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PELVIC PAIN AND NON-PREGNANT BLEEDING Alyssa Morris, R2 May 14, 2009 Thanks to Dr Jen Butler.

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Presentation on theme: "PELVIC PAIN AND NON-PREGNANT BLEEDING Alyssa Morris, R2 May 14, 2009 Thanks to Dr Jen Butler."— Presentation transcript:

1 PELVIC PAIN AND NON-PREGNANT BLEEDING Alyssa Morris, R2 May 14, 2009 Thanks to Dr Jen Butler

2 Objectives Causes of pelvic pain in women Causes of pelvic pain in women Mx of pelvic pain in the ED Mx of pelvic pain in the ED Causes of non-pregnant bleeding in adolescents Causes of non-pregnant bleeding in adolescents Causes of non-pregnancy bleeding in post- menopausal women Causes of non-pregnancy bleeding in post- menopausal women Dx and Mx of DUB In the ED Dx and Mx of DUB In the ED

3 Not Covered Pelvic anatomy Pelvic anatomy Menstrual Cycle Menstrual Cycle Pathophysiology of pelvic pain Pathophysiology of pelvic pain Pregnant bleeding Pregnant bleeding Sexual assault Sexual assault

4 CASE #1 18F with CC of lower pelvic pain which started yesterday and has gradually gotten worse What else do you want to know? What else do you want to know? (ie. nb features on Hx)

5 History PQRST PQRST Factors that exacerbate/alleviate Factors that exacerbate/alleviate Vaginal D/C Vaginal D/C Associated Sx Associated Sx GU Sxs GU Sxs

6 Hx Gynecologic Gynecologic LMP LMP Obstetrical Obstetrical Gravida, Para, Complications Gravida, Para, Complications Sexual Sexual #partners, current partner, previous STIs, contraception #partners, current partner, previous STIs, contraception

7 Case #1 Cont… States she has had 1 day of sharp, crampy RLQ pain, not radiating that is 5/10 States she has had 1 day of sharp, crampy RLQ pain, not radiating that is 5/10 Nothing alleviates nor exacerbates, not positional Nothing alleviates nor exacerbates, not positional No associated urinary/GI sxs No associated urinary/GI sxs No vaginal D/C No vaginal D/C Otherwise healthy Otherwise healthy No STDs, one partner, last sexual intercourse 3m ago, always used condoms No STDs, one partner, last sexual intercourse 3m ago, always used condoms LMP 2 weeks so says no chance she is pregnant… LMP 2 weeks so says no chance she is pregnant…

8 Annal Emerg Med 1989;18:48-50 Annal Emerg Med 1989;18: % of pts who stated their LMP was N and denied any chance of being pregnant had a positive serum beta 7% of pts who stated their LMP was N and denied any chance of being pregnant had a positive serum beta

9 Case #1 Cont… What is your DDX of acute pelvic pain? What is your DDX of acute pelvic pain?

10 DDX Pelvic Contents Vagina Vagina Uterus Uterus Fallopian tubes Fallopian tubes Ovaries Ovaries Ureter Ureter Bladder Bladder Sigmoid colon Sigmoid colon Rectum Rectum

11 DDX Think in terms of systems! 1 Reproductive tract Nonpregnant Nonpregnant Pregnant Pregnant 2 Intestinal tract 3 Urinary tract

12 DDX- Reproductive NON-PREGNANT Salpingitis/tubo-ovarian abscess Salpingitis/tubo-ovarian abscess Ovarian Cyst Ovarian Cyst Ovarian Torsion Ovarian Torsion Endometriosis Endometriosis Fibroids Fibroids Uterine Perforation Uterine Perforation Round Ligament Pain Round Ligament Pain PREGNANT 1 st Trimester 1 st Trimester Ectopic Ectopic Threatened abortion Threatened abortion Endometritis Endometritis Corpus Luteal Cyst Corpus Luteal Cyst Ovarian hyperstimulation Ovarian hyperstimulation Ovarian Torsion Ovarian Torsion 2 nd /3 rd Trimester 2 nd /3 rd Trimester Placenta Previa Placenta Previa Placental abruption Placental abruption

13 DDX- Intestinal Tract Appendicitis Appendicitis Diverticulitis Diverticulitis IBD IBD Gastroenteritis Gastroenteritis Ischemic bowel dz Ischemic bowel dz Bowel obstruction Bowel obstruction Incarcerated hernia Incarcerated hernia Perforated Viscus Perforated Viscus

14 DDx- Urinary Tract Pyelonephritis Pyelonephritis Cystitis Cystitis Ureteral stone Ureteral stone

15 Case #1 Cont… What would you like to do on physical exam?

16 Exam Vitals Vitals Abdo exam Abdo exam Speculum exam Speculum exam Bimanual exam Bimanual exam How good is the bimanual? How good is the bimanual?

17 CJEM 2003;5(2) CJEM 2003;5(2) Findings on pelvic exam are subjective Findings on pelvic exam are subjective Not reliably reproducible b/t observers Not reliably reproducible b/t observers Literature suggests unwise to base decisions on a clinical exam of the female pelvis Literature suggests unwise to base decisions on a clinical exam of the female pelvis

18 Obstet Gynecol 2000;96:593 Obstet Gynecol 2000;96:593 Compared ability of med students, obs residents, obs staff to accurately detect adnexal mass Compared ability of med students, obs residents, obs staff to accurately detect adnexal mass Sens of bimanual for adnexal mass: 15-36% Sens of bimanual for adnexal mass: 15-36% Spec 79-92% Spec 79-92% PPV 26-69% PPV 26-69% Up to 2/3 of surgically identified masses were missed on exam Up to 2/3 of surgically identified masses were missed on exam ¾ of pts thought to have mass o/e did not ¾ of pts thought to have mass o/e did not

19 Case #1 Temp 37.3, HR 75, RR 16, BP 120/80, O2 99% Temp 37.3, HR 75, RR 16, BP 120/80, O2 99% CVS, Resp exam N CVS, Resp exam N Abdo- mild tenderness to RLQ, no rebound/peritoneal signs Abdo- mild tenderness to RLQ, no rebound/peritoneal signs Speculum exam N Speculum exam N Bimanual- tender to right adnexa, No CMT Bimanual- tender to right adnexa, No CMT Labs are N and Urine Preg Negative Labs are N and Urine Preg Negative

20 Case #1 Cont… Let’s assume it is Sunday night at 8pm Let’s assume it is Sunday night at 8pm How are you going to manage this patient? How are you going to manage this patient?

21 Case #1 Cont… You ask the patient to come back in the morning for an U/S You ask the patient to come back in the morning for an U/S U/S shows a 3cm, uniloculated, R sided ovarian cyst U/S shows a 3cm, uniloculated, R sided ovarian cyst What are the complications of ovarian cysts? What are the complications of ovarian cysts?

22 Ovarian Cysts 1. Rupture 2. Hemorrhage 3. Torsion 4. Infection 5. Resolution What kind of cysts are worrisome?

23 Ovarian Cysts BENIGN FEATURES BENIGN FEATURES <8cm <8cm Uniloculated Uniloculated Unilateral Unilateral Thin walls Thin walls WORRISOME FEATURES WORRISOME FEATURES >8cm >8cm Loculated Loculated Solid Solid Calcification Calcification Thick walls and septations Thick walls and septations Ovarian endometriomas, dermoid cysts are CA until proven otherwis e

24 Ovarian Cysts- Mx <6cm <6cm Usually observed Usually observed Most spontaneously resolve in 1-2m Most spontaneously resolve in 1-2m +/- OCP +/- OCP >6cm, growing or worrisome features >6cm, growing or worrisome features Gyne o/p f/u Gyne o/p f/u

25 Case #1 Cont… Your patient is back... She was playing soccer, got kicked in the abdomen. 10 mins later had sudden severe right sided lower pelvic pain, 10/10 Your patient is back... She was playing soccer, got kicked in the abdomen. 10 mins later had sudden severe right sided lower pelvic pain, 10/10 What would you be concerned about? What would you be concerned about?

26 Ovarian/Adnexal Torsion Ischemia resulting from twisting of the ovary on it’s vascular pedicle Ischemia resulting from twisting of the ovary on it’s vascular pedicle Onset may occur after trauma, intercourse, increased intraabdo pressure or exercise Onset may occur after trauma, intercourse, increased intraabdo pressure or exercise R>L R>L Can occur at any age Can occur at any age

27

28 Torsion- Clinical Presentation Ann Emerg Med 2001;38(2):156-9 Ann Emerg Med 2001;38(2):156-9 The most common presentations in adolescents and adults: The most common presentations in adolescents and adults: N/V 70% N/V 70% Stabbing pain 70% Stabbing pain 70% Sudden and sharp pain in lower abdo 59% Sudden and sharp pain in lower abdo 59% Pain radiating to back, flank, groin 51% Pain radiating to back, flank, groin 51% Peritoneal signs 3% Peritoneal signs 3%

29

30 Ovarian Torsion U/S with doppler flow evaluation is used for diagnosis U/S with doppler flow evaluation is used for diagnosis Decreased flow suggestive but not definitive Decreased flow suggestive but not definitive Surgical evaluation is gold standard Surgical evaluation is gold standard Nb to consider it Nb to consider it Early gyne consultation!!! Early gyne consultation!!! Surgical intervention required for adnexal salvage Surgical intervention required for adnexal salvage

31 CASE#2 30F comes in with fever, malaise, n/v. Chief complaint is lower abdo pain. 30F comes in with fever, malaise, n/v. Chief complaint is lower abdo pain. Hx: Multiple sexual partners, previously treated for Chlamydia Hx: Multiple sexual partners, previously treated for Chlamydia O/E: T-38.6, thick d/c from cervix, +CMT O/E: T-38.6, thick d/c from cervix, +CMT What is at the top of your DDx? What is at the top of your DDx?

32 DDx PID PID Cervicitis Cervicitis Ectopic pregnancy Ectopic pregnancy Endometriosis Endometriosis Ovarian cyst Ovarian cyst Ovarian torsion Ovarian torsion Septic abortion Septic abortion Appendicitis Appendicitis Diverticulitis Diverticulitis Pyelonephritis Pyelonephritis Renal colic Renal colic cholecystitis cholecystitis

33 What do you need to rule out before diagnosing PID? What do you need to rule out before diagnosing PID?

34 Ectopic pregnancy Appendicitis

35 Pelvic Inflammatory Disease A spectrum of infections of the female upper reproductive tract A spectrum of infections of the female upper reproductive tract Initiated by ascending infection from the cervix and vagina Initiated by ascending infection from the cervix and vagina Includes: Includes: Salpingitis Salpingitis Endometritis Endometritis TOA TOA Pelvic peritonitis Pelvic peritonitis Perihepatitis Perihepatitis

36 What organisms are mostly responsible? What organisms are mostly responsible?

37 PID-MOs MO Gonorrhea and Chlamydia Gonorrhea and Chlamydia Polymicrobial- anaerobic and aerobic vaginal flora Polymicrobial- anaerobic and aerobic vaginal flora GAS, GBS, E. coli, Klebsiella, Proteus, Gardnerella vaginalis, H. influenzae, Streptococcus pyogenes, mycoplasma, Peptococcus GAS, GBS, E. coli, Klebsiella, Proteus, Gardnerella vaginalis, H. influenzae, Streptococcus pyogenes, mycoplasma, Peptococcus Can also be from TB in endemic areas Can also be from TB in endemic areas

38 What are RFs for PID?

39 PID- RFs New or multiple sexual partners New or multiple sexual partners Hx of other STDs Hx of other STDs IUD up to 1 month after insertion IUD up to 1 month after insertion Hx of sexual abuse Hx of sexual abuse Younger age of sexual activity Younger age of sexual activity Larger zone of cervical ectopy Larger zone of cervical ectopy Increased cervical mucosal permeability Increased cervical mucosal permeability Risk taking Risk taking

40 What are some complications of PID? What are some complications of PID?

41 PID- Complications TOA TOA Reported in 33% Reported in 33% Ectopic pregnancy Ectopic pregnancy Accounts for 50% of ectopic pregnancies Accounts for 50% of ectopic pregnancies Tubal factor infertility Tubal factor infertility Increased by 15-50% Increased by 15-50% Chronic pelvic pain/dyspareunia Chronic pelvic pain/dyspareunia

42 PID- Clinical Findings Lower abdo pain MC presenting complaint Lower abdo pain MC presenting complaint AbN vaginal discharge, vaginal bleeding, poistcoital bleeding, dyspareunia, irritative voiding sxs, fever, malaise, n/v AbN vaginal discharge, vaginal bleeding, poistcoital bleeding, dyspareunia, irritative voiding sxs, fever, malaise, n/v No single Hx, PE, lab finding is both sensitive and specific for dx of acute PID No single Hx, PE, lab finding is both sensitive and specific for dx of acute PID

43 What if your pt complained of RUQ pain? What if your pt complained of RUQ pain?

44 FitzHugh-Curtis Syndrome Infection may extend by direct or lymphatic spread beyond the pelvis to involve the hepatic capsule or diaphragm Infection may extend by direct or lymphatic spread beyond the pelvis to involve the hepatic capsule or diaphragm Associated w gonococcal and chlamydial salpingitis Associated w gonococcal and chlamydial salpingitis In up to 10% pts w PID In up to 10% pts w PID

45 PID-Dx Testing Pregnancy test always Pregnancy test always U/A U/A CBC CBC <50% pts with PID have elevated WBC! <50% pts with PID have elevated WBC! ?ESR/CRP ?ESR/CRP Gram stain and C+S Gram stain and C+S

46 PID-Swabs ① Gen Probe Kit Large cotton swab is to clean external cervix and the endo cervix, discard it Large cotton swab is to clean external cervix and the endo cervix, discard it Insert thin swab into cervix 1-2cm and leave there for secs and sent as cervical swab for GC/Chlamydia Insert thin swab into cervix 1-2cm and leave there for secs and sent as cervical swab for GC/Chlamydia ② Black Top Swab Use for rectal and oral swabs when you suspect Gonorrhea Use for rectal and oral swabs when you suspect Gonorrhea ③ Red Top Swab Used for regular C+S, BV, trichomonas, yeast, GBS Used for regular C+S, BV, trichomonas, yeast, GBS

47 PID-Imaging Improves accuracy of PID Dx Improves accuracy of PID Dx Transvaginal pelvic u/s Transvaginal pelvic u/s Thickened, fluid filled fallopian tubes, free pelvic fluid Thickened, fluid filled fallopian tubes, free pelvic fluid 85% sens, 100% spec 85% sens, 100% spec Laparoscopy is gold standard Laparoscopy is gold standard Hyperemia of the tubal surface, wall edema, exudates Hyperemia of the tubal surface, wall edema, exudates

48 PID- CDC Recommendations Empiric tx of PID should be initiated in sexually active young women and other women at risk for STDs if: Uterine/adnexal tenderness* Uterine/adnexal tenderness* CMT* CMT* Other factors Other factors T>38.3 T>38.3 AbN cervical/mucopurulent d/c AbN cervical/mucopurulent d/c Presence of WBCs on saline microscopy of vaginal secretions Presence of WBCs on saline microscopy of vaginal secretions Elevated ESR, CRP Elevated ESR, CRP

49 PID-Tx Many options Many options All should cover N. gonorrhea and C. trachomatis, and anaerobic bugs All should cover N. gonorrhea and C. trachomatis, and anaerobic bugs Quick antibiotics linked to prevention of long term sequelae Quick antibiotics linked to prevention of long term sequelae

50 PID-Tx 2007 CDC Guidelines (Parenteral) Cefoxitin 2g IV Q6h or Cefotetan 2g IV Q12h + Doxycycline 100mg PO/IV Q12h Cefoxitin 2g IV Q6h or Cefotetan 2g IV Q12h + Doxycycline 100mg PO/IV Q12h Clindamycin 900mg IV Q8h + Gentamicin 2mg/kg loading then 1.5mg/kg Q8h Clindamycin 900mg IV Q8h + Gentamicin 2mg/kg loading then 1.5mg/kg Q8h Ampicillin-sulbactam 3g IV Q6h + Doxycycline 100mg Po?IV Q12h Ampicillin-sulbactam 3g IV Q6h + Doxycycline 100mg Po?IV Q12h

51 PID-Tx 2007 CDC Guidelines (Oral) Ceftriaxone 250mg IM single dose + doxycycline 100mg PO BID for 14d +/- Flagyl 500mg PO BID for 14d Ceftriaxone 250mg IM single dose + doxycycline 100mg PO BID for 14d +/- Flagyl 500mg PO BID for 14d Cefoxitin 2g IM single dose with probenacid 1g PO + + doxycycline 100mg PO BID for 14d +/- Flagyl 500mg PO BID for 14d Cefoxitin 2g IM single dose with probenacid 1g PO + + doxycycline 100mg PO BID for 14d +/- Flagyl 500mg PO BID for 14d

52 PID-Tx 2008 Alberta Treatment Guidelines Ceftriaxone 250mg IM single dose + Doxycycline 100mg PO BID for 14 days +/- Flagyl 500mg PO BID for 14 days Ceftriaxone 250mg IM single dose + Doxycycline 100mg PO BID for 14 days +/- Flagyl 500mg PO BID for 14 days Ofloxacin 400mg BID +/- Flagyl 500mg PO BID for 14 days Ofloxacin 400mg BID +/- Flagyl 500mg PO BID for 14 days

53 PID-Tx Criteria for hospitalization Surgical emergencies cannot be excluded Surgical emergencies cannot be excluded Pregnant Pregnant Unable to tolerate o/p oral regimen Unable to tolerate o/p oral regimen TOA TOA

54 PID-Tx Treat the partner! Treat the partner! Avoid sexual contact until full course of tx for each partner Avoid sexual contact until full course of tx for each partner

55 Summary PID Has a varied presentation, suspect in all sexually active women Has a varied presentation, suspect in all sexually active women Swab everyone Swab everyone R/O surgically indicated pathology first R/O surgically indicated pathology first Treat early and cover appropriate bugs Treat early and cover appropriate bugs

56 CASE #3 16F presents with c/o 9 days of heavy period 16F presents with c/o 9 days of heavy period Otherwise healthy Otherwise healthy Urine and serum beta are negative Urine and serum beta are negative What is your differential dx of non-pregnant bleeding in adolescents? What is your differential dx of non-pregnant bleeding in adolescents?

57 DDx- Adolescents Early post-menarche Early post-menarche Anovulation Anovulation (hypo-pit axis immature) (hypo-pit axis immature) Bleeding d/o Bleeding d/o Stress (psychogenic, exercise, malnutrition) Stress (psychogenic, exercise, malnutrition) Infection Infection Reproductive years Reproductive years Anovulation Anovulation Cancer Cancer Polyps Polyps Fibroids Fibroids Adenomyosis Adenomyosis Infection Infection Endocrine (thyroid, PCOS, pituitary) Endocrine (thyroid, PCOS, pituitary) Bleeding d/o Bleeding d/o Medication related (OCP) Medication related (OCP)

58 Terminology DUB: excessive, noncyclical endometrial bleeding unrelated to anatomic or systemic dz DUB: excessive, noncyclical endometrial bleeding unrelated to anatomic or systemic dz Menorrhagia: menses >7d, or 80ml Menorrhagia: menses >7d, or 80ml Metrorrhagia: light bleeding from the uterus at irregular intervals Metrorrhagia: light bleeding from the uterus at irregular intervals Menometrorrhagia: heavy bleeding from the uterus at irregular intervals Menometrorrhagia: heavy bleeding from the uterus at irregular intervals

59 DUB- Causes

60 Dx Important in ED to rule out Pregnancy!!! Pregnancy!!! Trauma Trauma Bleeding d/o Bleeding d/o Infection Infection Foreign body Foreign body *Other tests and work up can be done as o/p

61 Mx Hemodynamic stability Hemodynamic stability R/O pregnancy R/O pregnancy +/- Iron supplementation +/- Iron supplementation +/- OCP +/- OCP Estrogen and progestin Estrogen and progestin Progestin only Progestin only GP f/u GP f/u If severe, unresponsive to tx- gyne consult If severe, unresponsive to tx- gyne consult

62 Case #4 60F presents with uterine bleeding, last period was 8 years ago, otherwise healthy 60F presents with uterine bleeding, last period was 8 years ago, otherwise healthy How does your differential change in the post-menopausal woman? How does your differential change in the post-menopausal woman?

63 DDX Endometrial ca Endometrial ca Atrophy Atrophy Endometrial or vaginal Endometrial or vaginal Polyps Polyps Cervical ca Cervical ca Endometrial hyperplasia Endometrial hyperplasia HRT HRT Leiomyomata Leiomyomata Infection Infection

64 O/E: Vitals N, maybe some vaginal atrophy but otherwise normal exam O/E: Vitals N, maybe some vaginal atrophy but otherwise normal exam How would you manage this patient? How would you manage this patient?

65 Mx Gyne referral for endometrial biopsy Gyne referral for endometrial biopsy

66 Case #5 30F presents with c/o of extremely heavy period for 10 days and using 15 pads/day. 30F presents with c/o of extremely heavy period for 10 days and using 15 pads/day. She usually has very heavy periods She usually has very heavy periods Otherwise healthy Otherwise healthy How would you approach her menorrhagia? How would you approach her menorrhagia?

67 Dx Hx! How many pads do you use a day? How many pads do you use a day? How often are you changing it? How often are you changing it? Are you passing clots? Are you passing clots? How many days does your period last? How many days does your period last?

68 Mx Hemodynamically unstable 2 large IVs 2 large IVs Foley catheter Foley catheter IV estrogen (CEE)+ antiemetic IV estrogen (CEE)+ antiemetic Premarin 25mg IV Q4H Premarin 25mg IV Q4H Gyne consult for emergent D+C Gyne consult for emergent D+C

69 Mx Hemodynamically stable Premarin 2.5mg PO QID for 21 d Premarin 2.5mg PO QID for 21 d High dose OCP (35 mcg estradiol) PO BID- QID for 7days then stopped for 4-5 High dose OCP (35 mcg estradiol) PO BID- QID for 7days then stopped for 4-5 Medroxyprogesterone acetate (depo- provera) 10-20mg BID for 5-10 days Medroxyprogesterone acetate (depo- provera) 10-20mg BID for 5-10 days Endometrial ablation Endometrial ablation

70 Mx Chronic Menorrhagia NSAIDS NSAIDS Ibuprofen 400mg PO TID Ibuprofen 400mg PO TID Mirena IUD Mirena IUD OCP OCP GnRH agonists (Lupron) GnRH agonists (Lupron) Gyne follow up Gyne follow up

71 Summary- General Approach How old is the patient? How old is the patient? Is the patient pregnant? Is the patient pregnant? When does the bleeding occur in the cycle? When does the bleeding occur in the cycle? Stable vs unstable Stable vs unstable GP vs Gyne consult in house vs as o/p follow up GP vs Gyne consult in house vs as o/p follow up


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