 2000.
3. Ectopic Pregnancy. https://thriveonline.oxygen.com/medical/library/article/000895.html.
4. Wong CM, Ganesh R, Ng KY. Ectopic pregnancy: Uncommon presentations and difficulty in diagnosis. Med J Malaysia 54(1):117–9, Mar. 1999.
5. Blanda M. Ovarian Torsion. www.emedicine. com/emerg/topic353.htm.
6. Kambiss SM, Hibbert ML, Macedonia C, Potter ME. Uterine perforation resulting in bowel infarction: Sharp traumatic bowel and mesenteric injury at the time of pregnancy termination. Mil Med 165(1):81–2, Jan. 2000.
7. Cornforth T. Cystitis. https://womenshealth. about.com/aa01219.html.
8. Johnson RA. Clinical Cornerstone 3:1–11, 2000.
9. Hemsel DL, Ledger WJ, Martens M, Monif GR, Osborne NG, Thomason JL. Concerns regarding the Centers for Disease Control’s published guidelines for pelvic inflammatory disease. Clin Infect Dis 32(1):103–7, Jan. 2001.
10. Suss AL, Homel P, Hammerschlag M, Bromberg K. Risk factors for pelvic inflammatory disease in inner-city adolescents. Sex Transm Dis 27(5):289–91, May 2000.
11. Flores G, Abreu M, Schwartz I, Hill M. The importance of language and culture in pediatric care: Case studies from the Latino community. J Pediatr 137(6):842–8, Dec. 2000.
