Abdominal pain is a very common symptom and is caused by wide range of illnesses. Most abdominal pain are acute unless the cause is cancer.1 Abdominal pain is caused by the diseases of abdominal skin, subcutaneous tissue, muscles, peritoneum and abdominal organs. Exclusive back pain caused by facet joint, spinal nerve pinch or irritation may not be associated with abdominal pain. But abdominal pain is also caused by diseases of sensory nerves and spinal cord when pain is felt over front and side of abdominal wall.2 Most abdominal pain is felt on front and lateral side of belly. The abdominal pain caused by skin diseases are much simple to diagnosed since skin lesions are seen by individual as well as examining physician.
Why Does Coughing Increase Intra-abdominal Pain?
The cause of generalized abdominal pain is often difficult to diagnose as compared to regional and dermatomal pain. Intensity of abdominal pain increases during coughing for following reason-
- Coughing Triggers Pain From Inflamed Or Injured Abdominal Muscle- The pain caused by diseases of muscles increases in intensity during cough. The coughing causes vigorous abdominal muscle contraction that increases pain if muscle is inflamed, injured or torn. Muscle inflammation is observed following persistent coughing, myofascial muscle disease and fibromyalgia. In most cases abdominal muscle gets fatigued because of repeated coughing. The fatigued muscle goes into severe spasm during coughing that causes intense pain. Coughing also causes bleeding and hematoma (blood clot) within abdominal muscle that causes abdominal pain.3
- Coughing Increases Intra-Abdominal Pressure- Increased frequency of coughing causes increased intra-abdominal pressure.4 The pain becomes severe if one is suffering with inflammatory disease of peritoneum and abdominal viscera. The increased abdominal pressure during coughing irritates inflamed peritoneum known as peritonitis that results in sudden gasping pain. Similarly, increased abdominal pressure during coughing squeezes the inflamed abdominal organ that results in severe pain. Such increase in pain is observed in individual suffering with appendicitis, torsion of fallopian tube and mesentery embolism. The publish data suggests coughing causes volvulus, hernia involves abdominal viscera and also causes perforation of viscera that is herniated or strangulated within abdomen.5
- Coughing Causes Intra-Abdominal Bowel Volvulus And Torsion- Intense coughing causes intestinal volvulus and torsion.6 Bowel volvulus and torsion causes bowel obstruction and strangulation that results in severe pain. If such complication is not treated soon then bowel become ischemic as blood supply is restricted and may goes into condition like gangrene.
- Coughing Causes Abdominal Hernia And Bowel Obstruction- Persistent intense cough sometime causes inguinal or umbilical hernia. The sudden popping of viscera like bowel in herniated mass causes intense pain. Occasionally bowel within hernia may get obstructed and cause severe pain. If bowel within hernia is strangulated, then bowel will go into stage of gangrene unless strangulation is relieved by surgery. The condition is considered emergency.
- Coughing Increases Epidural Pressure That Results In Irritation Or Pinch Of Spinal Nerve- Abdominal wall receives pain fibers from lower thoracic spinal nerves. Coughing increases pressure in epidural space. If nerve is pinched because of disc bulge or herniation, then coughing causes increases intensity of pain. Pain is felt in abdominal wall. Such pain may be associated with tingling, numbness and weakness of abdominal muscles. The intensity of pain caused by diabetes, post herpetic neuralgia or shingles increases in intensity during and following coughing.7
Causes of Abdominal Pain That Increases With Coughing-
Causes of Skin Diseases That Causes Abdominal Pain-
Skin diseases like furuncle, carbuncle and cellulitis causes abdominal pain. The contraction of underlying abdominal muscles during coughing increases the intensity of pain.
Following skin diseases causes abdominal pain-
- Furuncle or boil
Causes of Generalized Abdominal Pain.
Generalized abdominal pain is felt in entire abdomen. The pain is caused by disease of peritoneum, small intestine and large bowel. The pain is spread over entire abdomen because the disease is widely spread in peritoneum and viscera. Peritoneum covers the abdominal wall and all the abdominal visceral. Infection of peritoneum is known as peritonitis. Peritonitis widely spreads over parietal and visceral peritoneum. Symptoms caused by peritonitis always widely spreads over abdomen. Similarly, wide spread bowel infection also results in generalized abdominal pain. The bowel infection is known as bacterial dysentery. Chronic inflammatory bowel disease like ulcerative colitis or Crohn’s disease also causes wide spread abdominal pain. Rarely constipation also caused wide spread abdominal pain. Causes of generalized abdominal pain-
Causes of Upper Abdominal Pain
Upper abdominal pain is spread over right and left side of upper abdomen, as well as upper middle abdomen. The right side abdominal pain is caused by diseases of transverse colon, liver and gall bladder. Left side abdominal pain is caused by peptic ulcer. Peptic ulcer is caused by ulcer of stomach and duodenum. Upper abdominal pain is also observed in middle of abdomen. The middle upper abdominal pain is caused by diseases of lower esophagus, gall bladder and pancreas. Causes of Upper Abdominal Pain-
Causes of Middle Abdominal Pain
Middle abdominal pain is felt on right and left side of umbilicus as well as around umbilicus. The right side middle abdominal pain is caused by inflammatory disease of ascending colon and small intestine. Left side middle abdominal pain is caused by disease of spleen, duodenum, small intestine and descending colon. The pain that spreads around umbilicus is caused by aortic aneurysm, ruptured aorta, umbilical hernia and diseases of pancreas.
Causes of Lower Abdominal Pain
Lower abdominal pain is caused by diseases of pelvic organs as well as organs underlying the lower abdomen. Diseases of pelvic organs that causes lower abdominal pain are urinary bladder infection (cystitis) or cancer of urinary bladder in male and female. The disease of fallopian tube like infection, tubal pregnancy and torsion of fallopian tube causes lower abdominal pain. Ovarian cancer or torsion on left or right side causes either left or right lower abdominal pain. Pain caused by infection and inflammation of appendix is felt on right lower abdomen. The uterus fibroid or endometriosis causes pain over middle of lower abdomen.
Characteristics of Abdominal Pain Observed While Coughing-
Nevertheless, any case of abdominal pain needs thorough history taking and clinical assessment. This is all the more important when patient complains of cough triggering abdominal pain or coughing causes increased severity of abdominal pain. History of the pain helps to understand intensity of pain, duration of pain or for how long the abdominal pain has lasted and if pain is aggravated following consumption of a heavy meal. Understanding other details like types of pain, associated symptoms and worsening of abdominal pain following activities is also important to differentiate the cause and disease related to abdominal viscera.
Pain Intensity- Abdominal Pain intensity is important to evaluate the severity of disease. Most pain cause by inflammation, infection and cancer begins as mild pain and then become severe as illness advances. The torsion, obstruction and strangulation of bowel, fallopian tube and ovary causes sudden occurrence of severe pain. Embolism, tissue infarction and rupture aneurysm also causes intense severe pain. Abdominal pain intensity is measured as mild, moderate, severe and very severe or counted as visual analogue score (VAS) from number 0 to 10.
- Pain Intensity-
- Mild- VAS 0 to 3
- Moderate- 4 to 5
- Severe- 6 to 8
- Very severe- 9 to 10
Type of Pain Observed After Coughing-
Abdominal Cramp- The intestinal or bile duct contraction causes abdominal cramp. Abdominal cramp is also caused by bowel obstruction and volvulus.
Causes Of Abdominal Cramp After Cough-
- Gallstone blocking bile duct
- Chron’s disease
- Ulcerative colitis
- Intestinal obstruction
Stabbing Pain- The sudden intense abdominal pain is frequently felt like stabbing when it is caused by perforated stomach or duodenal ulcer, ruptured aortic aneurysm and obstructed hernia. Peritonitis also causes stabbing pain in abdomen.
Causes of Stabbing Abdominal Pain After Cough-
- Rupture abdominal aneurysm
- Mesentery infarction
- Mesentery artery embolism
- Perforated ulcer
- Strangulated inguinal or abdominal hernia
Squeezing Pain- Squeezing abdominal pain is also described as feeling of tightness. Most individual describe pain as if someone is squeezing organs inside the abdomen.
Causes of Squeezing Abdominal Pain Or Tightness Of Abdomen-
- Diarrhea and frequent bowel movement caused by food indigestion, food poisoning or dysentery.
- Inflammatory bowel disease like Crohn’s bowel disease and ulcerative colitis
- Menstruation or premenstrual pain
- Gall bladder inflammation
- Pancreatitis and
- Pancreatic cancer
- Uterus fibroid
- Menstrual pain
Twisting Pain- Twisting pain feels as abdominal viscera is twisted and pain is localized in one area. Twisting type of abdominal pain is also felt as squeezing and stabbing type of pain but more localized in one area. Individual is often unable to move, since pain intensity increases with movements.
The Causes Of Twisting Type Of Abdominal Pain Following Cough-
- Bowel obstruction
- Fallopian tube obstruction
- Fallopian tube torsion
- Strangulated abdominal hernia
- Hiatus hernia
- Menstrual pain
Piercing Pain- Piercing abdominal pain is felt as if something is piercing through the viscera. It is difficult to differentiate stabbing and piercing pain. Stabbing pain is felt in one segment while piercing pain is felt in wider area and pain migrates from one segment to another segment like upper abdominal piercing pain may felt in lower abdomen.
Causes Of Piercing Abdominal Pain Following Cough-
- Perforated ulcer
- Strangulated hernia
Associated Symptoms With Abdominal Pain When Coughing-
Nausea- Almost all diseases causing abdominal pain also causes nausea.
Vomiting- Vomiting in patients suffering with abdominal pain is caused by gastritis, enteritis, dysentery, peritonitis, appendicitis, mesentery infarction, fallopian tube torsion and gall bladder diseases.
Diarrhea- Diarrhea is observed in following condition when individual is suffering increase bowel pain following coughing-
- Bile duct obstruction,
- Mesentery infarction,
- Fallopian tube torsion
Evaluation and management of acute abdominal pain in the emergency department
Evaluating and Managing Acute Low Back Pain in the Primary Care Setting
Cough-induced internal oblique hematoma
Intra-abdominal Pressures during Voluntary and Reflex Cough
Coughing-induced bowel transection in a patient with an incarcerated inguinal hernia: a case report
Abdominal pain with a twist: a rare presentation of acute gastric volvulus
Varicella Zoster Infection: A Rare Cause of Abdominal Pain Mimicking Acute Abdomen