Unexplained Abdominal Pain: Causes and Diagnostic Options for Women

Abdominal discomfort and pain of unknown origin?

Hello Doctor, I have been experiencing discomfort in my abdomen, specifically a dull ache and pressure on both sides of my belly (around the area next to my navel and below the ribcage) since around October of last year.
This has been troubling me for quite some time, and I am unsure of the cause.
I now feel that the discomfort is spreading to my lower back, and I am concerned that it may be due to inflammation of certain organs or possibly something growing in my abdomen.

I undergo annual health check-ups, and over the past six years, I have had a few instances of urine showing trace blood (1+).
In the last two years, my amylase levels have been slightly elevated, around 166, while my lipase level is 18.
I often feel dry mouth, especially at night, to the point where it becomes uncomfortable.
I have a small uterine fibroid, and in December, I visited a gynecologist due to irregular menstrual cycles.
Urine tests showed no signs of inflammation, and the doctor mentioned that I am still early in menopause and that there are cysts on my ovaries.
However, I have not had my period for four months.

In February, I visited the Mackay Memorial Hospital gynecology department for an internal examination and gynecological ultrasound.
I was prescribed a vaginal suppository for vaginitis and was told that my discomfort is due to pelvic congestion.
In December, I also consulted a urologist who conducted X-rays and kidney ultrasounds.
Urine cytology tests over three days showed no issues, but the presence of trace blood (1+) in my urine led the doctor to advise caution and arrange for a venous urography.
However, the bowel prep was not thorough, and the doctor noted some unusual findings with the contrast agent in the kidney area.

I was given four options: 1.
Monitor the situation, 2.
Cystoscopy, 3.
Cystoscopy + ureteroscopy, 4.
Cystoscopy + ureteroscopy + nephroscopy.
I chose option 1 because I am quite apprehensive about anesthesia and invasive procedures.
In March of this year, I visited a gastroenterologist.
Since I have normal bowel movements daily, the doctor only prescribed probiotics and gas relief medication, and conducted a fecal occult blood test and abdominal ultrasound.
The doctor indicated that my pancreas is fine, but there are cysts on my liver.
My amylase level has slightly decreased to 156 compared to the check-up in September of last year.
If I continue to feel uncomfortable, the doctor suggested considering an endoscopy.
I would like to ask the doctor about the following:
- What could be the possible causes of the bilateral abdominal discomfort, pressure, and unease? Why has it persisted for so long, and what advanced tests or blood tests should I consider?
- Given the results of the venous urography and the presence of trace blood in my urine, should I proceed with cystoscopy + ureteroscopy + nephroscopy?
- Do you have any recommendations that could help resolve my concerns?
Thank you very much for your patience in reading my concerns.

Zi shen mei nv, 50~59 year old female. Ask Date: 2021/04/20

Dr. Cai Yonglong reply Obstetrics and Gynecology

1.
Related to menopausal pelvic atrophy, a blood test for hormone levels should be conducted.

2.
Observation is sufficient; increase water intake and consume more vegetables.

3.
Please visit an obstetrics and gynecology department or a menopause clinic.

Reply Date: 2021/04/20

More Info

Unexplained abdominal pain can be a challenging issue, especially when multiple diagnostic tests have been performed without a clear cause. Based on the symptoms you've described, including the bilateral abdominal discomfort, potential ovarian cysts, and previous findings of mild hematuria (blood in urine), there are several possible explanations and next steps to consider.

Possible Causes of Bilateral Abdominal Pain
1. Musculoskeletal Issues: Given that your pain is described as aching and uncomfortable, it could be related to musculoskeletal problems, such as muscle strain or tension in the abdominal wall. This is particularly relevant if you have been experiencing stress or changes in physical activity.

2. Gastrointestinal Disorders: Conditions such as irritable bowel syndrome (IBS), gastritis, or even mild pancreatitis could cause discomfort in the abdominal area. The fact that you have had elevated amylase levels could suggest a pancreatic issue, although your recent tests indicate that the pancreas is functioning normally.

3. Gynecological Issues: The presence of a small uterine fibroid and ovarian cysts could contribute to discomfort, especially if they are causing pressure on surrounding structures. Hormonal changes, especially if your menstrual cycle has become irregular, could also play a role in your symptoms.

4. Urinary Tract Issues: The presence of hematuria and the need for further evaluation of your urinary tract is significant. While your initial imaging studies did not show clear abnormalities, persistent hematuria warrants further investigation to rule out conditions such as urinary tract infections, kidney stones, or even tumors.

5. Chronic Pelvic Pain: This can be due to a combination of factors, including pelvic congestion syndrome, endometriosis, or chronic inflammation. The pelvic congestion syndrome, in particular, can cause discomfort due to the engorgement of pelvic veins.

Recommended Diagnostic Steps
1. Further Imaging: If your symptoms persist, consider discussing with your healthcare provider the possibility of advanced imaging studies such as a CT scan or MRI of the abdomen and pelvis. These can provide a more comprehensive view of the organs and help identify any abnormalities that may not have been visible on ultrasound.

2. Blood Tests: Comprehensive blood work, including a complete blood count (CBC), liver function tests, and inflammatory markers (such as CRP or ESR), can help identify underlying inflammatory or infectious processes. Additionally, checking for specific markers related to kidney function and pancreatic enzymes could provide further insight.

3. Urological Evaluation: Given the hematuria, a cystoscopy (bladder scope) and possibly ureteroscopy (to examine the ureters) may be warranted to rule out any lesions or abnormalities in the urinary tract that could be causing your symptoms.

4. Gastroenterological Assessment: If gastrointestinal issues are suspected, an upper endoscopy (EGD) may be beneficial to evaluate for conditions such as gastritis or peptic ulcers, especially if you have symptoms like abdominal discomfort after eating or changes in bowel habits.

Conclusion
It’s understandable to feel anxious about the ongoing discomfort and the need for further testing. It’s crucial to maintain open communication with your healthcare providers about your symptoms and concerns. They can help guide you through the diagnostic process, ensuring that all potential causes are explored thoroughly. Remember that persistent symptoms warrant further investigation, and it’s important to advocate for your health until you find a satisfactory explanation and treatment plan.

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