Ob Gyn and Male GU

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 • Ovarian torsion • PID • Ruptured ovarian cyst • Simple vs. hemorrhagic • Fibroids • Endometriosis • Renal stone • Appendicitis

4. Ectopic Pregnancy • How do they present?

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

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

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

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

9. Treatment • ABCs • Rhogam if Rh negative and bleeding • 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 • Common cause of pelvic pain • Most common serious infection in reproductive aged women

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

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

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

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

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

17. Inpatient Treatment • 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… • 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 • Gonorrhea or Chlamydia • 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 • Sudden, severe, sharp unilateral pain • Self resolving unless hemorrhagic or dermoid • Treatment – observe in ED

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

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

24. Kidney Stone Work Up • Urinalysis • Hematuria (unless complete obstruction) • What percentage of stones have no blood in the urine? • Infection = surgical emergency • Non-contrast CT scan abd/pelvis • Ultrasound • IVP • 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 • Left kidney is enlarged, with dilatation of the intrarenal collecting system

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

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

28. Male GU • Testicular torsion • Epididymitis • 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. • What are you thinking? • What tests do you want to order?

30. 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 • When do you call urology?

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

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

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

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

35. Fournier’s Gangrene

36. The End Any Questions??