Non-steroidal anti-inflammatory drugs in gynecological practice

Throughout life, a person repeatedly experiences abdominal pain. Under the age of 50, most often the cause of pain is not organic, but functional in nature, when drug therapy is most likely to be effective. The cause may be intestinal colic (in children in the first months of life), irritable bowel syndrome, biliary dyskinesia, dysfunction of the sphincter of Oddi, etc. About a third of cases of functional pain are accompanied by spasm of the smooth muscles of the gastrointestinal tract. This is why antispasmodics are so widely used without a doctor’s prescription. Providing a pronounced analgesic effect and normalizing the functioning of the organ, they, unlike non-narcotic and opioid analgesics, do not interfere with the mechanisms of pain, that is, they do not “erase” the picture of the disease, which is critically important in diagnosis.

Nota bene!

When a client asks for a remedy for abdominal pain, it is necessary to exclude urgent situations in order to send the sufferer to a doctor in time. These include:

1. Severe pain that prevents you from sleeping or doing anything, lasts longer than 1-2 hours.
2. Severe abdominal pain is accompanied by vomiting.
3. Severe pain is accompanied by elevated body temperature - 38.5°C and above.
4. Severe pain is accompanied by loss of consciousness.
5. Severe abdominal pain in a pregnant woman.
6. The abdominal muscles are tense and the stomach is as hard as a board.
7. Diarrhea mixed with bright red blood.
8. The stool is dark and tarry.
9. Vomiting blood.
10. Abdominal pain is accompanied by vomiting, diarrhea and severe dehydration.

What forms of medication are most effective for back pain?

To get rid of back pain, it is necessary to identify and eliminate the cause of the disease. However, before proceeding with diagnosis, it is necessary to alleviate the patient’s condition, relieving him of pain and inflammation. In pharmacies you can find a lot of drugs for back pain.

The most effective forms of medication are:

1. Pills . Tablet forms of drugs are selected depending on the location of the pain, its duration and intensity. These can be NSAIDs (pain reliever, relieve inflammation and fever), analgesics (pain relief), corticosteroids, chondroprotectors (restore articular cartilage), muscle relaxants (reduce skeletal muscle tone). The tablets act for a limited time and are used to alleviate the patient's condition. In addition, they can cause gastrointestinal side effects. That is why the course of taking tablets should be minimal.
2. Blockades . If the use of tablets turns out to be ineffective, indications arise for the introduction of anesthetic drugs into the paravertebral space. For this, solutions of local anesthetics (lidocaine, marcaine, novocaine, longocaine) are used. The essence of the procedure is to insert a needle perpendicularly into the skin near the spine. If everything is done correctly, the end of the needle ends up in the muscles and the anesthetic is injected there.
3. Preparations for topical use (balms, creams, ointments, gels, patches) . They are an excellent addition to standard therapy. They have a warming, analgesic, and local irritating effect. Particularly popular are medicinal patches that are glued to the affected area of ​​the back. They can be impregnated with dimexide (pain reliever), solutions of chondroprotectors (nourish joints with necessary substances), etc. Therapeutic patches are easy to use: they are small in size and do not take up much space in your bag. This “medicine” is invisible under clothing and can even be carried in a miniature handbag. In addition, the patches have a relatively low cost.

Each of the listed dosage forms has its own advantages and disadvantages. The choice of medications for back pain should be made by an experienced neurologist. The specialist will prescribe the necessary examinations, make a diagnosis, evaluate possible side effects and contraindications, and draw up an optimal treatment program.

Despite the fact that most drugs for back pain are available without a prescription, their independent and unsupervised use is strictly prohibited.

Cellular mechanism of pain

Smooth muscle cells are mainly found in the large intestine. There are significantly fewer of them in the small intestine. The mechanism of cell contraction depends on the concentration of calcium ions in the cytoplasm. The sources of calcium are the extracellular space, connected to the cytoplasm through calcium (slow) membrane channels, as well as the intracellular depot. The release of calcium causes the muscle cell to contract. The contraction of muscle cells forms a spasm and the person feels pain.

The process of muscle contraction is most often triggered by the mediator acetylcholine, binding to muscarinic cholinergic receptors (M-cholinergic receptors). Thus, blockade of M-cholinergic receptors leads to a decrease in tone and relaxation of smooth muscles (and therefore helps relieve abdominal pain). This, in particular, is the basis for the mechanism of action of a group of drugs called M-anticholinergics.

The interaction of calcium with calmodulin leads to the interaction of actin with myosin and cell contraction. CAMP (cyclic adenosine monophosphate) and cGMP (cyclic guanosine monophosphate) weaken the interaction of calcium with calmodulin and also impede the entry of calcium ions into the cell. The level of cAMP and cGMP is controlled by phosphodiesterase (PDE), which destroys excess of these nucleotides. Thus, if you reduce the activity of PDE, the concentration of calcium ions in the cytoplasm will decrease and the tone of the muscle cell will decrease.

Based on the described mechanisms for regulating the calcium concentration inside the muscle cell, which are disrupted under pathological conditions and lead to spasm, the main groups of antispasmodics have been created:

1. M-anticholinergics (atropine, hyoscine butyl bromide).
2. PDE IV inhibitors (drotaverine).
3. Blockers of calcium release from intracellular stores or sodium channel blockers (mebeverine).
4. Calcium channel blockers.

M-anticholinergics

M-anticholinergics are one of the oldest groups of drugs.
Atropine has been used in medicinal herbs since the 4th century BC. e. Thus, the ancient Greek naturalist Theophrastus described mandrake as a remedy for treating wounds, gout and insomnia, and also as a “love potion.” The ancient Greek military physician Dioscorides (1st century AD) described mandrake wine as an anesthetic to treat pain or insomnia, to be given before surgery or cauterization. M-anticholinergics most effectively affect the upper gastrointestinal tract. The use of non-selective M-anticholinergics (atropine, platyphylline, metacin) is limited by their prescription, as well as by the fact that they have a systemic effect and have a number of side effects, such as intestinal atony and obstruction.

One of the relatively oldest selective M-anticholinergics is hyoscine butyl bromide (first registered in Germany in 1951). It acts on the M1 and M3 subtypes of receptors, localized mainly in the walls of the upper gastrointestinal tract, gallbladder and biliary ducts. Hyoscine butyl bromide does not penetrate the blood-brain barrier and has a weak systemic effect, unlike atropine. However, it is contraindicated in people with glaucoma, benign prostatic hyperplasia, as well as organic stenosis of the gastrointestinal tract and tachyarrhythmias. Hyoscine butyl bromide accumulates in the smooth muscles of the gastrointestinal tract and is excreted unchanged by the kidneys. The drug is successfully used for sphincter of Oddi dysfunction, biliary dyskinesia and pyloric spasm.

The severity of the effect of hyoscine butylbromide also depends on the patient’s individual sensitivity to this drug. Unfortunately, the antispasmodic effect of hyoscine butyl bromide on the small intestine (except the duodenum) and large intestine can be realized when taking a dose 2–10 times higher than the therapeutic dose, so its use is useless for spasms in the lower abdomen. A large number of restrictions and risks when taking this drug require medical supervision, which is why the M-anticholinergics known to us are currently used less and less abroad. However, hyoscine butyl bromide is still available without a prescription.

Non-steroidal anti-inflammatory drugs in gynecological practice

Pain syndrome accompanies a number of common gynecological diseases and can be the main complaint presented by the patient. Pain not only brings physical suffering, it is always accompanied by difficult emotional experiences. Neurophysiologists argue that pain is largely a derivative of higher nervous activity. We are able to recognize pain and evaluate it; at the same time, pain can influence the perception of the world as a whole and distort it. Ultimately, long-lasting pain ends up at the center of all human life. She can take over consciousness and change personality.

Probably, almost every woman at least once in her life has encountered such a condition as painful menstruation. For some, the pain syndrome during menstruation is so severe that the woman is completely unable to work. At the same time, in gynecological practice we often have to perform all kinds of invasive interventions, accompanied by pain, sometimes quite severe, for which it is usually not customary to use general anesthesia. In this situation, it is necessary to resort to non-narcotic analgesics, the effectiveness of which can vary greatly. In this article, we intend to address the problems associated with pain in gynecological practice and offer treatment options for this condition.

Dysmenorrhea, or painful menstruation, is one of the most common reasons for missing work or school. In many state-owned enterprises there is still such a thing as “women’s day,” which allows a woman to experience “critical days” outside of the workplace once a month.

Dysmenorrhea is divided into primary and secondary. Primary dysmenorrhea refers to painful menstruation in the absence of pathological changes in the genital organs. With secondary dysmenorrhea, painful menstruation is caused by the presence of gynecological diseases, most often endometriosis, inflammatory diseases of the genital organs, uterine fibroids, etc. According to various authors, the incidence of dysmenorrhea, depending on age, ranges from 60 to 92%. It is obvious that primary dysmenorrhea occurs mainly in adolescents, while secondary dysmenorrhea is typical for older age groups.

Primary dysmenorrhea usually develops 6-12 months after menarche, when the first ovulatory cycles appear. Symptoms of dysmenorrhea usually occur with the onset of menstruation, rarely the day before it begins, and are characterized by cramping, aching, jerking, bursting pain that can radiate to the rectum, appendages and bladder. In addition, nausea, vomiting, headache, irritability, bloating and other autonomic phenomena may occur.

Among adolescents, the peak incidence of dysmenorrhea occurs at 17-18 years of age, i.e., at the time of the final formation of menstrual function and the formation of the ovulatory menstrual cycle. This pattern, in particular, indicates the significant role of ovulation in the pathogenesis of primary dysmenorrhea.

Although there is still no clear idea about the etiology of primary dysmenorrhea, most researchers agree that the leading role in the development of this disease is played by an imbalance of prostaglandins in the uterus.

As early as 1978, it was shown that prostaglandin F2α (PGF2α) and prostaglandin E2 (PGE2) accumulate in the endometrium during menstruation and cause symptoms of dysmenorrhea [1]. Prostaglandin F2α and PGE2 are synthesized from arachidonic acid through the so-called cyclooxygenase pathway. The activity of this enzyme pathway in the endometrium is regulated by sex hormones, more precisely by sequential stimulation of the endometrium, first with estrogens and then with progesterone. By the time of menstruation, a large concentration of prostaglandins accumulates in the endometrium, which are released due to lysis of endometrial cells. Prostaglandins released from the cells act on the myometrium, which leads to alternating constriction and relaxation of smooth muscle cells. Uterine contractions caused by prostaglandins can last several minutes, and the pressure in the uterus can reach 60 mm Hg. Art. Prolonged contractions of the uterus lead to the development of ischemia and, as a consequence, to the accumulation of anaerobic metabolic products, which, in turn, stimulate C-type pain neurons. In other words, primary dysmenorrhea can be called “uterine angina.”

The role of prostaglandins in the development of primary dysmenorrhea is confirmed by a study that found that the concentration of prostaglandins in the endometrium correlates with the severity of symptoms, i.e., the higher the concentration of PGF2α and PGE2 in the endometrium, the more severe the dysmenorrhea [2].

Many factors can modulate the effect of prostaglandins on the uterus. For example, vigorous exercise may increase uterine tone, possibly by reducing uterine blood flow. Many female athletes note that intense training during menstruation significantly increases the symptoms of dysmenorrhea. In addition to their effects on the uterus, PGF2α and PGE2 have the ability to cause bronchoconstriction, diarrhea and hypertension; in particular, diarrhea is especially often accompanied by primary dysmenorrhea.

For high production of prostaglandins in the endometrium, it is necessary to sequentially influence it first with estrogens and then with progesterone. It is obvious that women with an anovulatory menstrual cycle extremely rarely suffer from primary dysmenorrhea due to their lack of sufficient progesterone secretion. In this regard, the presence of ovulation is one of the factors causing the symptoms of dysmenorrhea.

The most common medications used to treat primary dysmenorrhea are oral contraceptives and nonsteroidal anti-inflammatory drugs (NSAIDs). The action of oral contraceptives is mainly aimed at turning off ovulation, since, as noted above, it is the ovulatory menstrual cycle that provides cyclic stimulation of the endometrium, which contributes to the accumulation of prostaglandins responsible for the development of symptoms of dysmenorrhea. This method of treatment is quite effective, but when choosing it it is necessary to take into account a number of factors. Firstly, the majority of patients with primary dysmenorrhea are teenagers who are not sexually active, for whom the problem of contraception accompanying treatment is not so relevant, but their conviction in the inevitable gain of excess weight “from hormones” is extremely strong. Secondly, it is not possible to prescribe oral contraceptives in all cases, since they have a number of contraindications.

Thirdly, the therapeutic effect of prescribing oral contraceptives develops only 2-3 months from the start of their use, which explains the irrationality of their prescribing in cases of particularly severe disease. Thus, oral contraceptives in the treatment of primary dysmenorrhea are optimally prescribed in cases where the patient, in addition to treatment, requires reliable contraception, as well as in cases of mild to moderate severity of symptoms.

Another, no less effective approach to the treatment of primary dysmenorrhea is the prescription of NSAIDs, in particular the drug ibuprofen (Nurofen), which is most widely used in clinical practice throughout the world.

Nurofen (ibuprofen) is a derivative of phenylpropionic acid. The drug inhibits the synthesis of prostaglandins by inhibiting the activity of cyclooxygenase. After oral administration, ibuprofen, which is part of Nurofen, is quickly absorbed from the gastrointestinal tract, its maximum concentration in the blood plasma is determined after 1-2 hours. Ibuprofen is metabolized in the liver, excreted by the kidneys unchanged and in the form of conjugates, the half-life is 2 h. Unlike other NSAIDs, Nurofen has almost no side effects; in rare cases, mild digestive disorders may occur. For the treatment of primary dysmenorrhea, Nurofen is prescribed at an initial dose of 400 mg, then the drug is used at a dose of 200-400 mg every 4 hours; the maximum daily dose is 1200 mg. Obviously, the dose of the drug should be selected depending on the severity of the symptoms of the disease.

If the analgesic effect of Nurofen is not enough, it is possible to use the combination drug Nurofen Plus. This drug combines ibuprofen with codeine, an analgesic that acts on opiate receptors in the central nervous system. The above combination provides a more pronounced analgesic effect.

In general, the use of NSAIDs for the treatment of primary dysmenorrhea has a number of advantages over the use of oral contraceptives. Unlike oral contraceptives, which should be taken for several months, NSAIDs are prescribed only for 2-3 days a month, which, on the one hand, is more convenient, and on the other, more economically profitable. In addition, NSAIDs not only effectively neutralize the negative effects of prostaglandins on the uterus, but also eliminate other symptoms of dysmenorrhea, such as nausea, vomiting and diarrhea.

It is the high effectiveness of NSAIDs in treating not only the main, but also concomitant symptoms of primary dysmenorrhea that served to confirm the hypothesis about the role of prostaglandins in the pathogenesis of this disease; in this regard, NSAIDs act as first-line drugs in the treatment of primary dysmenorrhea.

Although primary dysmenorrhea is one of the most common gynecological diseases accompanied by pain, a number of other gynecological pathologies often require the use of effective analgesics.

Secondary dysmenorrhea, as noted above, is caused by the presence of organic disorders of the genitals (table).

There are a number of factors that help distinguish secondary dysmenorrhea from primary.

• Symptoms of dysmenorrhea appear during the first or second menstrual cycle after menarche (congenital obstructive malformations).
• Symptoms of dysmenorrhea first appear after the age of 25 years.
• The presence of gynecological diseases: infertility (endometriosis, pelvic inflammatory disease (PID) or other causes of adhesions are assumed), heavy menstruation or intermenstrual bleeding (adenomyosis, uterine fibroids, polyps are assumed), dyspareunia.
• Lack of effect or its insignificant severity from therapy with NSAIDs and/or oral contraceptives.

The most common cause of secondary dysmenorrhea is endometriosis.

Characteristic symptoms of endometriosis are: the appearance of progressively increasing pain that occurs immediately before or during menstruation; dyspareunia, painful bowel movements, premenstrual spotting and polymenorrhea; pain over the pubis, dysuria and hematuria; infertility. Some patients may not identify pain as an acquired phenomenon, but simply note that they have painful menstruation, although most indicate increased pain. The pain is most often bilateral and ranges in intensity from mild to extremely severe. Often the pain is associated with a feeling of pressure in the rectum and can radiate to the back and leg. Constant “unpleasant sensations” throughout the menstrual cycle, intensifying before menstruation or during coitus, may be the only complaint presented by a patient with endometriosis. The cause of the pain has not been fully established; it is assumed that it may be associated with the phenomenon of “miniature menstruation” of endometriotic explants, which leads to irritation of the nerve endings. The disappearance of pain during the induction of amenorrhea in patients with endometriosis, i.e., the elimination of cyclic hormonal effects on endometriotic explants, actually proves the mechanism of the pain syndrome.

However, pain is not always associated with endometriosis, even in cases where the disease is severe. For example, bilateral large endometrioid ovarian cysts are most often asymptomatic unless they rupture, while severe discomfort may be a consequence of a minimal number of active endometrioid heterotopias.

Despite the fact that pathogenetic therapy for endometriosis has been developed, including the use of gonadotropin-releasing hormone agonists and 19-norsteroid derivatives, quite often, in the first stages of treatment, and sometimes for longer periods, it is necessary to add analgesics to the main drugs. This is due to the fact that basic drugs do not have their maximum effect immediately, and in some cases they are not able to completely eliminate the pain syndrome. Thus, the drugs Nurofen or Nurofen Plus also find a place in the treatment of endometriosis.

Everyday gynecological practice is not complete without such procedures as the introduction and removal of intrauterine devices, treatment of cervical pathology, endometrial biopsy, hysterosalpingography, etc. Of course, in most cases, for these interventions, you can not use painkillers at all. The era of abortions performed without any anesthesia has not yet been forgotten, but in modern conditions this approach seems quite archaic and inhumane. All of the above procedures can be carried out with fairly effective pain relief, thereby achieving good emotional tolerance of these interventions. For this purpose, you can also use Nurofen Plus, preferably 20-30 minutes before the procedure and after its completion. Taking this drug once or twice, depending on the severity of the pain syndrome, will eliminate the negative emotional perception on the part of the patient.

I would like to touch on one more, fairly common pain syndrome. We are talking about the so-called pelvic ganglioneuritis. This is a variant of radiculitis, in which the nerve trunks exiting in the pelvic area are pinched. Patients with this disease most often complain of recurrent pain in the iliac regions. As a rule, the examination fails to reveal any signs of an inflammatory process in the uterine appendages or any other pathological changes. The pain syndrome in these patients is quite well controlled by taking analgesics from the NSAID group, in particular Nurofen.

Since 2001, in our clinic, we began to use the method of uterine artery embolization to treat patients with uterine fibroids. After the procedure, patients usually experience pain of varying severity. The duration of this syndrome also varies, but on average it is 8 days. We tried various pain relief regimens in this category of patients and settled on a regimen that involved the use of Nurofen and Nurofen Plus. In particular, we were able to note a more pronounced analgesic effect of this drug, a rapid onset of effect and good tolerability.

Thus, Nurofen and Nurofen Plus are widely used in gynecological practice and effectively relieve women from pain.

A. L. Tikhomirov, Doctor of Medical Sciences, Professor D. M. Lubnin MGMSU, Department of Obstetrics and Gynecology, Moscow

For questions regarding literature, please contact the editor.

Phosphodiesterase inhibitors (PDE) type IV

These are traditionally widely used antispasmodics: drotaverine hydrochloride and papaverine. Their injectable forms are sold with a prescription, while their tablet forms are available without a prescription. PDE IV is widely present in smooth muscle along the entire length of the intestine, as well as in the biliary and urinary tracts. Thus, blocking PDE IV has a universal antispasmodic effect regardless of the severity of the spasm or its cause. In addition, drotaverine has anti-edematous and anti-inflammatory effects. Drotaverine can be used for acute abdominal pain - both to relieve acute spasms and for long-term treatment of biliary dyskinesia, cholelithiasis, chronic intestinal diseases with spastic syndrome, which are accompanied by colicky or bursting pain. Unlike M-anticholinergics, drotaverine can be used in elderly men with prostate pathology, as well as with concomitant pathology and combined use with other drugs. The therapeutic concentration of drotaverine in plasma when taken orally is achieved after 45 minutes.

List of the most effective suppositories for back pain

The most effective suppositories for back pain are listed below.

Voltaren

Voltaren is a non-steroidal anti-inflammatory drug

It is a non-steroidal anti-inflammatory drug produced by the Swiss company Novartis. Prescribed to patients with injuries, neurological symptoms, gynecological and urological diseases. It is used to treat rheumatism, gout, ENT diseases, as well as to relieve pain after surgery. The drug eliminates pain, reduces body temperature and eliminates inflammation.

Diclofenac

Diclofenac has anti-inflammatory and analgesic properties

Has anti-inflammatory and analgesic properties . The dosage form of this drug (rectal suppositories) allows it to quickly deliver the active substance to the affected area of ​​the spine (bypassing the gastrointestinal tract), reducing the risk of adverse reactions. The drug allows you to get rid of acute and chronic pain, reduce the strength of spasms, and eliminate inflammatory processes.

Nurofen

Nurofen stops the inflammatory process, eliminates pain, reduces fever

Belongs to the group of non-steroidal anti-inflammatory drugs. Stops the inflammatory process, eliminates pain, reduces fever . Sold in most pharmacies, dispensed without a doctor's prescription. Suppositories have a wide spectrum of action. They are used to treat pain of various etiologies, ligament injuries, infectious diseases, migraines, influenza and ARVI.

Piroxicam

The drug is effective within 42 hours from the moment of administration

It is a non-steroidal anti-inflammatory drug and has an antipyretic effect . The drug is effective within 42 hours from the moment of administration. It eliminates pain, relieves swelling of joints and improves their mobility. To achieve visible results, Piroxicam must be taken for a week.

Ketonal

The medicine is used to treat neuralgia, arthritis, radiculitis, osteoarthritis, migraine

Ketonal suppositories are a non-steroidal drug intended for the treatment of pain of various etiologies. The medicine is used to treat neuralgia, arthritis, radiculitis, osteoarthritis, and migraine. Candles help eliminate pain after injuries and operations, as well as rheumatism and cancer.

Analgin

Is an analgesic-antipyretic

It is an analgesic-antipyretic . Relieves fever, eliminates inflammation. It is used to relieve pain in myositis, radiculitis, neuralgia, and migraines. Reduces temperature and alleviates the condition of patients with fever. Affects the central nervous system and can be used to treat children. The effect of the drug lasts for 6 hours after taking it.

Akamol-Teva

It is an analgesic drug . Relieves fever, eliminates inflammation in muscles, joints and tissues. It is used to relieve pain of various origins (neuralgia, myalgia, post-traumatic pain). Improves well-being during fever.

Sodium channel blockers

These drugs block intracellular calcium stores through a cascade of reactions. The most famous drug is a derivative of veratric acid - mebeverine. Unlike anticholinergics, it does not cause hypotension of the colon. Most often, this drug is prescribed for functional disorders of the gastrointestinal tract or as an adjuvant for organic diseases of the gastrointestinal tract. Mebeverine is used only for course treatment. Mebeverine is most effective in combination with other pathogenetic drugs. Mebeverine is mainly available by prescription, but there is a dosage form in tablets that does not require a doctor's prescription.

We will not dwell on calcium channel blockers in more detail, since these drugs do not have any over-the-counter forms.

The over-the-counter myotropic antispasmodic trimebutine stands apart. Trimebutine acts on the enkephalinergic system of the intestine and peripheral opiate receptors - µ, κ and δ. Having an affinity for receptors that enhance and suppress peristalsis, it stimulates the contraction of intestinal smooth muscles in hypokinetic conditions and is an antispasmodic in hyperkinetic conditions. Trimebutine reduces the tone of the esophageal sphincter, promotes gastric emptying and increased intestinal motility, as well as the response of the smooth muscles of the colon to food irritants. It is used for various functional disorders of the gastrointestinal tract.

Ask and choose

How can a pharmacy client choose an over-the-counter antispasmodic from the extensive list of drugs for abdominal pain? Guiding questions will help:

• Does a person have a chronic organic gastrointestinal disease - peptic ulcer of the stomach or duodenum, chronic cholecystitis, chronic pancreatitis, biliary colic, biliary dyskinesia? As a rule, the patient already knows what helps him or what drug the doctor recommended for him during an exacerbation.
• Patient's age? Selective M-anticholinergics are not suitable for the elderly due to the risk of developing intestinal obstruction. Also, antispasmodics have age restrictions for children: mebeverine can be used from twelve years of age, hyoscine butylbromide and drotaverine - from six, trimebutine - from three.
• For women - pregnancy, lactation? The use of antispasmodics during pregnancy is possible only as prescribed by a doctor. PDE inhibitors and trimebutine are contraindicated during lactation. Anticholinergics and sodium channel blockers can be used during lactation.
• Pain in the upper abdomen, possibly accompanied by nausea or vomiting? A selective M-anticholinergic drug is suitable for adults, in the absence of contraindications described in the instructions for a particular drug.
• Pain in the lower abdomen? Type IV PDE inhibitors and sodium channel blockers are suitable.

Sources

1. Abdominal pain syndrome in the practice of general practitioner T. M. Benz “News of medicine and pharmacy.” Gastroenterology (239), 2008.
2. Pchelintsev M. V. “Anspasmodics: from clinical pharmacology to pharmacotherapy.” Attending Physician 7 (2008): 74–77.
3. Mikhailov I. B. Clinical pharmacology (textbook for students of medical universities) - 5th ed., revised. and additional - St. Petersburg: publishing house "Sotis-Med", 2013. - 588 p.
4. Yakovenko E. P., et al. "Opiate receptor agonist trimebutine in the treatment of functional disorders of the gallbladder and sphincter of Oddi." Journal "Attending Physician" 2–2014 (2017): 56.
5. Tytgat GN. Hyoscine butylbromide: a review of its use in the treatment of abdominal cramping and pain. Drugs 2007; 67:1343–57.