Ob Gyn and Male GU

1. 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

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?

18. Ovarian pain • Ruptured cyst • 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 • 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

31. THE END ANY QUESTIONS