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

2. Cases… 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?

3. Causes of Pelvic Pain Ectopic pregnancy Ectopic pregnancy Ovarian torsion Ovarian torsion PID PID Ruptured ovarian cyst Ruptured ovarian cyst –Simple vs. hemorrhagic Fibroids Fibroids Endometriosis Endometriosis Renal stone Renal stone Appendicitis Appendicitis

4. Ectopic Pregnancy How do they present? How do they present?

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

6. Ectopic Pregnancy 2% incidence 2% incidence Leading cause of first trimester maternal death Leading cause of first trimester maternal death Risk factors? Risk factors?

7. Ectopic Pregnancy Duration of the pregnancy Duration of the pregnancy –Is their LMP reliable? Site of implantation Site of implantation –Ampulla – most common –Isthmus – 10% – rupture common –Cornual – massive hemorrhage Extent of intraperitoneal hemorrhage Extent of intraperitoneal hemorrhage –Slow leakage (65% non ruptured) –Frank rupture

8. Diagnosis Physical exam – not always helpful Physical exam – not always helpful High index of suspicion High index of suspicion BhCG – all women with vaginal bleeding or abdominal pain in reproductive years BhCG – all women with vaginal bleeding or abdominal pain in reproductive years Pelvic ultrasound – Suggestive of ectopic pregnancy Pelvic ultrasound – Suggestive of ectopic pregnancy –No IUP, BhCG >1200 –Complex adnexal mass –Moderate-large amount cul-de-sac fluid

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

10. 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?

11. PID Cervicitis that ascends to become a polymicrobial endometritis, salpingitis, oophoritis Cervicitis that ascends to become a polymicrobial endometritis, salpingitis, oophoritis Common cause of pelvic pain Common cause of pelvic pain Most common serious infection in reproductive aged women Most common serious infection in reproductive aged women

12. PID Risk Factors Risk Factors –Prior PID –Multiple partners –IUD use –Instrumentation of uterine cavity

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

14. PE Vital signs? Vital signs? CMT CMT Bilateral adnexal tenderness Bilateral adnexal tenderness Purulent cervical discharge Purulent cervical discharge Diagnosis: Diagnosis: –Wait for cultures?

15. PID Work-up – –HCG (duh!) – –CBC – –UA – –Pelvic: Gram neg intracellular diplococci Gram neg intracellular diplococci C & S, DNA probe C & S, DNA probe – –Ultrasound?

16. Indications for Admission Suspected TOA or Fitz-Hugh-Curtis syndrome Suspected TOA or Fitz-Hugh-Curtis syndrome Patient unable to tolerate PO Patient unable to tolerate PO Peritonitis, septic appearing Peritonitis, septic appearing Prepubertal children Prepubertal children Indwelling IUD Indwelling IUD Pregnancy Pregnancy

17. Inpatient Treatment Look it up, it changes… BUT… Look it up, it changes… BUT… –Cefoxitin 2 g IV q 6 or –Cefotetan 2 g IV q 12 or –Unasyn 3 g IV q or –AND all above with Doxycycline 100 mg PO/IV q 12 – or - Clindamycin 900 mg IV q 8 with Gentamycin alone

18. Outpatient Treatment Changes more, look it up…BUT… Changes more, look it up…BUT… –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

19. Cervicitis Cervical infection – discharge without abdominal pain or constitutional symptoms Cervical infection – discharge without abdominal pain or constitutional symptoms Gonorrhea or Chlamydia Gonorrhea or Chlamydia Outpatient treatment Outpatient treatment –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

20. Next 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?

21. Ovarian Pain Ruptured cyst Ruptured cyst –Sudden, severe, sharp unilateral pain –Self resolving unless hemorrhagic or dermoid –Treatment – observe in ED

22. Ovarian Torsion Intermittent colicky pain or acute abdomen Intermittent colicky pain or acute abdomen Adnexal fullness/tenderness Adnexal fullness/tenderness BhCG, doppler ultrasound is diagnostic BhCG, doppler ultrasound is diagnostic Treatment – OR Treatment – OR

23. Kidney Stones Common – 10% incidence Common – 10% incidence Flank pain, radiating to groin or abdomen Flank pain, radiating to groin or abdomen Writhing pain, nausea, vomiting Writhing pain, nausea, vomiting CVA tenderness CVA tenderness GU exam (radiating pain) GU exam (radiating pain) Abdomen soft, nontender,  BS – ileus Abdomen soft, nontender,  BS – ileus

24. Kidney Stone Work Up Urinalysis Urinalysis –Hematuria (unless complete obstruction) What percentage of stones have no blood in the urine? What percentage of stones have no blood in the urine? –Infection = surgical emergency Non-contrast CT scan abd/pelvis Non-contrast CT scan abd/pelvis Ultrasound Ultrasound IVP IVP 90% radiopaque – visible on KUB 90% radiopaque – visible on KUB –75% Calcium, 15% struvite (Mg) –Others: uric acid, cystine, drug induced

25. Helical CT Scan Perinephric stranding of fat surrounding the left kidney and proximal left ureter Perinephric stranding of fat surrounding the left kidney and proximal left ureter Left kidney is enlarged, with dilatation of the intrarenal collecting system Left kidney is enlarged, with dilatation of the intrarenal collecting system

26. Treatment IV fluids IV fluids Strain urine Strain urine Analgesics – ketorolac, narcotics Analgesics – ketorolac, narcotics Antiemetics if vomiting Antiemetics if vomiting Tamsulosin – Flomax – alpha blocker Tamsulosin – Flomax – alpha blocker Depending on the location of the stone: Depending on the location of the stone: –< 5mm – usually pass spontaneously –> 8mm – often require surgery

27. Admission (Observation) Intractable pain Intractable pain Intractable vomiting Intractable vomiting Stone > 6mm Stone > 6mm Extravasation of dye on CT Extravasation of dye on CT Solitary kidney Solitary kidney Infected stone is a surgical emergency Infected stone is a surgical emergency –Stone plus UA with bacteria and WBCs –Why is this so bad?

28. Male GU Testicular torsion Testicular torsion Epididymitis Epididymitis Fourniere’s gangrene Fourniere’s gangrene

29. Next Case… 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. 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 are you thinking? What tests do you want to order? What tests do you want to order?

30. Testicular Torsion Sudden severe testicular or lower abd pain Sudden severe testicular or lower abd pain Often preceded by trauma/physical activity Often preceded by trauma/physical activity Most common in pre and pubescent males, but can occur at any age Most common in pre and pubescent males, but can occur at any age PE – diffusely tender, swollen testicle PE – diffusely tender, swollen testicle Diagnosis – no flow on testicular ultrasound Diagnosis – no flow on testicular ultrasound When do you call urology? When do you call urology?

31. Epididymitis Gradual pain Gradual pain Posterior epididymal tenderness and edema (later swollen scrotum obscures) Posterior epididymal tenderness and edema (later swollen scrotum obscures) Usually occurs in sexually active males Usually occurs in sexually active males UA – pyuria UA – pyuria Testicular ultrasound – to rule out torsion Testicular ultrasound – to rule out torsion –Not always necessary!

32. Epididymitis Treatment Treatment –Antibiotics GC and Chlamydia if <35 yo GC and Chlamydia if <35 yo E Coli if >35 yo E Coli if >35 yo –Analgesics –Scrotal support

33. Fourniere’s Gangrene Elderly or immunocompromised men Elderly or immunocompromised men Sudden onset of edematous, necrotic scrotum/perineum Sudden onset of edematous, necrotic scrotum/perineum Patients appear toxic Patients appear toxic Plain films – scrotal gangrene and intrascrotal gas Plain films – scrotal gangrene and intrascrotal gas

34. Fourniere’s Gangrene Treatment: Treatment: –Urologic/general surgery consult for surgical debridement –IVF –Broad spectrum IV antibiotics

35. Fournier’s Gangrene

36. The End Any Questions??