10/28/2016
Acute pelvic pain
I have no disclosures to report
UCSF Obstetrics and Gynecology Update
October 2016
Jennifer Kerns, MD, MS, MPH
Assistant Professor, UCSF
Department of Obstetrics, Gynecology and Reproductive
Sciences
For those of you working November 1…
Gynecologically speaking, what could
possibly be wrong?
C
G
B
A
F
E
D
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10/28/2016
Gynecologically speaking, what could
possibly be wrong?
A.
B.
C.
D.
E.
F.
G.
Intrauterine pregnancy
PID
Ectopic pregnancy C
Tubo-ovarian abscess
Ruptured ovarian cyst
Torsion
Fibroids
Case 1: Miranda Amanda
It’s 4:00 – you think your last patient is a no-show, and then…
G
she shows up.
B
New patient, scheduled for pap.
A
F
E
D
You walk in the room and she’s holding her lower belly.
She tells you that she’s had this pain for the last few days and it
started right after she had sex.
You ask her more about the pain…
Case 1: Miranda Amanda’s pain
Constant, started more mild, now more painful, across entire
lower abdomen
She was able to go to work yesterday, but was in pain
Reports the pain 6/10
Nothing makes it better or worse
Some nausea, no vomiting, no diarrhea, unsure about fever/
chills
No vaginal discharge, no vaginal bleeding
Case 1: Miranda Amanda’s history
29 yo G0
3 lifetime partners – currently with partner for 6 months
Has had LNG-IUS for 2 years - amenorrheic
Had chlamydia age 15 and was treated
Appendectomy at age 10
What’s on your DDX?
Ectopic
pregnancy
Pelvic
inflammatory
disease (PID),
+/-tubo-ovarian
abscess (TOA)
Ectopic pregnancy
Other adnexal mass
Ectopic pregnancy
Ruptured ovarian cyst
Fibroids
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Pelvic inflammatory disease:
More data on Miranda Amanda
Temp 38.0, otherwise normal vitals
Diffusely tender to palpation across entire lower abdomen
On pelvic exam, IUD strings visible, no discharge or bleeding, nl
appearing cervix, +cervical motion tenderness, +adnexal
tenderness L>R
what where why who when how
Spectrum of inflammatory disorders
Endocervical canal = barrier
Vaginal flora
salpingitis
Tubo-ovarian
abscess (TOA)
endometritis
upper tract
peritonitis
cervicitis
Sexually transmitted pathogens can disrupt this barrier
chlamydia or gonorrhea infection 15% progress to PID
What’s 1st on your differential? What’s after that?
Risk factors: age 16-24, hx of STI/PID, multiple partners,
partner w/ STI
CDC 2015 Sexually Transmitted Diseases Treatment Guidelines
Diagnosis of PID
Wide variation in presentation imprecise clinical findings
Clinical dx PID 65-90% PPV for salpingitis (via laparosc)
Even mild cases can lead to infertility
Infertility=17%, recurrent PID=14%, CPP=37%
Infertility assoc w/ delay in treatment
Low threshold for diagnosis
Favor sensitivity (and false pos)
Peipert et al. AJOG 2011
Gaitan et al. Infec Dis Obstet Gynecol 2002
Ness et al. AJOG 2002
Weisenfeld Obstet Gynecol 2012
Criteria for diagnosis of PID – NEW!!
Initiate presumptive treatment
Sexually-active young women or women at risk of STIs
Pelvic or lower abdom pain w/ no other known cause
CMT or uterine tenderness or adnexal tenderness
Additional (optional) criteria
Temp > 101 (38.4)
Mucopurulent discharge, friability
++ WBCs on saline wet mount of vag fluid
ESR, CRP
+ chlamydia or gonorrhea
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10/28/2016
Further workup
Ultrasound?
Yes: diagnosis of TOA, consideration of other etiologies
No: if pt is afebrile & access to usg difficult
STI testing: GC, CT, HIV, consider syphilis
★★Ceftriaxone
★★Doxy
(Metronidazole)
Azithro
Indications for hospitalization:
Treatment of PID: oral regimens
Azithro
(Metronidazole)
High fever
Unable to tolerate Pos (n/v)
Can’t r/o surgical emergency (e.g. appy, torsion)
TOA
Pregnancy
Outpatient mgmt failed
250mg IM OR Cefox 2g IM (+probenicid 1g PO)
100mg BID x14 days
500mg BID x14 days
500mg IV QD x2 days
250mg PO QD x14 days
500mg PO BID x14 days
Levofloxacin/ ofloxacin/ moxifloxacin
(Metronidazole)
500mg BID x14 days
Follow-up after PID
Treatment of PID: parenteral regimens
★★
★★
★★
★★
★★
Cefotetan
Cefoxitin
Doxy
2g IV q12 or
Complete 14 days w/
2g IV q6
doxy alone 100mg bid
100mg IV or PO BID
Clindamycin
Gentamicin
Complete 14 days w/
900mg IV q8
doxy alone 100mg bid
(daily dosing or q8) or clinda alone 450mg qid
For TOA……………………………
Complete 14 days w/
doxy + clinda
doxy + metronidazole
• For cephalosporin allergy
• Only if low risk for GC
• If GC +, treat based on
sensitivities or consult ID
Re-examine patient in 48 hours
If no improvement, consider
hospitalization
ultrasound (80% treatment failures bc of undiagnosed TOA)
medication change
Test and treat partner(s)!
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10/28/2016
Case 2: Fernanda Amanda:
Miranda Amanda’s twin sister
Difficulty walking into exam room
You know her well because you delivered her first baby 3 months ago
Vitals normal except HR 105
Other relevant history…
h/o dermoid cyst, Lapx left salpingo-oophorectomy 3 years ago
BMI 40
Exclusively breastfeeding, no menses since delivery
Her pain
“excruciating”, constant but w/ episodes of incr intensity
started right after sex yesterday
+ n/v
p k
in
th
.
a
is
w
ee
n
es
t p
u m
rg
Fernanda Amanda’s exam
Add-on, same day appt for a patient with pelvic pain
– uncomplicated NSVD
H a
llo
Th
e f
e
Granberg et al. Best Pract Res Clin Obstet Gynaecol 2009
Gjelland et al. AJOG 2005
Th
e l
a
ar
of
ha
llo
w
ee
n
is
ev
e.
..
c ..
.
No assoc w/ size, locularity
r..
93% success in largest study
18%
...
Unilocular, early, >5cm?
24% 25%
bo
lo
f s
t
More successful if
33%
m
Consult radiology/ interventional radiology
samhainophobia.
B. The largest pumpkin ever grown weighed 836
lbs.
C. Halloween is thought to have originated in 200
A.D.
D. Orange is a symbol of strength and endurance;
black is a symbol of death.
sy
Transvaginal, transrectal, transgluteal, percutaneous
A. The fear of halloween is called
ou
gh
t t
o
Early drainage may result in higher efficacy
Which of the following is false:
O r
an
ge
is
Drainage of TOA
+guarding, +rebound, +peritoneal signs
Diffuse tenderness w/ abdom and pelvic exam, R>L
No masses felt but limited by pt’s BMI of 40
(Most likely) DDX at this point?
But first, rule out…?
1. Torsion
2. Ruptured hemorrhagic cyst
3. Fibroids
4. PID/ TOA
1. Appendicitis
2. Ectopic pregnancy
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10/28/2016
Fernanda Amanda’s workup
Transvaginal ultrasound obtained
Radiologist calls in a panic:
“There’s no flow to the right ovary!”
1. Torsion
2. Ruptured hemorrhic cyst
3. Fibroids
4. PID/ TOA
Adnexal (ovarian) torsion
Complete or partial rotation of ovary or tube on its ligaments
Often results in impedance of blood flow pain
Risk increases w/ size of mass
Your next step is to…
More likely w/ benign masses
Rush her to the OR?
Ask if they see an adnexal mass
More common in pregnancy
7cm solid and cystic mass on R ovary, no free fluid, L ov WNL
Consistent with dermoid
Uterus 11 x 7 x 5 w/ 5cm intramural fibroid at fundus
Varras et al. Clin Exp Obstet Gynecol 2004
Pansky et al. Obstet Gynecol 2007
Houry et al. Ann Emerg Med 2001
Torsion diagnosis
Ultrasound to diagnose torsion
Prospective study of 199 women with acute pelvic pain:
Which of the following is true?
56%
A. Torsion is a clinical diagnosis
B. Ultrasound is the best way to diagnose
Specificity
PPV
Absent intra-ovarian vascularity
52%
91%
50%
Absent arterial flow
Absent venous flow
...
di
a
ay
to
be
st
w
21%
76%
100%
100%
99%
97%
100%
92%
85%
NPV
88%
91%
96%
100%
Skill & experience required (sensitivity and specificity in practice
are lower than in research studies)
Other studies: sensitivity 43%, specificity 92% for absent venous
flow
th
is
CT
so
U l
tr
a
To
rs
io
n
e
un
d
a
is
c li
th
e
ni
ca
l
be
st
w
d i
ag
n.
..
a.
..
10%
is
Sensitivity
Tissue edema
34%
torsion
C. CT is the best way to diagnose torsion
Finding
Nizar et al. J Clin Ultrasound 2009
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10/28/2016
How long before the ovary dies?
Fernanda Amanda’s treatment
Prompt surgical evaluation/ treatment
Untwist ovary + remove cyst… no salpingo-oophorectomy!
Exceptions?
Post menopausal women
Concern for malignancy
Technically difficult (pregnancy…)
Prevention for the future?
Ovarian suppression
Harkins et al. J Minim Invasive Gynecol 2007
Mashiach et al. Fertil Steril 1990
Depends on degree of ischemia
One study in children… median
time from onset of pain:
Viable ovary = 14 hrs
Non-viable ovary = 27 hrs
• OCPs
• Depo
• Nexplanon
Bider et al. Surg Gynecol Obstet 1991
Oelsner et al. Fertil Steril 1993
Early diagnosis is critical to save ovarian function
Gyn consult (even before ultrasound) if high suspicion
Fernanda Amanda’s fibroid
Fibroids rarely cause acute or severe pain
Acute pain
Degenerating
Torsion (twisting on a pedicle)
usg shows solid mass
Prolapsing through the cervix
crampy abd pain + bleeding
Degenerating fibroid
Risk factors
very large fibroids (>10cm)
pregnancy
Onset gradual, not acute
Exam
localized tenderness over the fibroid
no peritoneal signs
can have low grade fever, incr WBC
Usg shows fibroid; cystic changes can suggest degeneration
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10/28/2016
Case 3: Leandra Amanda
the younger sister
24yo G0, sudden onset pain after sex, brought in by friend
Pt is doubled over, crying
Pain started on left, now all over lower abdomen
Worse w/ movement and lying flat
No relevant PMH
What’s on the differential?
Rule out an ectopic!
Ruptured hemorrhagic cyst
Common!
Most likely cyst: Corpus luteum cyst, follicular cyst
Less likely cyst: dermoid, endometrioma, TOA
Usually occurs in luteal phase
Pain is from blood
accumulating within ovary stretching capsule
causing peritoneal irritation
Anti-coagulated / bleeding disorder (VWD) = risk
OCP use (or other methods of ovarian suppression) = risk
More data for Leandra Amanda
UPT negative
Normal vitals
TTP across lower abdomen, +guarding
Normal labs (hct = 35, repeat = 34)
Usg: ++ free fluid in pelvis, collapsed cyst
Usg can be normal (no collapsed cyst seen and/or minimal
free fluid)
Management of Adnexal Masses
Benign vs malignant
> 10cm, papillary or solid, irreg, high color Doppler
Simple cysts are almost always benign
> 2,700 PM women, simple cysts <10cm
Mean f/u 6.3 yrs
No cases of cancer, 2/3 resolved spontaneously
Observation recommended, even in PM women
1 yr if no solid components, 2 yrs if solid
Modesitt et al. Obstet Gynecol 2003
ACOG Practice Bulletin #174 2016
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10/28/2016
Take-aways
Always order a pregnancy test
Have a low threshold to treat PID
Leave an IUD in place, and only remove if
no improvement with PID treatment
Clinical diagnosis crucial – usg supportive
Prompt evaluation and treatment for
torsion
Common, supportive tx, prevention
Consider observation if appears benign
9