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Presentation on theme: "PELVIC PAIN AND NON-PREGNANT BLEEDING"— Presentation transcript:

Alyssa Morris, R2 May 14, 2009 Thanks to Dr Jen Butler

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

3 Not Covered Pelvic anatomy Menstrual Cycle
Pathophysiology of pelvic pain Pregnant bleeding 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? (ie. nb features on Hx)

5 History PQRST Factors that exacerbate/alleviate Vaginal D/C
Associated Sx GU Sxs Location of pain: lateral is often tube or ovary (also think appendicitis), central often related to utuerus or bladder Quality: crampy or progressive - Radiation: into rectum is often secondary to blood or fluid pooling in the cul-de-sac - Onset: Sudden- suggests acute hemorrhage , cystic rupture, or ovarian torsion; Gradual: inflammation or obstruction; Chronic or recurrent- endometriosis, ovarian cysts, mass

6 Hx Gynecologic LMP Obstetrical Gravida, Para, Complications Sexual
#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 Nothing alleviates nor exacerbates, not positional No associated urinary/GI sxs No vaginal D/C Otherwise healthy No STDs, one partner, last sexual intercourse 3m ago, always used condoms LMP 2 weeks so says no chance she is pregnant… - Do you believe her?

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

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

10 DDX Pelvic Contents Vagina Uterus Fallopian tubes Ovaries Ureter
Bladder Sigmoid colon Rectum - Therefore, DDx is very broad but best to think of it systematically

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

Salpingitis/tubo-ovarian abscess Ovarian Cyst Ovarian Torsion Endometriosis Fibroids Uterine Perforation Round Ligament Pain 1st Trimester Ectopic Threatened abortion Endometritis Corpus Luteal Cyst Ovarian hyperstimulation Ovarian Torsion 2nd/3rd Trimester Placenta Previa Placental abruption ** Rosen’s Box

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

14 DDx- Urinary Tract Pyelonephritis Cystitis Ureteral stone

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

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

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

18 Sens of bimanual for adnexal mass: 15-36% Spec 79-92% PPV 26-69%
Obstet Gynecol 2000;96:593 Compared ability of med students, obs residents, obs staff to accurately detect adnexal mass Sens of bimanual for adnexal mass: 15-36% Spec 79-92% PPV 26-69% Up to 2/3 of surgically identified masses were missed on exam ¾ of pts thought to have mass o/e did not - Pts under ideal conditions: GA therefore not guarding, squirming, no anxiety

19 Case #1 Temp 37.3, HR 75, RR 16, BP 120/80, O2 99% CVS, Resp exam N
Abdo- mild tenderness to RLQ, no rebound/peritoneal signs Speculum exam N Bimanual- tender to right adnexa, No CMT Labs are N and Urine Preg Negative - Remember that urine spec gravity needs to be >1.015 in order to be considered valid

20 Case #1 Cont… Let’s assume it is Sunday night at 8pm
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 U/S shows a 3cm, uniloculated, R sided ovarian cyst What are the complications of ovarian cysts?

22 Ovarian Cysts Rupture Hemorrhage Torsion Infection Resolution
What kind of cysts are worrisome?

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

24 Ovarian Cysts- Mx <6cm Usually observed
Most spontaneously resolve in 1-2m +/- OCP >6cm, growing or worrisome features 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 What would you be concerned about?

26 Ovarian/Adnexal Torsion
Ischemia resulting from twisting of the ovary on it’s vascular pedicle Onset may occur after trauma, intercourse, increased intraabdo pressure or exercise R>L Can occur at any age - Nonspecific clinical presentation and variable presentation so can be hard to dx, so you need to suspect it R>L suggests that sigmoid colon might help prevent torsion

27 94% occur in ovaries with cysts/tumors and the other 6% occur in normal ovaries in adults
- 50% occur in normal ovaries in pts <15

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

29 - How do you diagnose ovarian torsion

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

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

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

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

34 Ectopic pregnancy Appendicitis
- Up to 1/3 of women of childbearing age with appy are misdiagnosed; commonly with PID or UTI

35 Pelvic Inflammatory Disease
A spectrum of infections of the female upper reproductive tract Initiated by ascending infection from the cervix and vagina Includes: Salpingitis Endometritis TOA Pelvic peritonitis Perihepatitis -more often a community acquired infection from sexual contact rather than from medical procedures or pregnancy

36 What organisms are mostly responsible?

37 PID-MOs MO Gonorrhea and Chlamydia
Polymicrobial- anaerobic and aerobic vaginal flora GAS, GBS, E. coli, Klebsiella, Proteus, Gardnerella vaginalis, H. influenzae, Streptococcus pyogenes, mycoplasma, Peptococcus Can also be from TB in endemic areas Most cases of PID start with an STI like chlamydia or gonorrhea, followed by ascension into the upper repro areas % of unTx Chlamydia, gonorrhea infections progress to PID - Mechanism is unclear exactly

38 What are RFs for PID?

39 PID- RFs New or multiple sexual partners Hx of other STDs
IUD up to 1 month after insertion Hx of sexual abuse Younger age of sexual activity Larger zone of cervical ectopy Increased cervical mucosal permeability Risk taking Pregnancy decreases risk of PID b/c cervical os is protected by mucous plug - 75% of cases occur w/I 7d of menses b/c cervical mucus favors transmission of bugs at this time

40 What are some complications of PID?

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

42 PID- Clinical Findings
Lower abdo pain MC presenting complaint 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 Many vague complaints - abdo pain diffuse in lower quadrants Clinical dx of PID is not sensitive, very difficult to make. - can also have silent PID or subclinical PID

43 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 Associated w gonococcal and chlamydial salpingitis In up to 10% pts w PID Minimal stromal hepatic involvement, just the capsule and peritoneal surface - see these patchy purulent and fibrinous exudates that give this “violin string’ adhesions appearance - can get severe RUQ pain and referred shoulder tip pain

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

46 PID-Swabs Gen Probe Kit Black Top Swab Red Top Swab
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 Black Top Swab Use for rectal and oral swabs when you suspect Gonorrhea Red Top Swab Used for regular C+S, BV, trichomonas, yeast, GBS -leaving in cervix allows Mos to adhere

47 PID-Imaging Improves accuracy of PID Dx Transvaginal pelvic u/s
Thickened, fluid filled fallopian tubes, free pelvic fluid 85% sens, 100% spec Laparoscopy is gold standard 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* CMT* Other factors T>38.3 AbN cervical/mucopurulent d/c Presence of WBCs on saline microscopy of vaginal secretions Elevated ESR, CRP This is based on difficulty of dx and potential for damage to the reproductive capacity of women - with no other explanation for these * findings, you should treat as PID and the other factors below support the dx - the more of these criteria that are met, the specificity increases but the sensitivity decreases - U/S can be used and is especially good at identifying TOA

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

50 PID-Tx 2007 CDC Guidelines (Parenteral)
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 Ampicillin-sulbactam 3g IV Q6h + Doxycycline 100mg Po?IV Q12h Fluoroquinolones: increasing resistance of gonoccocus therefore don’t use - PO doxy preferred b/c of pain assoc w IV infusionsand oral bioavailability is same as parenteral - can usually transition to oral after 24 hrs

51 PID-Tx 2007 CDC Guidelines (Oral)
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 Recommend mixed oral/parenteral even if mild-moderate and if choose outpt tx they need very close f/u - decision to add flagyl based on clinical suspicion of anaerobic Mos (abscess, Trichomonas, BV, gynecological instrumentation)

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 Ofloxacin 400mg BID +/- Flagyl 500mg PO BID for 14 days

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

54 PID-Tx Treat the 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 Swab everyone R/O surgically indicated pathology first Treat early and cover appropriate bugs

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

57 DDx- Adolescents Early post-menarche Reproductive years Anovulation
(hypo-pit axis immature) Bleeding d/o Stress (psychogenic, exercise, malnutrition) Infection Reproductive years Anovulation Cancer Polyps Fibroids Adenomyosis Infection Endocrine (thyroid, PCOS, pituitary) Bleeding d/o Medication related (OCP) ** ddx is based on age, reproductive status and intercurrent illness -As a general rule, bleeding that is preceded by premenstrual symptoms is ovulatory and heavy bleeding that occurs irregularly is anovulatory

58 Terminology DUB: excessive, noncyclical endometrial bleeding unrelated to anatomic or systemic dz Menorrhagia: menses >7d, or <21 recurrance, >80ml Metrorrhagia: light bleeding from the uterus at irregular intervals Menometrorrhagia: heavy bleeding from the uterus at irregular intervals Think of DUB as anovulatory bleeding - menorrhagia is typically due to anatomic lesion or systemic dz in ovulatory women but can also be part of anovulation

59 DUB- Causes -Dx of exclusion - Need to work up for other causes first

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

61 Mx Hemodynamic stability R/O pregnancy +/- Iron supplementation
+/- OCP Estrogen and progestin Progestin only GP f/u If severe, unresponsive to tx- gyne consult Estrogen and progestin ns currently bleeding as estrogen promotes hemostasis (use a monophasic) - progestin only is an option if not currently bleeding

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

63 DDX Endometrial ca Atrophy Endometrial or vaginal Polyps Cervical ca
Endometrial hyperplasia HRT Leiomyomata Infection * Must r/o ca first even though 95% of cases are caused by a benign etiology

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

65 Mx Gyne referral for endometrial biopsy
we make sure they are stable but ultimately the pt needs an endometrial biopsy - could think about arranging an u/s as an o/p

66 Case #5 30F presents with c/o of extremely heavy period for 10 days and using 15 pads/day. She usually has very heavy periods Otherwise healthy How would you approach her menorrhagia? Remember that it is more than >80mL and normal is 35-40mL

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

68 Mx Hemodynamically unstable 2 large IVs Foley catheter
IV estrogen (CEE)+ antiemetic Premarin 25mg IV Q4H Gyne consult for emergent D+C Foley with a 30mL balloon and insert into the uterine cavity transcervically and inflate to help tamponade the bleeding - CEE conjugated equine estrogen -

69 Mx Hemodynamically stable Premarin 2.5mg PO QID for 21 d
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 Endometrial ablation

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

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


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