1 Barbara Plovie, MN, ARNP, BC April, 2011Acute Pelvic Pain Barbara Plovie, MN, ARNP, BC April, 2011

2 LEARNER OBJECTIVES Identify acute pelvic pain as an urgent patient complaint. Apply universal and etiology specific subjective, objective, assessment, and plan to at least two case studies. Access acute pelvic pain standard of care resources.

3 CHIEF COMPLAINT Rapid onset Colic/cramping obstruction Entire abdomenPerforation or ischemia Muscular contraction or obstruction Reaction to an irritating fluid in the peritoneum Rapid onset Colic/cramping Entire abdomen Referred pain Pelvic organ innervation Berek (2007)

4 PELVIC NERVES Abdominal wall Lower abdominal wall, lower back, vulvaPelvic floor Uterus, cervix, broad ligament, bladder Ovaries, fallopian tubes T12 – L1 L1 – L2 S2 – S4 T11 – L2 and S2 – S4 T11 – L2 Berek, 2007

5 UNIVERSAL SUBJECTIVE Menstrual, LMP Bleeding, discharge ContraceptionGYN HX Menstrual, LMP Bleeding, discharge Contraception Sexual activity Gyn infections Pregnancy/Infertility Gyn/medical diagnosis PAIN HX How and when started Intermittent/constant Dull/sharp/crampy Scale 1 to 10 GI sx Urinary sx Berek (2007); Barnhart (2008)

7 A DAY IN THE LIFE

8 TWILIGHT WHAT ELSE DO YOU WANT TO KNOW?16 yo accompanied by her mother c/o abdominal pain x 24 hours. Twilight denies nausea or vomiting and can’t remember her LMP. Missy also denies sexual activity and feels that her mother is over reacting. Missy wants to get back to school. WHAT ELSE DO YOU WANT TO KNOW?

9 WHAT IS YOUR DIFFERENTIAL?Pulse elevated Hct = 34% Sed rate WNL Urinalysis WNL Urine hCG is positive Twilight refuses a pelvic exam Abdominal exam reveals diffuse lower pelvic pain, normal bowel tones, no CVA tenderness

10 PREGNANCY

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12 VIABLE IUP Objective Urine culture CBC Sed rate Abd ultrasoundDifferential UTI Kidney, ureters Appendicitis Cholilithiasis PID Musculoskeletal Ovarian cyst

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14 INTRAUTERINE SAC Ectopic and abortion precautions Quantitative hCGObjective Quantitative hCG Repeat hCG 48 hrs Repeat U/S ? Progesterone Differential Ectopic Early IUP Blighted ovum Ectopic and abortion precautions

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17 ECTOPIC ETIOLOGY Tubule pathology ? IUD SUBJECTIVEUniversal subjective Triad 50% accurate Amenorrhea Bleeding Pain ACOG (2005); Berek (2007)

18 OBJECTIVE Universal objective Quantitative hCG Progesterone UltrasoundRepeat hCG 48 hours RH status if bleeding Consider: CBC, sed rate ACOG (2008); Berek (2007)

20 Medical Management Method of action Indications ContraindicationsSingle, two dose, multiple dose

21 METHOTREXATE DAY 1 Stat hCG plateau or risingSerum creat, CBC, SGOT, Blood type, RH Methotrexate dose 50mg/meter sq IM D/C folic acid, NSAIDs, ETOH, sunlight Administer MicRhogam if known RH neg

22 Repeat MTX dose if < 15% fall in hCG hCG every 2-3 days initially Repeat hCG and HCT DAY 7 hCG, CBC, SGOT Repeat MTX dose if < 15% fall in hCG Follow up hCG every 2-3 days initially Then hCG wkly until non-pregnant value Contraception x 2 mo ACOG (2008)

23 TWILIGHT IS PREGNANT DIFFERENTIAL NEXT STEP Confidentiality!Viable IUP Threatened AB Ectopic Ovarian cyst Abdominal U/S Depending on U/S, serum hCG Refer for care Confidentiality!

25 CHAU WHAT ELSE DO YOU WANT TO KNOW?Chau thinks that she has the flu. She is c/o cramping lower abdominal pain that seems to be worsening as the day goes on. She’s now feverish and she is becoming nauseous. Her LMP was one week ago. She’s had multiple abdominal surgeries due to a car accident and doesn’t know if she has an appendix or not. WHAT ELSE DO YOU WANT TO KNOW?

26 WHAT IS YOUR DIFFERENTIAL ?Temp 100F, P elevated, BP WNL WBC slightly elevated Sed rate slightly elevated Abdominal exam compromised due to multiple incisions and pt body habitus, some diffuse pain, no rebound tenderness No CVA tenderness + vaginal amine odor noted, + clue cells + CMT, unable to perform rest of pelvic exam

29 MINIMUM CRITERIA Cervical motion tenderness -OR- Uterine tendernessIf no other cause of symptoms identified and Cervical motion tenderness -OR- Uterine tenderness Adnexa tenderness PID CDC (2008)

31 CDC GUIDELINES Cefoxitin 2g IM + probenecid 1 g po -OR-Ceftriaxone 250 mg IM single dose -OR- Cefoxitin 2g IM + probenecid 1 g po -OR- Other third generation cephalosporin IM plus Doxycycline 100 mg po bid x 14 days with or without Metronidazole 500 mg po bid x 14 days

32 ALTERNATIVE assume community and pt risk of GC is lowLevofloxacin 500 mg po dly x 14 days OR Ofloxacin 400 mg po bid x 14 days with or without Metronidazole 500 mg po bid x 14 days Note: regimens with a quinolone agent are no longer recommended for PID

33 FOLLOW UP Pelvic rest Partner exam 3 days post dx 7 to 10 days post dxSTD test of cure Prevention & contraception Marrazzo, et al. (2007); Berek (2007); Youngkin & Davis (2004)

34 HOSPITALIZE Surgical emergency Pregnancy Severe illnessCannot use oral antibiotics Tubo-ovarian abscess CDC (2008)

35 CHAU has PID RX according to CDC guidelines and pt med allergy hxProbable bacterial vaginosis Add oral metronidazole Follow up visit in 3 days

36 NALALIA WHAT ELSE DO YOU WANT TO KNOW?Natalia left her daughter’s soccer practice due to a strong vaginal odor she was sure everyone else could smell. Pt is just finishing her menses and is surprised that she is still cramping. She is distraught and needs to return to soccer practice before her daughter misses her. WHAT ELSE DO YOU WANT TO KNOW?

37 WHAT IS YOUR DIFFERENTIAL ?Vitals WNL Pt refuses blood draw Urinalysis WNL Negative hCG WBC on wet mount Normal abdominal exam, no CVA tenderness Pelvic exam reveals retained tampon Bimanual exam WNL

38 NATALIA is at risk for PIDCan RX as though pt has PID Or, RX Doxycycline 100mg bid x 7 days Give PID and toxic shock precautions Pelvic rest x 7 days Follow up by phone Note: Reassure pt re frequency of retained tampon in normal Gyn practice

39 TUBO-OVARIAN ABSCESS ETIOLOGY SUBJECTIVE Sequela of acute salpingitisUsually bilateral, can be unilateral SUBJECTIVE Pain and temp > 7 days PID sx Berek (2007)

40 OBJECTIVE Tender Firm Fixed bilateral massesBILATERAL EXAM Tender Firm Fixed bilateral masses ULTRASOUND Confirm diagnosis Hospitalize Indeterminate Laparoscopy (Berek, 2007)

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42 ASHONTI WHAT ELSE DO YOU WANT TO KNOW?Ashonti is accompanied by her husband. She called him home from work with sudden onset sharp, debilitating right lower quadrant pelvic pain. By the time Adam got home, the pain subsided. The couple was concerned and decided to come in. Ashonti’s LMP was three weeks ago. The couple is planning pregnancy. WHAT ELSE DO YOU WANT TO KNOW?

43 WHAT IS YOUR DIFFERENTIAL ?Vitals WNL CBC WNL Sed rate WNL Urinalysis WNL Wet mount WNL hCG negative Abdominal exam reveals mild right lower quadrant pain, no CVA tenderness Pelvic exam is WNL with some diffuse left adnexa pain

44 ASHONTI RUPTURED A CYSTAshonti is now off hormonal contraception which may inhibit ovarian cysts Offer an abdominal and transvaginal U/S to verify your diagnosis Follow up by phone

46 OVARIAN CYST Physiologic Follicular or corpus luteumETIOLOGY Physiologic Follicular or corpus luteum Simple or hemorrhagic SUBJECTIVE Adolescence Sudden onset of pain, ? unilateral Luteal phase Generalized abdominal pain Dizziness, faint, nausea Berek (2007)

48 SIMPLE OVARIAN CYST gynaecologist4u.com

49 HEMORRHAGIC CYST radiology.rsnajnls.org

51 ZAMINA Zamina is 17 yo and accompanied by her gym coach and father. Morgan doubled up in pain during competition. She has amenorrhea during gymnastics season according to her father. Zamina is in too much pain to answer any questions. This is an emergency and the aid car is ten minutes away. What would you do for Morgan during that ten minutes?

52 R/O OVARIAN TORTION Abdominal U/S with color flowWhile it is tempting to initiate an IV and draw blood, the medics can perform these procedures in the aid car. They cannot perform an U/S.

53 TORTION SUBJECTIVE GYN ETIOLOGY Benign cystic teratomaPolycystic ovary SUBJECTIVE Rapid onset pelvic pain Severe and constant -or- intermittent Lifting, exercise, intercourse Autonomic reflexes (nausea, emesis, anxiety) Berek (2007)

54 OBJECTIVE Mild temp CBC, sed rate mild leukocystosisAbdominal tenderness Lower localized rebound tenderness Large unilateral pelvic mass ORDER U/S with DOPPLER FLOW

56 Voget (2006)

57 BELLA WHAT ELSE DO YOU WANT TO KNOW?While she is there, Bella’s mom, Monica would like to be seen for central lower pelvic pain that she’s had on and off for the past two weeks. She has seen her primary care provider with no relief. Bella is post menopausal and has no medical insurance. WHAT ELSE DO YOU WANT TO KNOW?

58 WHAT IS YOUR DIFFERENTIAL?Vitals WNL CBC WNL Sed rate WNL Urinalysis low specific gravity, + blood, +WBC Wet mount WNL Abdominal exam reveals low central pelvic discomfort, no CVA tenderness Pelvic exam no CMT, adnexa right and left not felt, low central pelvic pain, no fundal tenderness

59 BELLA has a UTI Don’t let the UA fool you. Monica has been pushing fluids Urine culture At risk for pyelo due to length of sx RX with broad-spectrum generic antibiotic for at least one week

60 NON GYN Urine culture Abdominal ultrasound CT with contrast ConsultCONTINUE WORK UP Urine culture Abdominal ultrasound CT with contrast Consult ? Refer

61 SUMMARY Same day appointment Universal objective at check-inArrange ultrasound Consult as necessary Follow up

62 DON’T CHASE ZEBRAS media.gmu.edu

63 CLINICAL CUUNDRUM Adeena is a 16 yo who presents with her mother for an ER follow up visit. Adeena was in the ER three days ago with a c/o pelvic pain. U/S at that time revealed a right collapsing hemorrhagic cyst. Adeena’s mother brings a copy of the ER visit and U/S report. Adeena’s pain has now resolved. You prescribe birth control pills for cyst suppression and schedule an U/S in 8 weeks for follow up. media.gmu.edu

64 TWO WEEKS LATER FOUR WEEKS LATERAdeena’s pain has not resolved. Her father initially refused to have his daughter on birth control pills. The father now consents to initiating BCP. FOUR WEEKS LATER Four weeks later, Adeena returns to clinic after missing three days of school due to pelvic pain. She is taking the birth control pills continuously as prescribed. She has a negative pregnancy test. All labs WNL. What do you do next? media.gmu.edu

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