Post on 16-Jan-2016
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Ob Gyn and Male GUOb Gyn and Male GU
William Beaumont HospitalWilliam Beaumont Hospital
Department of Emergency Department of Emergency MedicineMedicine
Causes of pelvic painCauses of pelvic pain
Ectopic pregnancyEctopic pregnancy
PIDPID Ovarian torsionOvarian torsion Ruptured ovarian cystRuptured ovarian cyst FibroidsFibroids EndometriosisEndometriosis
Pelvic pain case26 y/o F presents with RLQ pain and
vaginal spotting. Abdominal and pelvic exams are normal.
26 y/o F presents with RLQ pain, R shoulder pain, no spotting. Pelvic with R adnexal fullness and tenderness.
What are you thinking about?
Ectopic pregnancyEctopic pregnancy
Abdominal pain or vaginal Abdominal pain or vaginal bleeding in first trimester bleeding in first trimester pregnancypregnancy
2% incidence2% incidence Leading cause of first trimester Leading cause of first trimester
maternal deathmaternal death Risk factors – prior PID, failed IUD Risk factors – prior PID, failed IUD
or tubal ligation, history of or tubal ligation, history of infertility, prior ectopicinfertility, prior ectopic
Signs and symptomsSigns and symptoms
Duration of the pregnancyDuration of the pregnancy Extent of intraperitoneal Extent of intraperitoneal
hemorrhagehemorrhage– Slow leakage (65% non ruptured)Slow leakage (65% non ruptured)– Frank ruptureFrank rupture
Site of implantationSite of implantation– Ampulla – most common Ampulla – most common – Isthmus – 10% - rupture commonIsthmus – 10% - rupture common– Cornual – massive hemorrhageCornual – massive hemorrhage
Signs and symptomsSigns and symptoms
Abdominal pain 95%Abdominal pain 95% Abdominal tenderness 70%Abdominal tenderness 70% Vaginal bleeding – slight spottingVaginal bleeding – slight spotting TenesmusTenesmus 3 S’s3 S’s
– Syncope, shoulder pain, shockSyncope, shoulder pain, shock– Suggests ruptureSuggests rupture
DiagnosisDiagnosis
Physical exam – not always helpfulPhysical exam – not always helpful High index of suspicionHigh index of suspicion BhCG – all women with vag bleed or BhCG – all women with vag bleed or
abdominal pain in reproductive yrsabdominal pain in reproductive yrs Pelvic ultrasound – Suggestive of ectopic Pelvic ultrasound – Suggestive of ectopic
pregnancypregnancy– No IUP, BhCG >1200 (DZ)No IUP, BhCG >1200 (DZ)– Complex adnexal massComplex adnexal mass– Moderate-large amount cul-de-sac fluidModerate-large amount cul-de-sac fluid
TreatmentTreatment
Rhogam if Rh negative and Rhogam if Rh negative and bleedingbleeding
Gynecology consult for Gynecology consult for Methotrexate or surgical removalMethotrexate or surgical removal
ABCsABCs
Next case…
18 y/o F presents with low abdominal pain, fever, and last period about one week ago.
This is her pelvic.
What is this?
PIDPID
Most common cause of pelvic painMost common cause of pelvic pain Most common serious infection in Most common serious infection in
reproductive aged womenreproductive aged women Cervicitis that ascends to become a Cervicitis that ascends to become a
polymicrobial endometritis, salpingitis, polymicrobial endometritis, salpingitis, oophoritisoophoritis
Risk factors – prior PID, multiple Risk factors – prior PID, multiple partners, IUD use, instrumentation of partners, IUD use, instrumentation of uterine cavityuterine cavity
SymptomsSymptoms
Bilateral lower quadrant painBilateral lower quadrant pain Purulent vaginal discharge >50%Purulent vaginal discharge >50% Abnormal vaginal bleedingAbnormal vaginal bleeding Symptoms begin shortly after Symptoms begin shortly after
mensesmenses
PEPE
CMTCMT Bilateral adnexal tendernessBilateral adnexal tenderness Purulent cervical dischargePurulent cervical discharge Diagnosis – clinical to begin Diagnosis – clinical to begin
treatmenttreatment Gram neg intracellular diplococci Gram neg intracellular diplococci C & S, DNA probe (PCR, run late C & S, DNA probe (PCR, run late
am)am)
Indications for Indications for admissionadmission
Suspected TOA or Fitz-Hugh-Curtis Suspected TOA or Fitz-Hugh-Curtis syndromesyndrome
Patient unable to tolerate poPatient unable to tolerate po Peritonitis, septic appearingPeritonitis, septic appearing Prepubertal childrenPrepubertal children Indwelling IUD Indwelling IUD PregnancyPregnancy + /- nulliparous women+ /- nulliparous women
Inpatient treatmentInpatient treatment
Cefoxitin 2 g IV q 6 *Cefoxitin 2 g IV q 6 * Cefotetan 2 g IV q 12 *Cefotetan 2 g IV q 12 * Unasyn 3 g IV q 6*Unasyn 3 g IV q 6* * WITH Doxycycline 100 mg PO/IV q * WITH Doxycycline 100 mg PO/IV q
1212
oror Clindamycin 900 mg IV q 8 with Clindamycin 900 mg IV q 8 with
Gentamycin aloneGentamycin alone
Outpatient treatmentOutpatient treatment
Ceftriaxone 250 mg IM PLUSCeftriaxone 250 mg IM PLUS Cefoxitin 2 gm IM with Probenecid Cefoxitin 2 gm IM with Probenecid
1 gm po PLUS1 gm po PLUS– Doxycycline 100 mg BID x 14 dDoxycycline 100 mg BID x 14 d– +/-Metronidazole 500 mg BID x 14 d+/-Metronidazole 500 mg BID x 14 d
CervicitisCervicitis
Cervical infection – discharge without Cervical infection – discharge without abdominal pain or constitutional symptoms abdominal pain or constitutional symptoms
Gonorrhea or ChlamydiaGonorrhea or Chlamydia Treatment – outpatientTreatment – outpatient
– Ceftriaxone 125 mg IM with Doxycycline 100 mg Ceftriaxone 125 mg IM with Doxycycline 100 mg BID x 7 daysBID x 7 days
– Alternatives for GC: Cefixime 400 mg PO x 1Alternatives for GC: Cefixime 400 mg PO x 1– Alternative for Chlamydia: Azithromycin 1 g POAlternative for Chlamydia: Azithromycin 1 g PO– Alternative for both: Azithromycin 2 g POAlternative for both: Azithromycin 2 g PO
Flank Pain Case
26 y/o F presents with L flank pain, LLQ pain, and pain that radiates to the vagina. She also has urinary frequency. She has L CVA and LLQ tenderness on exam.
What could this be?
What was missed?
Ovarian painOvarian pain
Ruptured cystRuptured cyst– Sudden, severe, sharp unilateral painSudden, severe, sharp unilateral pain– self resolving unless hemorrhagic or dermoidself resolving unless hemorrhagic or dermoid– Treatment – observe in EDTreatment – observe in ED
Ovarian torsionOvarian torsion– Intermittent colicky pain or acute abdomenIntermittent colicky pain or acute abdomen– Adnexal fullness/tenderness Adnexal fullness/tenderness – BhCG, doppler ultrasound is diagnosticBhCG, doppler ultrasound is diagnostic– Treatment – admit via ORTreatment – admit via OR
Kidney stonesKidney stones
Common - @ 10% incidenceCommon - @ 10% incidence Flank pain, radiating to groin or Flank pain, radiating to groin or
abdomenabdomen Writhing in pain, nausea, vomitingWrithing in pain, nausea, vomiting CVA tendernessCVA tenderness GU exam (radiating pain)GU exam (radiating pain) Abdomen soft, nontender, Abdomen soft, nontender, BS - BS -
ileusileus
Kidney stones work upKidney stones work up
UrinalysisUrinalysis– Hematuria (unless complete obstruction)Hematuria (unless complete obstruction)– Infection = surgical emergencyInfection = surgical emergency
CT scan (non contrast) abd/pelvisCT scan (non contrast) abd/pelvis UltrasoundUltrasound IVPIVP 90% radiopaque – visible on KUB90% radiopaque – visible on KUB
– 75% Calcium 15% struvite (Mg)75% Calcium 15% struvite (Mg)– Others: uric acid, cystine, drug inducedOthers: uric acid, cystine, drug induced
Helical CT scanHelical CT scan
perinephric perinephric stranding of fat stranding of fat surrounding the surrounding the left kidney and left kidney and proximal left ureterproximal left ureter
Left kidney is Left kidney is enlarged, with enlarged, with dilatation of the dilatation of the intrarenal intrarenal collecting systemcollecting system
TreatmentTreatment
IV fluidsIV fluids Strain urineStrain urine Analgesics – ketorolac, narcoticsAnalgesics – ketorolac, narcotics Antiemetics if vomitingAntiemetics if vomiting Tamsulosin – Flomax – alpha blockerTamsulosin – Flomax – alpha blocker < 5mm – usually pass spontaneously< 5mm – usually pass spontaneously > 8 mm – often require surgery> 8 mm – often require surgery
Admission Admission (Observation)(Observation) Intractable painIntractable pain Intractable vomitingIntractable vomiting Stone > 6mmStone > 6mm Solitary kidney or congenital Solitary kidney or congenital
abnormalities (horseshoe kidney)abnormalities (horseshoe kidney) Infected stone is a true surgical Infected stone is a true surgical
emergency (perinephric abscess, emergency (perinephric abscess, sepsis and death)sepsis and death)
Testicular painTesticular pain
18 y/o male c/o of pain in his right 18 y/o male c/o of pain in his right testicle that was sudden onset 2 testicle that was sudden onset 2 hours ago with nausea and vomiting. hours ago with nausea and vomiting. It began while he was running. Exam It began while he was running. Exam shows a diffusely tender swollen right shows a diffusely tender swollen right testicle, with loss of cremasteric testicle, with loss of cremasteric reflex. reflex.
What are you thinking?What are you thinking? What tests do you want to order?What tests do you want to order?
Male GU Male GU
Testicular torsionTesticular torsion EpididymitisEpididymitis Fourniere’s gangreneFourniere’s gangrene
Testicular torsionTesticular torsion
Sudden severe testicular or lower abd painSudden severe testicular or lower abd pain Often preceded by trauma/physical activityOften preceded by trauma/physical activity Most common in pre and pubescent males, Most common in pre and pubescent males,
but can occur at any agebut can occur at any age PE – diffusely tender, swollen testiclePE – diffusely tender, swollen testicle Diagnosis – no flow on testicular ultrasoundDiagnosis – no flow on testicular ultrasound Admit via the OR, stat urologic consultAdmit via the OR, stat urologic consult
EpididymitisEpididymitis
Gradual painGradual pain Posterior epididymal tenderness and Posterior epididymal tenderness and
edema (later swollen scrotum obscures)edema (later swollen scrotum obscures) Usually occurs in sexually active malesUsually occurs in sexually active males U/A – pyuriaU/A – pyuria Testicular ultrasound – to rule out Testicular ultrasound – to rule out
torsiontorsion Outpatient Abs to cover GC and Outpatient Abs to cover GC and
Chlamydia, analgesics, scrotal supportChlamydia, analgesics, scrotal support
Fourniere’s gangreneFourniere’s gangrene
Elderly or immunocompromised menElderly or immunocompromised men Sudden onset of edematous, necrotic Sudden onset of edematous, necrotic
scrotumscrotum Patients appear toxicPatients appear toxic Plain films – scrotal gangrene and Plain films – scrotal gangrene and
intrascrotal gasintrascrotal gas Urologic consult for surgical Urologic consult for surgical
debridementdebridement IVF, broad spectrum IV antibioticsIVF, broad spectrum IV antibiotics
Fournier’s Gangrene
THE END
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