Pelvic Pain and

Pelvic Inflammatory Disease

Joshua Radke, MDEmergency Medicine

UC Davis Medical Center

Disclosures

• None

Outline• Pregnant

– Ectopic– Early pregnancy failure– Placental abruption– Uterine failure

• Not Pregnant– Ovarian cyst– Ovarian torsion

• Infectious Disease – Vaginitis– Cervicitis– PID

• TOA• Fitz-Hugh-Curtis Syndrome

Pregnancy

PregnantClassify by Trimester

• First trimester– Ectopic Pregnancy– Early pregnancy failure

• Second trimester– Round ligament pain– Ovarian torsion

• Third trimester– Placenta abruption– Uterine rupture

• Don’t forget non-gynecologic causes!

Ectopic Pregnancy

• Implantation of blastocyst anywhere other than endometrial lining of uterus

• Majority are tubal– Tubal – 95%– Ovarian – 3.2%– Abdominal – 1.3%

Ectopic PregnancyEpidemiology

• 2% of pregnancies

• Incidence increasing in US– 4.5 per 1000 in 1970– 19.7 per 1000 in 1992

• Mortality decreasing

Ectopic PregnancyRisk Factors

Factor Odds Ratio

Prior ectopic 12.5

Prior tubal surgery 4.0

Smoking (>20 cigs/day) 3.5

Prior PID 3.4

≥ 3 prior SAB 3.0

Age ≥ 40 2.9

Prior medical or surgical abortion 2.8

Infertility >1 year 2.6

Lifelong sexual partners >5 1.6

Previous IUD use 1.3

Ectopic PregnancySymptoms

• Amenorrhea• Abdominal pain• Vaginal bleeding• 18% of women presenting to ER with 1st trimester bleeding and

abdominal pain • Symptoms of normal pregnancy

– Nausea– Urinary frequency– Breast tenderness

• More serious symptoms– Shoulder pain (phrenic nerve irritation)– Syncope/orthostatic/vertigo

Ectopic PregnancySigns

• Vital Signs– Normal– Hypotensive and tachycardic

• Physical exam– Minimal prior to rupture– Marked tenderness on abdominal and pelvic

examination– Pelvic mass palpated in only ~20%

Ectopic PregnancyDiagnosis

• β-hcg– Discriminatory zone – Abnormal rise

• TVUS– Absence of intrauterine pregnancy– Adnexal mass– “Pseudosac” in uterus– Free fluid in pelvis (rupture)

β-hcg

Finding on TVUS Weeks from LMP β-hcg

Gestational sac 5 1000

“Discriminatory Zone” 5-6 1500-2000

Yolk sac 6 2500

Fetal pole 7 5000

Fetal heart motion 8 17,000

Ectopic Adjacent to Ovary

Tubal Ectopic

Pseudosac

Heterotopic Pregnancy

Ectopic PregnancyManagement

• Stabilize – ABC’s

• Medical Management – Methotrexate– Absolute contraindications: hepatic, renal, or hematologic

disorders, PUD, breastfeeding– Relative contraindications: GS > 3.5cm, fetal cardiac activity– Reliable patient

• Surgical Management– Salpingectomy– Salpingostomy (tubal preservation)

Ectopic PregnancyLaparoscopy

Early Pregnancy FailureEpidemiology

• 1 in 4 women will experience a miscarriage in her lifetime

• 31 % of pregnancies will fail after implantation– 2/3 of these are silent

• 80% of spontaneous abortions are in the first 12 weeks– At least 50% are from chromosomal abnormalities

Early Pregnancy FailureRisk Factors

• Age– 12% risk < 20 yo– 26% risk > 40 yo

• Infection• Endocrine Abnormalities

– Hypothyroidism– Diabetes mellitus

• Drug Use• Inherited Thrombophilias• Trauma • Uterine abnormalities

Early Pregnancy FailureClassification

• Threatened

• Inevitable

• Incomplete

• Missed

Early Pregnancy FailureSonographic Features

• No gestational sac at β-hcg of 3000

• No yolk sac with gestational sac of 13 mm

• 5 mm crown-rump length with no fetal heart tones

• No fetus with gestational sac of 25 mm mean diameter

• No fetal heart tones after 10-12 weeks gestational age

Early Pregnancy FailureManagement

• Expectant– 81% will resolve spontaneously

• Prostaglandin E1 (Misoprostol)– Off-label use– Orally or vaginally – 85% completed abortion in 7 days

• Manual Vacuum Aspiration– Performed at bedside with sedation and/or local anesthesia– Patient must be stable– 3% failure rate (?)

• Dilation & Curettage– Performed in OR under sedation or general anesthesia– Almost 100% success rate– Increased risk of intrauterine scarring with sharp curettage

Placental Abruption

• Separation of the placenta from the uterine wall

• Accounts for ~30% of episodes of bleeding in 2nd half of pregnancy

• 1 in 75 to 1 in 226 deliveries

Placental AbruptionRisk Factors

• Increasing parity and/or maternal age• Cigarette smoking• Cocaine abuse• Trauma• Maternal hypertension• PPROM• Multiple gestation• Polyhydramnios• Thrombophilia• Uterine malformations• Placental anomalies• Previous abruption

Placental AbruptionClinical Manifestations - Grading

• Grade 1 (40%)– Slight vaginal bleeding, minimal uterine irritability– Normal maternal and fetal VS

• Grade 2 (45%)– Moderate bleeding with significant uterine irritability or

contractions– Maternal HR often elevated– FHR often shows signs of compromise

• Grade 3 (15%)– Severe bleeding, painful contractions– Maternal hypotension– Significant risk of fetal death

Placental AbruptionDiagnosis

• Clinical– Severe abdominal pain– Titanic uterine contractions– Abnormal fetal heart rate (bradycardia, decelerations)– Bleeding silent in 10-20%

• Sonography– Low sensitivity

• Laboratory Findings– Anemia– Consumptive coagulopathy

Placental AbruptionManagement

• Expectant– 82% have term delivery if abruption occurs < 20 weeks GA– Only 27% have term delivery if abruption occurs > 20 weeks

GA

• Delivery– Non-reassuring fetal status– Women presenting at or near term

• Supportive Care– Blood products

Uterine RuptureRisk Factors

• Prior uterine surgery– Cesarean section– Myomectomy

• Enlarged uterus– Multiple gestation– Polyhydramnios– Fetal macrosomia

Uterine RupturePresentation

• Abdominal pain

• Vaginal bleeding

• Non-reassuring fetal heart rate

Uterine Rupture

Uterine RuptureManagement

• Stabilize the patient (ABC’s)

• Emergency cesarean delivery

Fetal parts in abdomen

Non-Pregnant

Gynecologic Sources of Acute Pelvic Pain

Gynecologic

• Adnexal mass

• Ovarian torsion

Ovarian Mass

• Most benign and malignant ovarian masses are cystic

• Incidence 5-15%

• Divided into 2 groups– Cystic neoplasms– Functional ovarian cysts

Ovarian MassSymptoms

• Asymptomatic

• Cyclic pain– May indicate endometriosis

• Intermittent, severe pain– Torsion

• Increased abdominal girth– Ascites– Concerning for malignancy

• Hormonal disruption– Abnormal menses– Virilization (increased

androgens)

Ovarian MassDiagnosis

• Ultrasound– TVUS or TAS– Simple or complex– Fluid or solid– Color flow doppler to

evaluate for torsion

• CT scan– If concern for

malignancy– Ascites– Omental masses / caking– Liver nodules

Simple Ovarian Cyst

Polycystic Ovary“string of pearls”

Endometrioma“ground glass”

Complex Mass

Ovarian MassManagement

• Pain control

• Observation vs Surgical excision

• Risk of torsion if >5cm

Ovarian Torsion

• Twisting of adnexal components– Ovary and fallopian tube rotate around the broad

ligament

• Mass is identified in 50-80% of unilateral torsion

• 70% in women 20-39 yo– 20-25% during pregnancy

Ovarian TorsionPresentation

• Sharp lower abdominal pain

• Usually localized to involved side

• Sudden in onset, worsening over several hours

• Nausea and vomiting

• Low grade fever suggests adnexal necrosis

Ovarian TorsionDiagnosis

• Sonography (color doppler)– Disruption of normal adnexal blood flow

– Blood congestion and edema

– Can also characterize any pelvic masses

– Presence of flow does NOT rule-out torsion

Ovarian TorsionManagement

• Adnexal detorsion– 95% success rate

• Excision of associated ovarian lesions

• Removal of ovary and tube often unnecessary

Infectious Diseases

• Vaginitis

• Cervicitis

• PID• TOA• Fitz-Hugh-Curtis Syndrome

Vaginitis

• Bacterial Vaginosis

• Candida vaginitis

Bacterial Vaginosis

• Caused by alteration in normal vaginal flora

• Reduction in Lactobacillus species– Hydrogen peroxide producers

• Increase in Gardnerella vaginalis, Ureaplasma urealyticum, Mobiluncus species, Mycoplasma hominis, and Proteus species– Anaerobic

Bacterial VaginosisDiagnosis

• Malodorous vaginal discharge

• 3 Criteria for diagnosis– Wet Prep

• Clue cells

– pH > 4.5

– “Whiff test”• Release of volatile amines by anaerobic metabolism

Bacterial VaginosisWet Prep - Clue Cells

Bacterial VaginosisTreatment

• Metronidazole PO– 500 mg BID x7 days

• Metronidazole gel 0.75%– 1 applicator intravaginally qday x5 days

• Clindamycin cream 2%– 1 applicator intravaginally qhs x5 days

Candida Vaginitis

• Related to immunosuppresion, diabetes, pregnancy, antibiotic use

• Can be sexually transmitted

Candida VaginitisDiagnosis

• Pruritis, pain, swelling

• Thick white discharge

• KOH Prep– Yeast buds and hyphae

CandidaKOH Prep – Hyphae & Spores

Candida VaginitisTreatment

• Oral– Fluconazole 150 mg x1– Repeat in 48 hours if symptomatic

• Intravaginal– Butoconazole– Clotrimazole– Miconazole– Nystatin– Tioconazole– Terconazole

Cervicitis

• Trichomonas

• Neisseria gonorrhea

• Chlamydia trachomatis

Trichomoniasis

• Most prevalent non-viral STI in US

• Most men are asymptomatic

Trichomoniasis Diagnosis

• ½ women are asymptomatic

• Foul, thin, yellow/green discharge

• Dysuria, dyspareunia, pruritis, pain

• Microscopic identification

Trichomonas“Strawberry Cervix”

TrichomonasWet Prep

TrichomoniasisTreatment

• Primary Therapy– Metronidazole

• 1g PO x1

– Tinidazole• 2g PO x1

• Alternative Regimen– Metronidazole

• 500 mg PO BID x7 days

Neisseria gonorrhea

• Often asymptomatic– Regular screening for those at risk

• Vaginitis or cervicitis– Non-irritating white-yellow discharge

• Diagnosis– Endocervical culture +/- empiric antibiotic

coverage

Neisseria gonorrhea Treatment

• Ceftriaxone– 250 mg IM x1

• Cefixime– 400 mg PO x1

• Treat for Chlamydia

• Treat sexual partnersCenter for Disease Control and Prevention, 2010

Chlamydia trachomatis

• 2nd most prevalent STD in US

• Many are asymptomatic

• Mucopurulent discharge

• Diagnosis– ELISA

Chlamydia trachomatismucopurulent discharge

Chlamydia trachomatisTreatment

• Azithromycin– 1 g PO x1

• Doxycycline– 100 mg PO BID x7 days

• Treat for Neisseria

• Treat sexual partnersCenter for Disease Control and Prevention, 2010

Pelvic Inflammatory Disease (PID)

• Infection of upper reproductive tract organs

• AKA acute salpingitis

• Incidence unknown

PIDMicrobiology

• ALWAYS polymicrobial

• Cultures from different sites in same women differ

• N. gonorrhea, T. vaginalis, and C. trachomatis commonly recovered

• Other organisms such as E. coli, Enterococcus, and Bacteroides have been implicated

PIDDiagnosis

• Clinical

• Sexually active female at risk with “pelvic pain and other etiologies not feasible”– Uterine tenderness– Adnexal tenderness– Cervical motion tenderness– Mucopurulent cervical discharge– Red, inflamed cervix

PID - Diagnosis

• Oral temp > 38.3 C

• Mucopurulent discharge

• Abundant numbers of WBC on saline microscopy

• Elevated ESR/CRP

• Laboratory documentation of infection with N. gonorrhea or C. trachomatis

Fitz-Hugh-Curtis Syndrome

• Ascending pelvic infection– AKA perihepatitis

• RUQ pain, R shoulder pain (referred)

• RUQ U/S, LFTs are normal

• Treatment is same as PID

Fitz-Hugh-Curtis SyndromeLaparoscopy

PIDOutpatient Treatment Regimens

Ceftriaxone250 mg IM x 1

OR

Cefixime400 mg PO x 1

AND

Azithromycin1 g PO x 1

OR

Doxycycline100 mg PO BID x 7 days

WITHor

WITHOUT

Metronidazole500mg PO BID x 14 days

PIDInpatient Treatment Regimens

Parenteral Regimen ACefotetan 2 g IV every 12 hours

ORCefoxitin 2 g IV every 6 hours

ANDDoxycycline 100 mg orally or IV every 12 hours

Parenteral Regimen BClindamycin 900 mg IV every 8 hours

ANDGentamicin loading dose IV or IM (2 mg/kg), followed by

maintenance (1.5mg/kg) every 8 hours OR single-daily dosing (5mg/kg) every 24 hours

Tubo-Ovarian Abscess (TOA)

• Eval PID patient’s for TOA with ultrasound

• Patient’s receive IV antibiotics until they are afebrile at least 24 hours

• Surgery is rarely required– Consider for abscesses >8 cm– Failure of antibiotic therapy

PIDTuboovarian Abscess

References• Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 28 Jan. 2011. Web. 18 Apr. 2012.

http://www.cdc.gov/std/treatment/2010/toc.htm.• Gabbe, Steven G., Jennifer R. Niebyl, and Joe Leigh Simpson. "Chapter 18: Antepartum and Postpartum Hemorrhage."

Obstetrics: Normal and Problem Pregnancies. New York: Churchill Livingstone, 2002• Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K. Aaron. "Chapter 98:

Selected Gynecologic Disorders.” Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.

• Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K. Aaron. "Chapter 176: Acute Complications of Pregnancy." Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.

• Williams, John Whitridge., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L. Hoffman, Karen D. Bradshaw, and F. Gary. Cunningham. "Chapter 6: First-Trimester Abortion." Williams Gynecology. Nueva York: McGraw-Hill, 2008.

• Williams, John Whitridge., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L. Hoffman, Karen D. Bradshaw, and F. Gary. Cunningham. "Chapter 7: Ectopic Pregnancy." Williams Gynecology. Nueva York: McGraw-Hill, 2008.

• Williams, John Whitridge., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L. Hoffman, Karen D. Bradshaw, and F. Gary. Cunningham. "Chapter 9: Pelvic Mass.” Williams Gynecology. Nueva York: McGraw-Hill, 2008.

Questions??