Ob Gyn and Male GUOb Gyn and Male GU

William Beaumont HospitalWilliam Beaumont Hospital

Department of Emergency Department of Emergency MedicineMedicine

Causes of pelvic painCauses of pelvic pain

Ectopic pregnancyEctopic pregnancy

PIDPID Ovarian torsionOvarian torsion Ruptured ovarian cystRuptured ovarian cyst FibroidsFibroids EndometriosisEndometriosis

Pelvic pain case26 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?

Ectopic pregnancyEctopic pregnancy

Abdominal pain or vaginal Abdominal pain or vaginal bleeding in first trimester bleeding in first trimester pregnancypregnancy

2% incidence2% incidence Leading cause of first trimester Leading cause of first trimester

maternal deathmaternal death Risk factors – prior PID, failed IUD Risk factors – prior PID, failed IUD

or tubal ligation, history of or tubal ligation, history of infertility, prior ectopicinfertility, prior ectopic

Signs and symptomsSigns and symptoms

Duration of the pregnancyDuration of the pregnancy Extent of intraperitoneal Extent of intraperitoneal

hemorrhagehemorrhage– Slow leakage (65% non ruptured)Slow leakage (65% non ruptured)– Frank ruptureFrank rupture

Site of implantationSite of implantation– Ampulla – most common Ampulla – most common – Isthmus – 10% - rupture commonIsthmus – 10% - rupture common– Cornual – massive hemorrhageCornual – massive hemorrhage

Signs and symptomsSigns and symptoms

Abdominal pain 95%Abdominal pain 95% Abdominal tenderness 70%Abdominal tenderness 70% Vaginal bleeding – slight spottingVaginal bleeding – slight spotting TenesmusTenesmus 3 S’s3 S’s

– Syncope, shoulder pain, shockSyncope, shoulder pain, shock– Suggests ruptureSuggests rupture

DiagnosisDiagnosis

Physical exam – not always helpfulPhysical exam – not always helpful High index of suspicionHigh index of suspicion BhCG – all women with vag bleed or BhCG – all women with vag bleed or

abdominal pain in reproductive yrsabdominal pain in reproductive yrs Pelvic ultrasound – Suggestive of ectopic Pelvic ultrasound – Suggestive of ectopic

pregnancypregnancy– No IUP, BhCG >1200 (DZ)No IUP, BhCG >1200 (DZ)– Complex adnexal massComplex adnexal mass– Moderate-large amount cul-de-sac fluidModerate-large amount cul-de-sac fluid

TreatmentTreatment

Rhogam if Rh negative and Rhogam if Rh negative and bleedingbleeding

Gynecology consult for Gynecology consult for Methotrexate or surgical removalMethotrexate or surgical removal

ABCsABCs

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?

PIDPID

Most common cause of pelvic painMost common cause of pelvic pain Most common serious infection in Most common serious infection in

reproductive aged womenreproductive aged women Cervicitis that ascends to become a Cervicitis that ascends to become a

polymicrobial endometritis, salpingitis, polymicrobial endometritis, salpingitis, oophoritisoophoritis

Risk factors – prior PID, multiple Risk factors – prior PID, multiple partners, IUD use, instrumentation of partners, IUD use, instrumentation of uterine cavityuterine cavity

SymptomsSymptoms

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

mensesmenses

PEPE

CMTCMT Bilateral adnexal tendernessBilateral adnexal tenderness Purulent cervical dischargePurulent cervical discharge Diagnosis – clinical to begin Diagnosis – clinical to begin

treatmenttreatment Gram neg intracellular diplococci Gram neg intracellular diplococci C & S, DNA probe (PCR, run late C & S, DNA probe (PCR, run late

am)am)

Indications for Indications for admissionadmission

Suspected TOA or Fitz-Hugh-Curtis Suspected TOA or Fitz-Hugh-Curtis syndromesyndrome

Patient unable to tolerate poPatient unable to tolerate po Peritonitis, septic appearingPeritonitis, septic appearing Prepubertal childrenPrepubertal children Indwelling IUD Indwelling IUD PregnancyPregnancy + /- nulliparous women+ /- nulliparous women

Inpatient treatmentInpatient treatment

Cefoxitin 2 g IV q 6 *Cefoxitin 2 g IV q 6 * Cefotetan 2 g IV q 12 *Cefotetan 2 g IV q 12 * Unasyn 3 g IV q 6*Unasyn 3 g IV q 6* * WITH Doxycycline 100 mg PO/IV q * WITH Doxycycline 100 mg PO/IV q

1212

oror Clindamycin 900 mg IV q 8 with Clindamycin 900 mg IV q 8 with

Gentamycin aloneGentamycin alone

Outpatient treatmentOutpatient treatment

Ceftriaxone 250 mg IM PLUSCeftriaxone 250 mg IM PLUS Cefoxitin 2 gm IM with Probenecid Cefoxitin 2 gm IM with Probenecid

1 gm po PLUS1 gm po PLUS– Doxycycline 100 mg BID x 14 dDoxycycline 100 mg BID x 14 d– +/-Metronidazole 500 mg BID x 14 d+/-Metronidazole 500 mg BID x 14 d

CervicitisCervicitis

Cervical infection – discharge without Cervical infection – discharge without abdominal pain or constitutional symptoms abdominal pain or constitutional symptoms

Gonorrhea or ChlamydiaGonorrhea or Chlamydia Treatment – outpatientTreatment – outpatient

– Ceftriaxone 125 mg IM with Doxycycline 100 mg Ceftriaxone 125 mg IM with Doxycycline 100 mg BID x 7 daysBID x 7 days

– Alternatives for GC: Cefixime 400 mg PO x 1Alternatives for GC: Cefixime 400 mg PO x 1– Alternative for Chlamydia: Azithromycin 1 g POAlternative for Chlamydia: Azithromycin 1 g PO– Alternative for both: Azithromycin 2 g POAlternative for both: Azithromycin 2 g PO

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?

Ovarian painOvarian pain

Ruptured cystRuptured cyst– Sudden, severe, sharp unilateral painSudden, severe, sharp unilateral pain– self resolving unless hemorrhagic or dermoidself resolving unless hemorrhagic or dermoid– Treatment – observe in EDTreatment – observe in ED

Ovarian torsionOvarian torsion– Intermittent colicky pain or acute abdomenIntermittent colicky pain or acute abdomen– Adnexal fullness/tenderness Adnexal fullness/tenderness – BhCG, doppler ultrasound is diagnosticBhCG, doppler ultrasound is diagnostic– Treatment – admit via ORTreatment – admit via OR

Kidney stonesKidney stones

Common - @ 10% incidenceCommon - @ 10% incidence Flank pain, radiating to groin or Flank pain, radiating to groin or

abdomenabdomen Writhing in pain, nausea, vomitingWrithing in pain, nausea, vomiting CVA tendernessCVA tenderness GU exam (radiating pain)GU exam (radiating pain) Abdomen soft, nontender, Abdomen soft, nontender, BS - BS -

ileusileus

Kidney stones work upKidney stones work up

UrinalysisUrinalysis– Hematuria (unless complete obstruction)Hematuria (unless complete obstruction)– Infection = surgical emergencyInfection = surgical emergency

CT scan (non contrast) abd/pelvisCT scan (non contrast) abd/pelvis UltrasoundUltrasound IVPIVP 90% radiopaque – visible on KUB90% radiopaque – visible on KUB

– 75% Calcium 15% struvite (Mg)75% Calcium 15% struvite (Mg)– Others: uric acid, cystine, drug inducedOthers: uric acid, cystine, drug induced

Helical CT scanHelical CT scan

perinephric perinephric stranding of fat stranding of fat surrounding the surrounding the left kidney and left kidney and proximal left ureterproximal left ureter

Left kidney is Left kidney is enlarged, with enlarged, with dilatation of the dilatation of the intrarenal intrarenal collecting systemcollecting system

TreatmentTreatment

IV fluidsIV fluids Strain urineStrain urine Analgesics – ketorolac, narcoticsAnalgesics – ketorolac, narcotics Antiemetics if vomitingAntiemetics if vomiting Tamsulosin – Flomax – alpha blockerTamsulosin – Flomax – alpha blocker < 5mm – usually pass spontaneously< 5mm – usually pass spontaneously > 8 mm – often require surgery> 8 mm – often require surgery

Admission Admission (Observation)(Observation) Intractable painIntractable pain Intractable vomitingIntractable vomiting Stone > 6mmStone > 6mm Solitary kidney or congenital Solitary kidney or congenital

abnormalities (horseshoe kidney)abnormalities (horseshoe kidney) Infected stone is a true surgical Infected stone is a true surgical

emergency (perinephric abscess, emergency (perinephric abscess, sepsis and death)sepsis and death)

Testicular painTesticular pain

18 y/o male c/o of pain in his right 18 y/o male c/o of pain in his right testicle that was sudden onset 2 testicle that was sudden onset 2 hours ago with nausea and vomiting. hours ago with nausea and vomiting. It began while he was running. Exam It began while he was running. Exam shows a diffusely tender swollen right shows a diffusely tender swollen right testicle, with loss of cremasteric testicle, with loss of cremasteric reflex. reflex.

What are you thinking?What are you thinking? What tests do you want to order?What tests do you want to order?

Male GU Male GU

Testicular torsionTesticular torsion EpididymitisEpididymitis Fourniere’s gangreneFourniere’s gangrene

Testicular torsionTesticular torsion

Sudden severe testicular or lower abd painSudden severe testicular or lower abd pain Often preceded by trauma/physical activityOften preceded by trauma/physical activity Most common in pre and pubescent males, Most common in pre and pubescent males,

but can occur at any agebut can occur at any age PE – diffusely tender, swollen testiclePE – diffusely tender, swollen testicle Diagnosis – no flow on testicular ultrasoundDiagnosis – no flow on testicular ultrasound Admit via the OR, stat urologic consultAdmit via the OR, stat urologic consult

EpididymitisEpididymitis

Gradual painGradual pain Posterior epididymal tenderness and Posterior epididymal tenderness and

edema (later swollen scrotum obscures)edema (later swollen scrotum obscures) Usually occurs in sexually active malesUsually occurs in sexually active males U/A – pyuriaU/A – pyuria Testicular ultrasound – to rule out Testicular ultrasound – to rule out

torsiontorsion Outpatient Abs to cover GC and Outpatient Abs to cover GC and

Chlamydia, analgesics, scrotal supportChlamydia, analgesics, scrotal support

Fourniere’s gangreneFourniere’s gangrene

Elderly or immunocompromised menElderly or immunocompromised men Sudden onset of edematous, necrotic Sudden onset of edematous, necrotic

scrotumscrotum Patients appear toxicPatients appear toxic Plain films – scrotal gangrene and Plain films – scrotal gangrene and

intrascrotal gasintrascrotal gas Urologic consult for surgical Urologic consult for surgical

debridementdebridement IVF, broad spectrum IV antibioticsIVF, broad spectrum IV antibiotics

Fournier’s Gangrene

THE END

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