GU

Question 1

Risk factors for ectopic pregnancy?

Answer 1

Hx PID
Hx ectopic pregnancy
Tubal surgery including BTL
Previous pelvic or abdominal surgery
Tubal pathology
In utero DES exposure
IUD
Smoking
Infertility/infertility Rx

Question 2

Classic presentation of ectopic pregnancy?

Answer 2

Abdominal pain, delayed menses, vaginal bleeding

Remember that paradoxic bradycardia can occur in ectopic pregnancy, so vital signs should not be reassuring.

Question 3

Initial actions and primary survey in ectopic pregnancy?

Answer 3

ABCs
Pregnancy test
Monitor, 2 large bore IVs
CBC, T&S, quantitative beta-hCG
Narcotic analgesia
Immediate bolus of NS if ill-appearing, severe pain, or abnormal vitals
Consider O- transfusion if hypotension
FAST exam if concern for rupture
Bedside pelvic US 

Call Ob-Gyn immediately if +FAST with +pregnancy test

Question 4

Diagnostic work-up in stable patients with possible ectopic pregnancy?

Answer 4

TVUS to evaluate for the presence or absence of an IUP. If visualized, concurrent ectopic pregnancy is statistically unlikely unless the patient has received fertility treatments.

Beta-hCG

Question 5

Signs of IUP on TVUS?

Answer 5

Earliest - double decidual sac sign (4.5-5 weeks after LMP)
Yolk sac (5-6 weeks)
Fetal pole and embryonic cardiac activity (6-7 weeks)

Question 6

What has a 100% predictive value for IUP?

Answer 6

Yolk sac

Question 7

Discuss interpretation of quantitative beta-hCG levels in early pregnancy.

Answer 7

Produced by trophoblasts, doubles Q48-72 hours in T1.

Discriminatory zone for when an IUP should be visible on TVUS: 1500-2000 mIU/mL

Ectopic is highly likely if level >1500 with absence of IUP on TVUS

Question 8

If ectopic pregnancy is not ruled out in the ED, what can be done?

Answer 8

Outpatient OBG - serial US with serial serum quant beta-hCG levels. Rise in level slower than expected is highly suspicious.

Question 9

Rx ectopic pregnancy?

Answer 9

If unstable - surgery

Fluid and blood resuscitation, pain management, OBG consultation

RhoGAM if Rh-negative

MTX (medical management) - can give 2 doses if 1st dose fails

Question 10

Contraindications to MTX in ectopic pregnancy?

Answer 10

Hemodynamic instability, inability to follow-up, breastfeeding, immunodeficiency, renal/liver/pulmonary disease, PUD, blood dyscrasias

Question 11

Initial actions and primary survey in patients with suspected PID?

Answer 11

Pelvic exam
Pregnancy test (if pregnant, consider other causes of pelvic pain, as PID is less likely in pregnancy)

Question 12

Classic presentation of PID?

Answer 12

Bilateral lower abdominal pain
Purulent vaginal discharge (vaginal bleeding less frequently)

Symptoms begin shortly after the start of the menstrual cycle when there are fewer defenses by the mucosal barrier to ascending infections

N/V, general malaise

Hx STDs, multiple sexual partners, IUD use, adolescence, sexual intercourse at an early age, recent instrumentation of the uterine cavity

Bilateral adnexal tenderness, purulent cervical discharge, cervical motion, uterine, lower abdominal tenderness

Question 13

What physical exam finding suggests tubo-ovarian abscess?

Answer 13

Unilateral adnexal tenderness or fullness with PID symptoms

Question 14

What physical exam finding suggests Fitz-Hugh-Curtis?

Answer 14

RUQ tenderness with PID symptoms

Question 15

Dx testing for PID?

Answer 15

UA
CBC with diff
LFTs (if FHC is suspected)
PCR or DNA testing for CG (more sensitive than culture, can be run on cervical secretions or urine, more rapid)
Pelvic US if TOA is suspected or if diagnosis is unclear (r/o other diseases)
CT (not preferred, often ordered if appendicitis or other intraabdominal pathology is suspected)

Question 16

Diagnose PID?

Answer 16

Negative pregnancy test + elevated WBC with fever, bilateral adnexal tenderness, and mucopurulent cervical discharge -> certain diagnosis

PCR positive for G/C in appropriate clinical setting

Question 17

Who gets empiric Rx for PID?

Answer 17

All patients who meet minimum clinic criteria for PID (lower abdominal or pelvic pain + adnexal, uterine, or cervical motion tenderness in an at-risk patient with no other discernible cause)

Question 18

Complications of PID?

Answer 18

Chronic pelvic pain, dyspareunia, infertility, ectopic pregnancy, TOA, FHC syndrome

Question 19

Rx PID inpatient?

Answer 19

-Cefoxitin or Cefotetan 2g IV Q6hrs with Doxycycline 100 mg PO or IV Q12hrs

OR

-Clindamycin 900 mg IV Q8hrs with Gentamicin (if allergic to cephalosporins)

OR

-Unasyn 3g IV Q6hrs with doxycycline 100 mg PO or IV Q12 hrs

(Always give doxy PO when possible)

Question 20

Rx PID outpatient?

Answer 20

Ceftriaxone 250 mg IM OR Cefoxitin 2g IM

and

Probenecid 1g PO

and

Doxycycline 100 mg BID for 14 days

Must add metronidazole 500 mg BID for 14 days if more severe infection or history of uterine instrumentation within 3 weeks

Question 21

Indications for admission in PID?

Answer 21

Suspected TOA or FHC syndrome
Intractable vomiting
Septic patients
Peritonitis
Prepubertal children
Women with indwelling IUD
Pregnant patients

Strongly consider if nulliparous to preserve fertility, as well as women with comorbidities such as DM or HIV/AIDS

IUD removal after initiaiton of ABX

Question 22

DC instructions for PID treated outpatient?

Answer 22

Avoid sexual contact
Refer partners for treatment
Follow-up in 72 hours unless symptoms worsen
STD testing

Question 23

Initial actions and primary survey in suspected ovarian torsion?

Answer 23

Vitals and IV access
Focused H&P
US to assess for vascular flow
Consult gynecology early if torsion is suspected

Question 24

DDx - ovarian torsion?

Answer 24

Ovarian cyst
TOA
Ectopic pregnancy
Appendicitis
Kidney stone

Question 25

Pathophysiology of ovarian torsion?

Answer 25

Ovary (and often the fallopian tube) twist around the vascular pedicle -> obstructs venous flow -> engorgement and edema -> arterial flow compromise -> ischemia and infarction

Question 26

Classic presentation of ovarian torsion?

Answer 26

Unilateral lower abdominal pain (initial visceral) +/- N/V, may radiate to groin or flank May have several episodes over hours, days, or even weeks if intermittent torsion Hx of prior cyst or mass, torsion, current pregnancy should increase suspicion Lower abdominal tenderness Adnexal tenderness or mass Fever is uncommon, usually low-grade if present

Question 27

Dx testing for ovarian torsion?

Answer 27

Pregnancy test UA (UTI, nephrolithiasis) CBC (TOA) US with Doppler (presence of blood flow does not exclude diagnosis) CT is non-specific, may be helpful in ruling out DDx

Question 28

Most common US and CT finding in ovarian torsion?

Answer 28

Enlarged ovary

Question 29

Rx ovarian torsion

Answer 29

ABCs IV line, treat pain and nausea NPO Surgery (best outcomes within 8 hours)

Question 30

Pathophysiology of testicular torsion?

Answer 30

Normally, the testicle is anchored within the scrotum by the tunica vaginalis, which surrounds the testicle and attaches posteriorly to the scrotal wall and epidiymis. Tunica vaginalis consists of a visceral and parietal layer with an interposed potential space which allows the testicle to rotate about the spermatic cord if a firm posterior scrotal attachment is lacking. When the tunica attaches higher up on the cord, the testicle can move and twist within the scrotum (bell-clapper deformity) Appendix testes are also prone to torsion

Question 31

Initial actions/primary survey in suspected testicular torsion?

Answer 31

``` VS, IV access Focused H&P IV pain control US Consult urology early if torsion is suspected ```

Question 32

DDx - testicular torsion

Answer 32

``` Appendix testis torsion Epididymitis Orchitis Renal colic Varicocele Kidney stone Appendicitis Hernia Hydrocele Testicular trauma ```

Question 33

Classic presentation of testicular torsion?

Answer 33

Most common in the first year of life and at puberty; can occur at any age Fairly sudden severe unilateral testicular pain, sometimes radiating to the abdomen, associated with N/V Urgency, frequency, dysuria L>R Possible trauma Exam: distress, trouble walking, exquisite tenderness/swelling, high-riding in scrotum, may have transverse lie Absence of cremasteric reflex

Question 34

Dx testing for testicular torsion?

Answer 34

UA or urethral swab for GC if infectious epididymitis or orchitis is suspected US with comparison of asymptomatic and symptomatic testes.

Question 35

Compare the age of presentation of testicular torsion vs. appendage torsion vs. epididymitis.

Answer 35

Bimodal peak (infancy and puberty) 7-14 years Adult

Question 36

Compare the features of pain/associated symptoms of presentation of testicular torsion vs. appendage torsion vs. epididymitis.

Answer 36

Entire testicle, onset over hours; assc. with nausea Upper pole of testicle, onset over hours to days; no assc. symptoms Epididymis, onset over days; assc. with fever/dysuria

Question 37

Compare the physical exam findings of testicular torsion vs. appendage torsion vs. epididymitis.

Answer 37

Cremasteric reflex absent, diffusely swollen tender testicle Cremasteric reflex present Cremasteric reflex present, epididymal tenderness +/- testicular tenderness

Question 38

Compare the lab findings of testicular torsion vs. appendage torsion vs. epididymitis.

Answer 38

Not helpful Not helpful WBC, LE, nitrites

Question 39

Compare the US findings of testicular torsion vs. appendage torsion vs. epididymitis.

Answer 39

Affected testicle large and hypoechoic compared to asymptomatic side, decreased flow Body similar to asymptomatic side with focal hypoechoic area Body similar to asymptomatic side with hypoechoic epididymis

Question 40

Compare the Rx of testicular torsion vs. appendage torsion vs. epididymitis.

Answer 40

Surgical detorsion and bilateral orchiopexy Supportive ABX

Question 41

If you anticipate any delay in getting a patient with testicular torsion to the OR, what should be done?

Answer 41

Attempt manual detorsion (rotate away from the midline)