Presentation on theme: "PELVIC PAIN AND NON-PREGNANT BLEEDING"— Presentation transcript:
1PELVIC PAIN AND NON-PREGNANT BLEEDING Alyssa Morris, R2May 14, 2009Thanks to Dr Jen Butler
2Objectives Causes of pelvic pain in women Mx of pelvic pain in the ED Causes of non-pregnant bleeding in adolescentsCauses of non-pregnancy bleeding in post- menopausal womenDx and Mx of DUB In the ED
4CASE #118F with CC of lower pelvic pain which started yesterday and has gradually gotten worseWhat else do you want to know?(ie. nb features on Hx)
5History PQRST Factors that exacerbate/alleviate Vaginal D/C Associated SxGU SxsLocation of pain: lateral is often tube or ovary (also think appendicitis), central often related to utuerus or bladderQuality: 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
6Hx Gynecologic LMP Obstetrical Gravida, Para, Complications Sexual #partners, current partner, previous STIs, contraception
7Case #1 Cont…States she has had 1 day of sharp, crampy RLQ pain, not radiating that is 5/10Nothing alleviates nor exacerbates, not positionalNo associated urinary/GI sxsNo vaginal D/COtherwise healthyNo STDs, one partner, last sexual intercourse 3m ago, always used condomsLMP 2 weeks so says no chance she is pregnant…- Do you believe her?
8Annal Emerg Med 1989;18:48-507% 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!
9Case #1 Cont…What is your DDX of acute pelvic pain?
10DDX Pelvic Contents Vagina Uterus Fallopian tubes Ovaries Ureter BladderSigmoid colonRectum- Therefore, DDx is very broad but best to think of it systematically
11DDX Think in terms of systems! Reproductive tract Nonpregnant Pregnant Intestinal tractUrinary tract
14DDx- Urinary TractPyelonephritisCystitisUreteral stone
15Case #1 Cont…What would you like to do on physical exam?
16Exam Vitals Abdo exam Speculum exam Bimanual exam How good is the bimanual?
17Findings on pelvic exam are subjective CJEM 2003;5(2)Findings on pelvic exam are subjectiveNot reliably reproducible b/t observersLiterature suggests unwise to base decisions on a clinical exam of the female pelvis- Back to the case….
18Sens of bimanual for adnexal mass: 15-36% Spec 79-92% PPV 26-69% Obstet Gynecol 2000;96:593Compared ability of med students, obs residents, obs staff to accurately detect adnexal massSens of bimanual for adnexal mass: 15-36%Spec 79-92%PPV 26-69%Up to 2/3 of surgically identified masses were missed on exam¾ of pts thought to have mass o/e did not- Pts under ideal conditions: GA therefore not guarding, squirming, no anxiety
19Case #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 signsSpeculum exam NBimanual- tender to right adnexa, No CMTLabs are N and Urine Preg Negative- Remember that urine spec gravity needs to be >1.015 in order to be considered valid
20Case #1 Cont… Let’s assume it is Sunday night at 8pm How are you going to manage this patient?
21Case #1 Cont…You ask the patient to come back in the morning for an U/SU/S shows a 3cm, uniloculated, R sided ovarian cystWhat are the complications of ovarian cysts?
22Ovarian Cysts Rupture Hemorrhage Torsion Infection Resolution What kind of cysts are worrisome?
23Ovarian Cysts BENIGN FEATURES <8cm Uniloculated Unilateral Thin wallsWORRISOME FEATURES>8cmLoculatedSolidCalcificationThick walls and septationsOvarian endometriomas, dermoid cysts are CA until proven otherwise
24Ovarian Cysts- Mx <6cm Usually observed Most spontaneously resolve in 1-2m+/- OCP>6cm, growing or worrisome featuresGyne o/p f/u
25Case #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, 10/10What would you be concerned about?
26Ovarian/Adnexal Torsion Ischemia resulting from twisting of the ovary on it’s vascular pedicleOnset may occur after trauma, intercourse, increased intraabdo pressure or exerciseR>LCan occur at any age- Nonspecific clinical presentation and variable presentation so can be hard to dx, so you need to suspect itR>L suggests that sigmoid colon might help prevent torsion
2794% occur in ovaries with cysts/tumors and the other 6% occur in normal ovaries in adults - 50% occur in normal ovaries in pts <15
28Torsion- Clinical Presentation Ann Emerg Med 2001;38(2):156-9The 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%
30Ovarian Torsion U/S with doppler flow evaluation is used for diagnosis Decreased flow suggestive but not definitiveSurgical evaluation is gold standardNb to consider itEarly gyne consultation!!!Surgical intervention required for adnexal salvage
31CASE#230F comes in with fever, malaise, n/v. Chief complaint is lower abdo pain.Hx: Multiple sexual partners, previously treated for ChlamydiaO/E: T-38.6, thick d/c from cervix, +CMTWhat is at the top of your DDx?
33What do you need to rule out before diagnosing PID?
34Ectopic pregnancy Appendicitis - Up to 1/3 of women of childbearing age with appy are misdiagnosed; commonly with PID or UTI
35Pelvic Inflammatory Disease A spectrum of infections of the female upper reproductive tractInitiated by ascending infection from the cervix and vaginaIncludes:SalpingitisEndometritisTOAPelvic peritonitisPerihepatitis-more often a community acquired infection from sexual contact rather than from medical procedures or pregnancy
37PID-MOs MO Gonorrhea and Chlamydia Polymicrobial- anaerobic and aerobic vaginal floraGAS, GBS, E. coli, Klebsiella, Proteus, Gardnerella vaginalis, H. influenzae, Streptococcus pyogenes, mycoplasma, PeptococcusCan also be from TB in endemic areasMost 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
39PID- RFs New or multiple sexual partners Hx of other STDs IUD up to 1 month after insertionHx of sexual abuseYounger age of sexual activityLarger zone of cervical ectopyIncreased cervical mucosal permeabilityRisk takingPregnancy 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
41PID- Complications TOA Reported in 33% Ectopic pregnancy Accounts for 50% of ectopic pregnanciesTubal factor infertilityIncreased by 15-50%Chronic pelvic pain/dyspareunia-ectopic b/c of scaring and adnhesions
42PID- Clinical Findings Lower abdo pain MC presenting complaintAbN vaginal discharge, vaginal bleeding, poistcoital bleeding, dyspareunia, irritative voiding sxs, fever, malaise, n/vNo single Hx, PE, lab finding is both sensitive and specific for dx of acute PIDMany vague complaints- abdo pain diffuse in lower quadrantsClinical dx of PID is not sensitive, very difficult to make.- can also have silent PID or subclinical PID
44FitzHugh-Curtis Syndrome Infection may extend by direct or lymphatic spread beyond the pelvis to involve the hepatic capsule or diaphragmAssociated w gonococcal and chlamydial salpingitisIn up to 10% pts w PIDMinimal 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
45PID-Dx Testing Pregnancy test always U/A CBC <50% pts with PID have elevated WBC!?ESR/CRPGram stain and C+S
46PID-Swabs Gen Probe Kit Black Top Swab Red Top Swab Large cotton swab is to clean external cervix and the endo cervix, discard itInsert thin swab into cervix 1-2cm and leave there for secs and sent as cervical swab for GC/ChlamydiaBlack Top SwabUse for rectal and oral swabs when you suspect GonorrheaRed Top SwabUsed for regular C+S, BV, trichomonas, yeast, GBS-leaving in cervix allows Mos to adhere
47PID-Imaging Improves accuracy of PID Dx Transvaginal pelvic u/s Thickened, fluid filled fallopian tubes, free pelvic fluid85% sens, 100% specLaparoscopy is gold standardHyperemia of the tubal surface, wall edema, exudates
48PID- 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 factorsT>38.3AbN cervical/mucopurulent d/cPresence of WBCs on saline microscopy of vaginal secretionsElevated ESR, CRPThis 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
49PID-TxMany optionsAll should cover N. gonorrhea and C. trachomatis, and anaerobic bugsQuick antibiotics linked to prevention of long term sequelae- Different regimens but same principle
50PID-Tx 2007 CDC Guidelines (Parenteral) Cefoxitin 2g IV Q6h or Cefotetan 2g IV Q12h + Doxycycline 100mg PO/IV Q12hClindamycin 900mg IV Q8h + Gentamicin 2mg/kg loading then 1.5mg/kg Q8hAmpicillin-sulbactam 3g IV Q6h + Doxycycline 100mg Po?IV Q12hFluoroquinolones: 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
51PID-Tx 2007 CDC Guidelines (Oral) Ceftriaxone 250mg IM single dose + doxycycline 100mg PO BID for 14d +/- Flagyl 500mg PO BID for 14dCefoxitin 2g IM single dose with probenacid 1g PO + + doxycycline 100mg PO BID for 14d +/- Flagyl 500mg PO BID for 14dRecommend 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)
52PID-Tx 2008 Alberta Treatment Guidelines Ceftriaxone 250mg IM single dose + Doxycycline 100mg PO BID for 14 days +/- Flagyl 500mg PO BID for 14 daysOfloxacin 400mg BID +/- Flagyl 500mg PO BID for 14 days
53PID-Tx Criteria for hospitalization Surgical emergencies cannot be excludedPregnantUnable to tolerate o/p oral regimenTOA
54PID-Tx Treat the partner! Avoid sexual contact until full course of tx for each partner
55Summary PIDHas a varied presentation, suspect in all sexually active womenSwab everyoneR/O surgically indicated pathology firstTreat early and cover appropriate bugs
56CASE #3 16F presents with c/o 9 days of heavy period Otherwise healthy Urine and serum beta are negativeWhat is your differential dx of non-pregnant bleeding in adolescents?
57DDx- Adolescents Early post-menarche Reproductive years Anovulation (hypo-pit axis immature)Bleeding d/oStress (psychogenic, exercise, malnutrition)InfectionReproductive yearsAnovulationCancerPolypsFibroidsAdenomyosisInfectionEndocrine (thyroid, PCOS, pituitary)Bleeding d/oMedication 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
58TerminologyDUB: excessive, noncyclical endometrial bleeding unrelated to anatomic or systemic dzMenorrhagia: menses >7d, or <21 recurrance, >80mlMetrorrhagia: light bleeding from the uterus at irregular intervalsMenometrorrhagia: heavy bleeding from the uterus at irregular intervalsThink 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
59DUB- Causes-Dx of exclusion- Need to work up for other causes first
60Dx Important in ED to rule out Pregnancy!!! Trauma Bleeding d/o InfectionForeign body*Other tests and work up can be done as o/p- Including sexual abuse
61Mx Hemodynamic stability R/O pregnancy +/- Iron supplementation +/- OCPEstrogen and progestinProgestin onlyGP f/uIf severe, unresponsive to tx- gyne consultEstrogen and progestin ns currently bleeding as estrogen promotes hemostasis (use a monophasic)- progestin only is an option if not currently bleeding
62Case #460F presents with uterine bleeding, last period was 8 years ago, otherwise healthyHow does your differential change in the post-menopausal woman?
63DDX Endometrial ca Atrophy Endometrial or vaginal Polyps Cervical ca Endometrial hyperplasiaHRTLeiomyomataInfection* Must r/o ca first even though 95% of cases are caused by a benign etiology
64O/E: Vitals N, maybe some vaginal atrophy but otherwise normal exam How would you manage this patient?
65Mx 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
66Case #530F presents with c/o of extremely heavy period for 10 days and using 15 pads/day.She usually has very heavy periodsOtherwise healthyHow would you approach her menorrhagia?Remember that it is more than >80mL and normal is 35-40mL
67Dx 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?
68Mx Hemodynamically unstable 2 large IVs Foley catheter IV estrogen (CEE)+ antiemeticPremarin 25mg IV Q4HGyne consult for emergent D+CFoley with a 30mL balloon and insert into the uterine cavity transcervically and inflate to help tamponade the bleeding- CEE conjugated equine estrogen-
69Mx Hemodynamically stable Premarin 2.5mg PO QID for 21 d High dose OCP (35 mcg estradiol) PO BID- QID for 7days then stopped for 4-5Medroxyprogesterone acetate (depo- provera) 10-20mg BID for 5-10 daysEndometrial ablation
70Mx Chronic Menorrhagia NSAIDS Ibuprofen 400mg PO TID Mirena IUD OCP GnRH agonists (Lupron)Gyne follow up
71Summary- General Approach How old is the patient?Is the patient pregnant?When does the bleeding occur in the cycle?Stable vs unstableGP vs Gyne consult in house vs as o/p follow up