3Pelvic 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?
4Ectopic pregnancyAbdominal pain or vaginal bleeding in first trimester pregnancy2% incidenceLeading cause of first trimester maternal deathRisk factors – prior PID, failed IUD or tubal ligation, history of infertility, prior ectopic
5Signs and symptoms Duration of the pregnancy Extent of intraperitoneal hemorrhageSlow leakage (65% non ruptured)Frank ruptureSite of implantationAmpulla – most commonIsthmus – 10% - rupture commonCornual – massive hemorrhageExplain how variable presentation is because of this
7Diagnosis Physical exam – not always helpful High index of suspicion BhCG – all women with vag bleed or abdominal pain in reproductive yrsPelvic ultrasound – Suggestive of ectopic pregnancyNo IUP, BhCG >1200 (DZ)Complex adnexal massModerate-large amount cul-de-sac fluid
8Treatment Rhogam if Rh negative and bleeding Gynecology consult for Methotrexate or surgical removalABCs
9Next 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?
10PID Most common cause of pelvic pain Most common serious infection in reproductive aged womenCervicitis that ascends to become a polymicrobial endometritis, salpingitis, oophoritisRisk factors – prior PID, multiple partners, IUD use, instrumentation of uterine cavity
11Symptoms Bilateral lower quadrant pain Purulent vaginal discharge >50%Abnormal vaginal bleedingSymptoms begin shortly after menses
12PE CMT Bilateral adnexal tenderness Purulent cervical discharge Diagnosis – clinical to begin treatmentGram neg intracellular diplococciC & S, DNA probe (PCR, run late am)
13Indications for admission Suspected TOA or Fitz-Hugh-Curtis syndromePatient unable to tolerate poPeritonitis, septic appearingPrepubertal childrenIndwelling IUDPregnancy+ /- nulliparous women
14Inpatient 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 12orClindamycin 900 mg IV q 8 with Gentamycin alone
15Outpatient treatment Ceftriaxone 250 mg IM PLUS Cefoxitin 2 gm IM with Probenecid 1 gm po PLUSDoxycycline 100 mg BID x 14 d+/-Metronidazole 500 mg BID x 14 d
16CervicitisCervical infection – discharge without abdominal pain or constitutional symptomsGonorrhea or ChlamydiaTreatment – outpatientCeftriaxone 125 mg IM with Doxycycline 100 mg BID x 7 daysAlternatives for GC: Cefixime 400 mg PO x 1Alternative for Chlamydia: Azithromycin 1 g POAlternative for both: Azithromycin 2 g PO
17Flank Pain Case26 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
18Ovarian pain Ruptured cyst Ovarian torsion Sudden, severe, sharp unilateral painself resolving unless hemorrhagic or dermoidTreatment – observe in EDOvarian torsionIntermittent colicky pain or acute abdomenAdnexal fullness/tendernessBhCG, doppler ultrasound is diagnosticTreatment – admit via OR
19Kidney stones Common - @ 10% incidence Flank pain, radiating to groin or abdomenWrithing in pain, nausea, vomitingCVA tendernessGU exam (radiating pain)Abdomen soft, nontender, BS - ileus
20Kidney stones work up Urinalysis CT scan (non contrast) abd/pelvis Hematuria (unless complete obstruction)Infection = surgical emergencyCT scan (non contrast) abd/pelvisUltrasoundIVP90% radiopaque – visible on KUB75% Calcium 15% struvite (Mg)Others: uric acid, cystine, drug induced
21Helical CT scanperinephric stranding of fat surrounding the left kidney and proximal left ureterLeft kidney is enlarged, with dilatation of the intrarenal collecting system
22Treatment IV fluids Strain urine Analgesics – ketorolac, narcotics Antiemetics if vomitingTamsulosin – Flomax – alpha blocker< 5mm – usually pass spontaneously> 8 mm – often require surgery
23Admission (Observation) Intractable painIntractable vomitingStone > 6mmSolitary kidney or congenital abnormalities (horseshoe kidney)Infected stone is a true surgical emergency (perinephric abscess, sepsis and death)
24Testicular pain18 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?
26Testicular torsion Sudden severe testicular or lower abd pain Often preceded by trauma/physical activityMost common in pre and pubescent males, but can occur at any agePE – diffusely tender, swollen testicleDiagnosis – no flow on testicular ultrasoundAdmit via the OR, stat urologic consult
27Epididymitis Gradual pain Posterior epididymal tenderness and edema (later swollen scrotum obscures)Usually occurs in sexually active malesU/A – pyuriaTesticular ultrasound – to rule out torsionOutpatient Abs to cover GC and Chlamydia, analgesics, scrotal support
28Fourniere’s gangrene Elderly or immunocompromised men Sudden onset of edematous, necrotic scrotumPatients appear toxicPlain films – scrotal gangrene and intrascrotal gasUrologic consult for surgical debridementIVF, broad spectrum IV antibiotics