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William Beaumont Hospital Department of Emergency Medicine

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Presentation on theme: "William Beaumont Hospital Department of Emergency Medicine"— Presentation transcript:

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

2 Causes of pelvic pain Ectopic pregnancy PID Ovarian torsion
Ruptured ovarian cyst Fibroids Endometriosis

3 Pelvic pain case 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?

4 Ectopic pregnancy Abdominal pain or vaginal bleeding in first trimester pregnancy 2% incidence Leading cause of first trimester maternal death Risk factors – prior PID, failed IUD or tubal ligation, history of infertility, prior ectopic

5 Signs and symptoms Duration of the pregnancy
Extent of intraperitoneal hemorrhage Slow leakage (65% non ruptured) Frank rupture Site of implantation Ampulla – most common Isthmus – 10% - rupture common Cornual – massive hemorrhage Explain how variable presentation is because of this

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

7 Diagnosis Physical exam – not always helpful High index of suspicion
BhCG – all women with vag bleed or abdominal pain in reproductive yrs Pelvic ultrasound – Suggestive of ectopic pregnancy No IUP, BhCG >1200 (DZ) Complex adnexal mass Moderate-large amount cul-de-sac fluid

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

9 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?

10 PID Most common cause of pelvic pain
Most common serious infection in reproductive aged women Cervicitis that ascends to become a polymicrobial endometritis, salpingitis, oophoritis Risk factors – prior PID, multiple partners, IUD use, instrumentation of uterine cavity

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

12 PE CMT Bilateral adnexal tenderness Purulent cervical discharge
Diagnosis – clinical to begin treatment Gram neg intracellular diplococci C & S, DNA probe (PCR, run late am)

13 Indications for admission
Suspected TOA or Fitz-Hugh-Curtis syndrome Patient unable to tolerate po Peritonitis, septic appearing Prepubertal children Indwelling IUD Pregnancy + /- nulliparous women

14 Inpatient 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 12 or Clindamycin 900 mg IV q 8 with Gentamycin alone

15 Outpatient treatment 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

16 Cervicitis Cervical infection – discharge without abdominal pain or constitutional symptoms Gonorrhea or Chlamydia Treatment – outpatient 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

17 Flank Pain 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? Pelvic exam missed for torsion

18 Ovarian pain Ruptured cyst Ovarian torsion
Sudden, severe, sharp unilateral pain self resolving unless hemorrhagic or dermoid Treatment – observe in ED Ovarian torsion Intermittent colicky pain or acute abdomen Adnexal fullness/tenderness BhCG, doppler ultrasound is diagnostic Treatment – admit via OR

19 Kidney stones Common - @ 10% incidence
Flank pain, radiating to groin or abdomen Writhing in pain, nausea, vomiting CVA tenderness GU exam (radiating pain) Abdomen soft, nontender, BS - ileus

20 Kidney stones work up Urinalysis CT scan (non contrast) abd/pelvis
Hematuria (unless complete obstruction) Infection = surgical emergency CT scan (non contrast) abd/pelvis Ultrasound IVP 90% radiopaque – visible on KUB 75% Calcium 15% struvite (Mg) Others: uric acid, cystine, drug induced

21 Helical CT scan perinephric stranding of fat surrounding the left kidney and proximal left ureter Left kidney is enlarged, with dilatation of the intrarenal collecting system

22 Treatment IV fluids Strain urine Analgesics – ketorolac, narcotics
Antiemetics if vomiting Tamsulosin – Flomax – alpha blocker < 5mm – usually pass spontaneously > 8 mm – often require surgery

23 Admission (Observation)
Intractable pain Intractable vomiting Stone > 6mm Solitary kidney or congenital abnormalities (horseshoe kidney) Infected stone is a true surgical emergency (perinephric abscess, sepsis and death)

24 Testicular pain 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 tests do you want to order?

25 Male GU Testicular torsion Epididymitis Fourniere’s gangrene

26 Testicular torsion Sudden severe testicular or lower abd pain
Often preceded by trauma/physical activity Most common in pre and pubescent males, but can occur at any age PE – diffusely tender, swollen testicle Diagnosis – no flow on testicular ultrasound Admit via the OR, stat urologic consult

27 Epididymitis Gradual pain
Posterior epididymal tenderness and edema (later swollen scrotum obscures) Usually occurs in sexually active males U/A – pyuria Testicular ultrasound – to rule out torsion Outpatient Abs to cover GC and Chlamydia, analgesics, scrotal support

28 Fourniere’s gangrene Elderly or immunocompromised men
Sudden onset of edematous, necrotic scrotum Patients appear toxic Plain films – scrotal gangrene and intrascrotal gas Urologic consult for surgical debridement IVF, broad spectrum IV antibiotics


30 Fournier’s Gangrene


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