Week 50: EM Gynecology

This patient is presenting with ovarian torsion. This patient’s cyst is greater than 5cm, putting her at risk for ovarian torsion. Her history of episodes of sudden onset pain is concerning for stuttering, intermittent torsion leading up to this event. Although ultrasound demonstrates intact arterial blood flow, the most frequent ultrasonographic abnormality in ovarian torsion is either decreased or absence of venous flow in the presence of intact arterial flow. Laparoscopy is the gold standard for diagnosis and management.

Trichomonas vaginalis, a protozoa, is the causative agent of trichomoniasis. It is the most common non-viral sexually transmitted infection worldwide. Patients typically complain of yellow-green, frothy and malodorous vaginal discharge, with protozoa seen on wet mount. “Strawberry cervix”, or punctate hemorrhage around cervix, is seen on exam. Vaginal pH becomes more alkalotic, and is generally greater than 4.5. Treatment of trichomonas vaginitis is metronidazole. Clue cell is seen in bacterial vaginosis. Recent antibiotics use is a common risk factor for candidal vaginitis.

The most common causes of postmenopausal vaginal bleeding is vaginal/endometrial atrophy 60%) and endometrial polyps (12%). However, endometrial cancer comprises about 10% of incidence. Given the stability of the patient, no further emergent imaging is indicated at this time, and urgent outpatient gynecology referral for further workup, including, but not limited to, endometrial biopsy, cervical cytology, and/or transvaginal ultraosund.

First line treatment of symptomatic atrophic vaginitis is vaginal moisturizing agents and lubricants. If that fails, and there is no contraindication for hormonal therapy (such as estrogen-based tumors like breast cancer), then low dose vaginal estrogen is the next step. In this question, the patient is stable and first-line therapy is nonhormonal moisturizing/lubricating agents and outpatient gynecology referral for endometrial biopsy, cervical cytology, and/or ultrasound to exclude endometrial cancer first.  The biopsy should be obtained BEFORE starting any treatment. While the workup for vaginal bleeding may include serum testing, there is no indication with this clinically stable and otherwise normal patient to emergently order blood tests. These tests, along with other imaging or biopsy/cytology testing, may be performed on an outpatient basis.

An ultrasound exam is usually the initial diagnostic study in the workup for ovarian torsion. The most common ultrasound finding in ovarian torsion is enlargement of the ovary. Enlargement develops due to impaired venous and lymphatic drainage, in addition to edema and hemorrhage that may occur. Less common findings include identification of a twisted pedicle (whirlpool sign), free pelvic fluid, and identification of an ovarian mass. RISK FACTORS: ovarian mass >5mm, reproductive age, pregnancy, ovulation induction, prior torsion. CLINICAL: adnexal pain/mass, vomiting, fever, vaginal bleeding
Free pelvic and intraperitoneal fluid (B) may surround the twisted ovary. This is usually the result of interstitial fluid that weeps off an affected ovary rather than true rupture of the capsule. Many cases of surgically proven ovarian torsion will have documented blood flow (C) on Doppler exam because the ovary has a dual blood supply from both the ovarian and uterine arteries. In addition, torsion is often intermittent, so findings may vary, depending on the time of the exam. Identification of an ovarian mass or cyst (>4 cm) (D) may suggest the diagnosis of ovarian torsion, but it is not the most common finding on ultrasound.

This patient presents with a Bartholin’s abscess and should have incision and drainage (I+D) performed with the incision on the mucosal surface. Bartholin’s abscesses are infections located in the Bartholin’s glands which lie inferiorly to the vaginal opening. Patients develop cysts of the gland that become secondarily infected. These abscesses typically are caused by normally occurring aerobic and anaerobic bacteria in the vagina but may also be caused by sexually transmitted infections. Patients present with swelling and pain near the labium. Examination revels a tender, fluctuant mass along the posterolateral margin of the vaginal vestibule. Treatment focuses on incision and drainage with insertion of a Word catheter. The Word catheter has a small balloon at the end that is inflated after insertion and remains in place for 6 to 8 weeks. Because of this duration, the incision should be made on the mucosal surface so that the Word catheter can be tucked into the vaginal opening for patient comfort. Incision and drainage is usually adequate but patients with overlying cellulitis may require antibiotics. After discharge, patients should perform sitz baths to aid with drainage. Recurrence is common.

This patient has a clinical presentation consistent with pelvic inflammatory disease (PID). PID is an ascending infection that begins in the vagina or cervix. In the sexually active female, the most common responsible organisms are Chlamydia trachomatis and Neisseria gonorrhoeae. Frequently, the infection is polymicrobial. The most common presenting symptom is lower abdominal pain. Patients may also develop fever, vaginal discharge, dyspareunia or abnormal bleeding. On physical examination, the patient typically has a fever and is tender on pelvic examination either in the lower abdomen over the uterus, on cervical motion or in the adnexa. The absence of cervical motion tenderness does not rule out PID and the CDC recommends empiric treatment for sexually active women presenting with lower abdominal pain and one of the following if no other cause is identified: cervical motion tenderness, adnexal tenderness or uterine tenderness. For outpatient management, patients are treated with ceftriaxone 250 mg IM followed by a two-week course of doxycycline. Metronidazole is sometimes added to the regimen at the judgment of the clinician.

The correct answer is IV estrogens. High-dose estrogen is thought to promote rapid regrowth of endometrium and stabilize uterine bleeding within the first five hours of administration. In hemodynamically unstable patients, IV estrogen is recommended, while oral estrogen is appropriate for hemodynamically stable patients. Oxytocin and methylergonovine can be used in post-partum bleeding.

Carbaprost tromethamine is a prostaglandin analog used in postpartum bleeding that stimulates uterine contractility, promoting hemostasis at the placental site. Methylergonovine is used in post-partum uterine bleeding, by increasing uterine smooth muscle contractions to reduce blood loss. Recombinant factor VIIa has been FDA-approved for use in bleeding in patients with hemophilia A/B, factor VII deficiency, or acquired hemophilia. Off-label, recombinant factor VIIa has been used as a general hemostatic agent – in this patient, IV estrogen should be first utilized before moving onto more controversial, last-ditch efforts.

This patient likely has ovarian cancer and the biomarker likely to support this diagnosis is CA-125. AFP is elevated in certain germ cell tumors as well as in Hepatocellular CA. CEA is elevated in colorectal CA. CA 19-9 is elevated in pancreatic and some types of colorectal CA.

Fitz-Hugh-Curtis syndrome is a condition that occurs in the setting of pelvic inflammatory disease (PID) and results in inflammation of the capsule surrounding the liver and the peritoneal surface of the anterior abdominal wall. It occurs in about 10% of patients with PID. Although it can be caused by any organisms responsible for pelvic inflammatory disease, Chlamydia trachomatis is most often implicated. Patients present with right upper quadrant pleuritic pain and tenderness. They may also have symptoms of PID, such as pelvic pain and vaginal discharge although these symptoms may be mild or lacking. Treatment regimens are similar to those for PID.
nfection with Gardnerella vaginalis (B) results in symptoms of vaginitis, but does not play a role in the development of Fitz-Hugh-Curtis syndrome. Hepatitis C virus (C) causes hepatitis, but is also not involved in the development of Fitz-Hugh-Curtis syndrome. Neisseria gonorrhoeae (D) can cause Fitz-Hugh-Curtis syndrome although it is more likely to be due to a C. trachomatis.

Vaginal foreign bodies can manifest as vaginal discharge. The discharge associated with a foreign body is often malodorous and bloody or dark brown in color and occurs daily. Potential foreign bodies include small pieces of toilet paper and small objects or toys. In this case, the child recently started attending school and is likely toileting by herself. As a result, she may be at risk of poor hygiene and potentially may have a small piece of toilet paper stuck within the vagina. Attempted manual removal can be performed on cooperative children over 7 years of age through irrigation with normal saline. Vaginoscopy under anesthesia in the operating room may be necessary in younger children.