Ob Gyn and Male GU
William Beaumont Hospital
Department of Emergency Medicine
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?
Causes of Pelvic Pain
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Ectopic pregnancy
Ovarian torsion
PID
Ruptured ovarian cyst
– Simple vs. hemorrhagic
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Fibroids
Endometriosis
Renal stone
Appendicitis
Ectopic Pregnancy
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How do they present?
Signs and Symptoms
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Abdominal pain 95%
Abdominal tenderness 70%
Vaginal bleeding – slight spotting
Tenesmus
3 S’s
– Syncope, shoulder pain, shock
– Suggests rupture
Ectopic Pregnancy
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2% incidence
Leading cause of first trimester
maternal death
Risk factors?
Ectopic Pregnancy
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Duration of the pregnancy
– Is their LMP reliable?
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Site of implantation
– Ampulla – most common
– Isthmus – 10% – rupture common
– Cornual – massive hemorrhage
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Extent of intraperitoneal hemorrhage
– Slow leakage (65% non ruptured)
– Frank rupture
Diagnosis
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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
Treatment
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ABCs
Rhogam if Rh negative and bleeding
Gynecology consult for surgical
removal or Methotrexate
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?
PID
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Cervicitis that ascends to become a
polymicrobial endometritis, salpingitis,
oophoritis
Common cause of pelvic pain
Most common serious infection in
reproductive aged women
PID
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Risk Factors
– Prior PID
– Multiple partners
– IUD use
– Instrumentation of uterine cavity
Symptoms
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Bilateral lower quadrant pain
Purulent vaginal discharge >50%
Abnormal vaginal bleeding
Symptoms begin shortly after menses
PE
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Vital signs?
CMT
Bilateral adnexal tenderness
Purulent cervical discharge
Diagnosis:
– Wait for cultures?
PID
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Work-up
– HCG (duh!)
– CBC
– UA
– Pelvic:
Gram neg intracellular diplococci
 C & S, DNA probe
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– Ultrasound?
Indications for Admission
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Suspected TOA or Fitz-Hugh-Curtis syndrome
Patient unable to tolerate PO
Peritonitis, septic appearing
Prepubertal children
Indwelling IUD
Pregnancy
Inpatient Treatment
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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
Outpatient Treatment
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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
Cervicitis
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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
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?
Ovarian Pain
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Ruptured cyst
– Sudden, severe, sharp unilateral pain
– Self resolving unless hemorrhagic or
dermoid
– Treatment – observe in ED
Ovarian Torsion
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Intermittent colicky pain or acute
abdomen
Adnexal fullness/tenderness
BhCG, doppler ultrasound is diagnostic
Treatment – OR
Kidney Stones
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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
Kidney Stone Work Up
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Urinalysis
– Hematuria (unless complete obstruction)
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What percentage of stones have no blood in the urine?
– Infection = surgical emergency
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Non-contrast CT scan abd/pelvis
Ultrasound
IVP
90% radiopaque – visible on KUB
– 75% Calcium, 15% struvite (Mg)
– Others: uric acid, cystine, drug induced
Helical CT Scan
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Perinephric
stranding of fat
surrounding the left
kidney and proximal
left ureter
Left kidney is
enlarged, with
dilatation of the
intrarenal collecting
system
Treatment
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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
Admission (Observation)
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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?
Male GU
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Testicular torsion
Epididymitis
Fourniere’s gangrene
Next Case…
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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?
Testicular Torsion
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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?
Epididymitis
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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!
Epididymitis
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Treatment
– Antibiotics
GC and Chlamydia if <35 yo
 E Coli if >35 yo
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– Analgesics
– Scrotal support
Fourniere’s Gangrene
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Elderly or immunocompromised men
Sudden onset of edematous, necrotic
scrotum/perineum
Patients appear toxic
Plain films – scrotal gangrene and
intrascrotal gas
Fourniere’s Gangrene
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Treatment:
– Urologic/general surgery consult for surgical
debridement
– IVF
– Broad spectrum IV antibiotics
Fournier’s Gangrene
The End
Any Questions??