Approach to the Patient
History
• Dyspareunia, vaginal bleeding or d/c? Urinary sxs, ROS PMH (STDs, recent procedure) MEDS (contraceptive devices, hormonal therapy), social (domestic violence)
Physical Exam
• Abdominal exam; Gyn exam (d/c or bleeding, masses or tenderness)
Diagnostics
• Labs: UA, GC/Chlamydia, Wet mount
• Imaging: Pelvic U/S (assess flow, torsion, mass, fluid)
Ovarian Cyst
History
• Dull, vague, unilateral sensation of pelvic pain or dyspareunia
• Rupture: Sudden, unilateral, sharp pelvic pain; can also present as diffuse peritonitis
Physical Exam
• Lower quadrant abdominal tenderness, adnexal tenderness/mass, vaginal bleeding
Evaluation
• Labs: CBC, type and screen (crossmatch if HD unstable)
• Imaging: Pelvic U/S to assess for size, complexity, torsion, presence of free fluid. Bedside FAST if HD unstable.
Treatment
• Supportive: IVFs, transfuse if HD unstable
• Analgesia: NSAIDs, Narcotics prn
• Consult: Gyn Service for persistent pain, large-volume hemorrhage
Disposition
• Home: Stable, pain well controlled; f/u w/ Gyn or PCP in 1–2 mo for repeat U/S to reassess size
• Admit: HD unstable
Ovarian Torsion
History
• Acutely worsening unilateral lower abdominal/pelvic pain, N/V
• Can present as intermittent torsion w/ intermittent sxs
• RFs: Ovarian cysts, dermoid and other tumors, pregnancy
Physical Exam
• Nonspecific and variable; Gyn exam reveals unilateral, adnexal mass in majority of cases ± tenderness (though tenderness absent ∼30% of the time)
Evaluation
• Labs: Urine hCG
• Imaging: Pelvic U/S to assess for ovarian edema, cyst/mass, blood flow
Treatment
• Analgesia/antiemetics
• Consult: Gyn service for urgent laparoscopy