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Women have two additional diseases that must be added to the differential diagnosis of their abdominal pain. PID and ovarian torsion.
Pelvic Inflammatory Disease (and Tube-Ovarian Abscess)
Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well
History
- Symptoms
- Lower Abdominal Pain
- Fevers
- Vaginal Symptoms (especially discharge)
- Red Flags
- High risk sex
- Delayed presentations
- IUD (Don’t need to remove if patient has PID, but needs to be noted)
Exam
It is controversial whether all women with pelvic complaints need a full speculum exam (my opinion is that they don’t and that it almost never changes management)
- Bimanual Exam
- Cervical motion tenderness
- Adnexal/Uterine tenderness
Testing
- Gonorrhea
- Chlamydia
- CBC
- Ultrasound to evaluate for tubo-ovarian ABSCESS
Treatment
Patients who are septic, unable to keep antibiotics down, getting worse on oral antibiotics, pregnant, immunosuppressed, or with TOA generally get admitted for IV antibiotics.
- Treat chlamydia
- Doxycycline
- Treat gonorrhea
- Cefoxitin/cefotetan (2nd generation cephalosporins provides better anaerobic coverage than a third generation cephalosporins)
- Ceftriaxone
- Treat anaerobes
- 2nd generation cephalosporin
- Metronidazole
Ovarian Torsion
Ovary twists on its pedicle and becomes ischemic
NOTE: The ovary actually has a dual arterial blood supply. When the pedicle twists, it’s not the artery is being pinched off that causes ischemia, rather its the venous outflow becoming blocked and resulting in swelling of the ovary and the poor perfusion that results)
History
- Sudden onset pain
- Severe pain with vomiting
- Usually unilateral pain (although 25% have bilateral pain)
Exam
- Peritonitis in the lower abdomen
- Large mass or adnexal tenderness on pelvic exam
Testing
- Pelvic ultrasound (with doppler)
- Swollen/edematous ovary
- Large cyst/mass causing the torsion
- IMPORTANT- You can frequently see normal arterial flow on the doppler (remember DUAL BLOOD SUPPLY)
- CT scan with NORMAL ovaries 100% negative predictive value for torsion in some studies
Treatment
OBGYN consult for surgery
Additional Reading
- Pelvic inflammatory disease review (Medscape)
- Ovarian torsion review (Medscape)
Thank you so much for making this podcast possible, Zack!
I’m a third-year medical student at the University of Sao Paulo (Brazil). Med school here is 6 years long and I’m planning to take the USMLE Step 1 by December next year. Even though my EM clerkship is only during my 6th year of med school, your podcasts help me study when I’m working out, walking on the street, getting ready to go to class, etc. Times that otherwise would be wasted or, at least, not as productive as they are thanks to these podcasts!
This might not seem much, but I’m sure you’re helping tremendously a lot of students, in the US and worlwide!
Keep up the great work, Zack! I wish you all the best,
Rafael