PID and Ovarian Torsion
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 28 July 2019
⏱️ 18 minutes
🧾️ Download transcript
Summary
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)
Transcript
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| 0:00.0 | Hello, med students. My name is Zach Olson, and thank you for downloading this week's |
| 0:05.0 | episode of the EM Clerkship Podcast. Dr. Olson, I have a 30-year-old female with no surgical |
| 0:14.2 | history and no significant past medical history who presents with abdominal pain. She describes it |
| 0:19.6 | as a severe, sudden onset pain that started about |
| 0:23.4 | three hours ago, actually woke her up from sleep. She denies dysuria, hematuria, fevers, vomiting, |
| 0:29.0 | or any other symptoms at this time. Her vitals are within normal limits, but she does appear |
| 0:34.6 | to be in pain. On exam, she has tenderness of the right lower quadrant |
| 0:39.0 | in the right kind of side of her pelvis with voluntary guarding, no rebound. She has no |
| 0:45.2 | CVA tenderness or upper abdominal pain. I think she might have an ovarian cysts, but we need to |
| 0:50.5 | rule out the diagnoses of ectopic pregnancy, ovarian torsion, urinary tract infection, |
| 0:55.8 | and kidney stone. |
| 0:56.8 | I don't think it's appendicitis because of how suddenly it started. |
| 1:00.2 | I would like to get a CBC, a BMP, a urine, a urine pregnancy, and a pelvic ultrasound, |
| 1:05.5 | and we should probably do a pelvic exam to feel for masses and cervical motion tenderness. I would like to get her |
| 1:12.4 | four milligrams of IV morphine and four milligrams of IV Zofrin for the pain and nausea. |
| 1:17.4 | And then I'll check back on her and see if she needs any more. |
| 1:22.8 | All right. So we've been going through our critical abdominal pain diagnoses. |
| 1:29.4 | And we've been focusing recently on the GU genital urinary causes of abdominal pain. |
| 1:35.0 | And so far we've covered ectopic pregnancy. |
| 1:38.2 | That was kind of the queen of abdominal pain. |
| 1:41.3 | And we also talked about urinary tract infections of very, very common diagnosis, |
| 1:48.6 | but also frequently misdiagnosed, but very common. So you obviously have to cover it. |
... |
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