1. William Beaumont Hospital Department of Emergency Medicine
Ob Gyn and Male GU
William Beaumont Hospital
Department of Emergency Medicine

2. Causes of pelvic pain Ectopic pregnancy PID Ovarian torsion
Ruptured ovarian cyst
Fibroids
Endometriosis

3. Pelvic pain case
26 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?

4. Ectopic pregnancy
Abdominal pain or vaginal bleeding in first trimester pregnancy
2% incidence
Leading cause of first trimester maternal death
Risk factors – prior PID, failed IUD or tubal ligation, history of infertility, prior ectopic

5. Signs and symptoms Duration of the pregnancy
Extent of intraperitoneal hemorrhage
Slow leakage (65% non ruptured)
Frank rupture
Site of implantation
Ampulla – most common
Isthmus – 10% - rupture common
Cornual – massive hemorrhage
Explain how variable presentation is because of this

6. Signs and symptoms Abdominal pain 95% Abdominal tenderness 70%
Vaginal bleeding – slight spotting
Tenesmus
3 S’s
Syncope, shoulder pain, shock
Suggests rupture

7. Diagnosis Physical exam – not always helpful High index of suspicion
BhCG – all women with vag bleed or abdominal pain in reproductive yrs
Pelvic ultrasound – Suggestive of ectopic pregnancy
No IUP, BhCG >1200 (DZ)
Complex adnexal mass
Moderate-large amount cul-de-sac fluid

8. Treatment Rhogam if Rh negative and bleeding
Gynecology consult for Methotrexate or surgical removal
ABCs

9. 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?

10. PID Most common cause of pelvic pain
Most common serious infection in reproductive aged women
Cervicitis that ascends to become a polymicrobial endometritis, salpingitis, oophoritis
Risk factors – prior PID, multiple partners, IUD use, instrumentation of uterine cavity

11. Symptoms Bilateral lower quadrant pain
Purulent vaginal discharge >50%
Abnormal vaginal bleeding
Symptoms begin shortly after menses

12. PE CMT Bilateral adnexal tenderness Purulent cervical discharge
Diagnosis – clinical to begin treatment
Gram neg intracellular diplococci
C & S, DNA probe (PCR, run late am)

13. Indications for admission
Suspected TOA or Fitz-Hugh-Curtis syndrome
Patient unable to tolerate po
Peritonitis, septic appearing
Prepubertal children
Indwelling IUD
Pregnancy
+ /- nulliparous women

14. Inpatient treatment Cefoxitin 2 g IV q 6 * Cefotetan 2 g IV q 12 *
Unasyn 3 g IV q 6*
* WITH Doxycycline 100 mg PO/IV q 12 or
Clindamycin 900 mg IV q 8 with Gentamycin alone

15. Outpatient treatment Ceftriaxone 250 mg IM PLUS
Cefoxitin 2 gm IM with Probenecid 1 gm po PLUS
Doxycycline 100 mg BID x 14 d
+/-Metronidazole 500 mg BID x 14 d

16. Cervicitis
Cervical infection – discharge without abdominal pain or constitutional symptoms
Gonorrhea or Chlamydia
Treatment – outpatient
Ceftriaxone 125 mg IM with Doxycycline 100 mg BID x 7 days
Alternatives for GC: Cefixime 400 mg PO x 1
Alternative for Chlamydia: Azithromycin 1 g PO
Alternative for both: Azithromycin 2 g PO

17. 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?
Pelvic exam missed for torsion

18. Ovarian pain Ruptured cyst Ovarian torsion
Sudden, severe, sharp unilateral pain
self resolving unless hemorrhagic or dermoid
Treatment – observe in ED
Ovarian torsion
Intermittent colicky pain or acute abdomen
Adnexal fullness/tenderness
BhCG, doppler ultrasound is diagnostic
Treatment – admit via OR

19. Kidney stones Common - @ 10% incidence
Flank pain, radiating to groin or abdomen
Writhing in pain, nausea, vomiting
CVA tenderness
GU exam (radiating pain)
Abdomen soft, nontender, BS - ileus

20. Kidney stones work up Urinalysis CT scan (non contrast) abd/pelvis
Hematuria (unless complete obstruction)
Infection = surgical emergency
CT scan (non contrast) abd/pelvis
Ultrasound
IVP
90% radiopaque – visible on KUB
75% Calcium 15% struvite (Mg)
Others: uric acid, cystine, drug induced

21. Helical CT scan
perinephric stranding of fat surrounding the left kidney and proximal left ureter
Left kidney is enlarged, with dilatation of the intrarenal collecting system

22. Treatment IV fluids Strain urine Analgesics – ketorolac, narcotics
Antiemetics if vomiting
Tamsulosin – Flomax – alpha blocker
< 5mm – usually pass spontaneously
> 8 mm – often require surgery

23. Admission (Observation)
Intractable pain
Intractable vomiting
Stone > 6mm
Solitary kidney or congenital abnormalities (horseshoe kidney)
Infected stone is a true surgical emergency (perinephric abscess, sepsis and death)

24. Testicular pain
18 y/o male c/o of pain in his right testicle that was sudden onset 2 hours ago with nausea and vomiting. It began while he was running. Exam shows a diffusely tender swollen right testicle, with loss of cremasteric reflex.
What are you thinking?
What tests do you want to order?

25. Male GU
Testicular torsion
Epididymitis
Fourniere’s gangrene

26. Testicular torsion Sudden severe testicular or lower abd pain
Often preceded by trauma/physical activity
Most common in pre and pubescent males, but can occur at any age
PE – diffusely tender, swollen testicle
Diagnosis – no flow on testicular ultrasound
Admit via the OR, stat urologic consult

27. Epididymitis Gradual pain
Posterior epididymal tenderness and edema (later swollen scrotum obscures)
Usually occurs in sexually active males
U/A – pyuria
Testicular ultrasound – to rule out torsion
Outpatient Abs to cover GC and Chlamydia, analgesics, scrotal support

28. Fourniere’s gangrene Elderly or immunocompromised men
Sudden onset of edematous, necrotic scrotum
Patients appear toxic
Plain films – scrotal gangrene and intrascrotal gas
Urologic consult for surgical debridement
IVF, broad spectrum IV antibiotics

30. Fournier’s Gangrene

31. THE END
ANY QUESTIONS