Hypogastric pain resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amr Marawan, M.D. [2]

Hypogastric Pain Resident Survival Guide Microchapters


The hypogastrium (alternative names including hypogastric region, pubic region and suprapubic region) is an area of the human abdomen located below the navel. The pubis bone constitutes its lower limit.



Shown below is an algorithm depicting the diagnostic approach of acute abdominal pain in the hypogastric region.

Peritoneal signs, shock or toxic appearing
Symptoms, signs, risk factors or ECG suggestive of acute coronary syndrome
Symptoms, signs or risk factors suggestive of abdominal aortic aneurysm
❑ Initiate resuscitation
❑ Obtain immediate surgical consultation
❑ Perform bedside ultrasound (evaluate aorta, hemoperitoneum, pericardium and inverior vena cava)
❑ Obtain indicated tests and studies (e.g. x-ray, ECG, lactate, lipase and LFTs)
Appropriate management
❑ Surgical consultation
❑ Bedside ultrasound
❑ Abdominal CT
History, examination and risk factors suggest mesentric ischemia (pain out of proportion to exam)
❑ Surgical consultation
❑ Abdominal CT
History and examination suggest bowel obstruction (diffuse tenderness with distention and persistent vomiting) or perforation (rigidity with absent bowel sounds
Abdominal x-ray series
Where is pain localized
Presence of free air
Presence of obstruction
Absent free air and absent obstruction
Epigastric or upper right quadrant tenderness
Right lower quadrant tenderness
Left lower quadrant tenderness
Surgical consult
Abdominal CT
Abdominal CT
Hypogastric pain/Suprapubic pain
Left upper quadrant tenderness
No urinary symptom
Presence of dysuria and voiding dysfunction
Dysuria and voiding dysfunction
No urinary symptoms
Consider bowel or vascular disease
Urine culture, suprapubic USS and catheterization
Urine culture, pelvic ultrasound and catheterization
Pain at the cervix or vaginal fornices
Vaginal examination
Refer to general surgery
Consider prostatitis, cystitis or urine retention
Consider cystitis or extrinsic bladder compression causing urine retention
Consider gynecological referral
If examination was unremarkable, refer to general surgery
Refer to urology
Refer to urology


  • Start the approach to acute abdominal pain by rapid assessment of the patient using the pneumonic "ABC:" airway, breathing and circulation, to identify unstable patients.
  • Consider abdominal aortic aneurysm, mesenteric ischemia and malignancy in patients above 50 years as it is much less likely for younger patients.
  • Perform pelvic and testicular examination in patients with low abdominal pain.
  • Re-examine patients at high risk who were initially diagnosed with pain of unclear etiology.
  • Taking careful history, characterizing the pain precisely and thorough physical examination is crucial for creating narrow differential diagnosis.
  • Correlate the CD4 count in HIV positive patients with the most commonly occurring pathology.
  • Order a pregnancy test before proceeding with a CT scan in females in the child bearing age.
  • Order an ultrasound or magnetic resonance among pregnant females to avoid exposure to radiation. In case the previous tests were inconclusive and appendicitis is suspected, the next step in the management includes proceeding with either laparoscopy or limited CT scan.
  • Consider peritonitis with cervical motion tenderness as it isn't specific for pelvic inflammatory disease.
  • Suspect abdominal aortic aneurysm in old patients presenting with abdominal pain with history of tobacco use.[1]
  • Suspect acute mesenteric ischemia or acute pancreatitis in patients presenting with poorly localized pain out of proportion to physical findings.[1]
  • Recommend initial imaging studies based on the location of abdominal pain:


  • Fail to evaluate elder patients in the presence of overt clinical signs.
  • Over rely on laboratory tests, they are only used as adjuncts.
  • Do not delay the initial intervention.
  • Do not order blood cultures routinely in all patients
  • Don’t delay resuscitation or surgical consultation for ill patient while waiting for imaging.
  • Don’t restrict the differential diagnosis of abdominal pain based on the location; for example, right-sided structures may refer pain to the left abdomen.[1]


  1. 1.0 1.1 1.2 "Diagnosis and management of 528 abdom... [Br Med J (Clin Res Ed). 1981] - PubMed - NCBI".
  2. 2.0 2.1 2.2 "http://www.acr.org/". External link in |title= (help)
  3. "http://www.ebmedicine.net/content.php?action=showPage&pid=94&cat_id=16". External link in |title= (help)

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