PELVIC PAIN AND NON-PREGNANT BLEEDING Alyssa Morris, R2 May 14, 2009 Thanks to Dr Jen Butler
Objectives • Causes of pelvic pain in women • Mx of pelvic pain in the ED • Causes of non-pregnant bleeding in adolescents • Causes of non-pregnancy bleeding in post-menopausal women • Dx and Mx of DUB In the ED
Not Covered • Pelvic anatomy • Menstrual Cycle • Pathophysiology of pelvic pain • Pregnant bleeding • Sexual assault
CASE #1 18F with CC of lower pelvic pain which started yesterday and has gradually gotten worse • What else do you want to know? (ie. nb features on Hx)
History • PQRST • Factors that exacerbate/alleviate • Vaginal D/C • Associated Sx • GU Sxs
Hx • Gynecologic • LMP • Obstetrical • Gravida, Para, Complications • Sexual • #partners, current partner, previous STIs, contraception
Case #1 Cont… • States she has had 1 day of sharp, crampy RLQ pain, not radiating that is 5/10 • Nothing alleviates nor exacerbates, not positional • No associated urinary/GI sxs • No vaginal D/C • Otherwise healthy • No STDs, one partner, last sexual intercourse 3m ago, always used condoms • LMP 2 weeks so says no chance she is pregnant…
Annal Emerg Med 1989;18:48-50 • 7% of pts who stated their LMP was N and denied any chance of being pregnant had a positive serum beta
Case #1 Cont… • What is your DDX of acute pelvic pain?
DDX Pelvic Contents • Vagina • Uterus • Fallopian tubes • Ovaries • Ureter • Bladder • Sigmoid colon • Rectum
DDX Think in terms of systems! • Reproductive tract • Nonpregnant • Pregnant • Intestinal tract • Urinary tract
DDX- Reproductive NON-PREGNANT PREGNANT 1st Trimester Ectopic Threatened abortion Endometritis Corpus Luteal Cyst Ovarian hyperstimulation Ovarian Torsion 2nd/3rd Trimester Placenta Previa Placental abruption • Salpingitis/tubo-ovarian abscess • Ovarian Cyst • Ovarian Torsion • Endometriosis • Fibroids • Uterine Perforation • Round Ligament Pain
DDX- Intestinal Tract • Appendicitis • Diverticulitis • IBD • Gastroenteritis • Ischemic bowel dz • Bowel obstruction • Incarcerated hernia • Perforated Viscus
DDx- Urinary Tract • Pyelonephritis • Cystitis • Ureteral stone
Case #1 Cont… What would you like to do on physical exam?
Exam • Vitals • Abdo exam • Speculum exam • Bimanual exam • How good is the bimanual?
CJEM 2003;5(2) • Findings on pelvic exam are subjective • Not reliably reproducible b/t observers • Literature suggests unwise to base decisions on a clinical exam of the female pelvis
Obstet Gynecol 2000;96:593 • Compared ability of med students, obs residents, obs staff to accurately detect adnexal mass • Sens of bimanual for adnexal mass: 15-36% • Spec 79-92% • PPV 26-69% • Up to 2/3 of surgically identified masses were missed on exam • ¾ of pts thought to have mass o/e did not
Case #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 signs • Speculum exam N • Bimanual- tender to right adnexa, No CMT • Labs are N and Urine Preg Negative
Case #1 Cont… • Let’s assume it is Sunday night at 8pm • How are you going to manage this patient?
Case #1 Cont… • You ask the patient to come back in the morning for an U/S • U/S shows a 3cm, uniloculated, R sided ovarian cyst • What are the complications of ovarian cysts?
Ovarian Cysts • Rupture • Hemorrhage • Torsion • Infection • Resolution What kind of cysts are worrisome?
Ovarian Cysts • BENIGN FEATURES • <8cm • Uniloculated • Unilateral • Thin walls • WORRISOME FEATURES • >8cm • Loculated • Solid • Calcification • Thick walls and septations Ovarian endometriomas, dermoid cysts are CA until proven otherwise
Ovarian Cysts- Mx • <6cm • Usually observed • Most spontaneously resolve in 1-2m • +/- OCP • >6cm, growing or worrisome features • Gyne o/p f/u
Case #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, 10/10 • What would you be concerned about?
Ovarian/Adnexal Torsion • Ischemia resulting from twisting of the ovary on it’s vascular pedicle • Onset may occur after trauma, intercourse, increased intraabdo pressure or exercise • R>L • Can occur at any age
Torsion- Clinical Presentation • Ann Emerg Med 2001;38(2):156-9 • The 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%
Ovarian Torsion • U/S with doppler flow evaluation is used for diagnosis • Decreased flow suggestive but not definitive • Surgical evaluation is gold standard • Nb to consider it • Early gyne consultation!!! • Surgical intervention required for adnexal salvage
CASE#2 • 30F comes in with fever, malaise, n/v. Chief complaint is lower abdo pain. • Hx: Multiple sexual partners, previously treated for Chlamydia • O/E: T-38.6, thick d/c from cervix, +CMT • What is at the top of your DDx?
DDx • PID • Cervicitis • Ectopic pregnancy • Endometriosis • Ovarian cyst • Ovarian torsion • Septic abortion • Appendicitis • Diverticulitis • Pyelonephritis • Renal colic • cholecystitis
Ectopic pregnancy Appendicitis
Pelvic Inflammatory Disease • A spectrum of infections of the female upper reproductive tract • Initiated by ascending infection from the cervix and vagina • Includes: • Salpingitis • Endometritis • TOA • Pelvic peritonitis • Perihepatitis
PID-MOs MO • Gonorrhea and Chlamydia • Polymicrobial- anaerobic and aerobic vaginal flora • GAS, GBS, E. coli, Klebsiella, Proteus, Gardnerella vaginalis, H. influenzae, Streptococcus pyogenes, mycoplasma, Peptococcus • Can also be from TB in endemic areas
PID- RFs • New or multiple sexual partners • Hx of other STDs • IUD up to 1 month after insertion • Hx of sexual abuse • Younger age of sexual activity • Larger zone of cervical ectopy • Increased cervical mucosal permeability • Risk taking
PID- Complications • TOA • Reported in 33% • Ectopic pregnancy • Accounts for 50% of ectopic pregnancies • Tubal factor infertility • Increased by 15-50% • Chronic pelvic pain/dyspareunia
PID- Clinical Findings • Lower abdo pain MC presenting complaint • AbN vaginal discharge, vaginal bleeding, poistcoital bleeding, dyspareunia, irritative voiding sxs, fever, malaise, n/v • No single Hx, PE, lab finding is both sensitive and specific for dx of acute PID
FitzHugh-Curtis Syndrome • Infection may extend by direct or lymphatic spread beyond the pelvis to involve the hepatic capsule or diaphragm • Associated w gonococcal and chlamydial salpingitis • In up to 10% pts w PID
PID-Dx Testing • Pregnancy test always • U/A • CBC • <50% pts with PID have elevated WBC! • ?ESR/CRP • Gram stain and C+S
PID-Swabs • Gen Probe Kit • Large cotton swab is to clean external cervix and the endo cervix, discard it • Insert thin swab into cervix 1-2cm and leave there for 15-30 secs and sent as cervical swab for GC/Chlamydia • Black Top Swab • Use for rectal and oral swabs when you suspect Gonorrhea • Red Top Swab • Used for regular C+S, BV, trichomonas, yeast, GBS
PID-Imaging • Improves accuracy of PID Dx • Transvaginal pelvic u/s • Thickened, fluid filled fallopian tubes, free pelvic fluid • 85% sens, 100% spec • Laparoscopy is gold standard • Hyperemia of the tubal surface, wall edema, exudates
PID- 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 factors • T>38.3 • AbN cervical/mucopurulent d/c • Presence of WBCs on saline microscopy of vaginal secretions • Elevated ESR, CRP
PID-Tx • Many options • All should cover N. gonorrhea and C. trachomatis, and anaerobic bugs • Quick antibiotics linked to prevention of long term sequelae
PID-Tx 2007 CDC Guidelines (Parenteral) • Cefoxitin 2g IV Q6h or Cefotetan 2g IV Q12h + Doxycycline 100mg PO/IV Q12h • Clindamycin 900mg IV Q8h + Gentamicin 2mg/kg loading then 1.5mg/kg Q8h • Ampicillin-sulbactam 3g IV Q6h + Doxycycline 100mg Po?IV Q12h