Rosen & Barkin's 5-Minute Emergency Medicine Consult (243 page)

• Pregnancy test
  
• GC/chlamydia testing
  
• Other tests as directed by history and physical exam
  
• Rarely diagnosed in ED
  

• Pregnancy test
  
• GC/chlamydia testing
  
• Hematocrit if bleeding
  
• Type and screen if significant bleeding
  
• Other labs as directed by history and physical exam
  

• Ultrasound (11% sensitivity)
  
• Doppler ultrasound
  
• CT scan (15% sensitivity)
  
• MRI (69% sensitivity; 75% specificity)
  
• Typically not helpful in ED
  

Laparoscopy usually required for definitive diagnosis

• Appendicitis
  
• Dysfunctional uterine bleeding
  
• Ectopic pregnancy
  
• Inflammatory bowel disease
  
• Irritable bowel disease
  
• Menstrual cramps/mittelschmerz
  
• Ovarian cyst
  
• Ovarian torsion
  
• Pelvic inflammatory disease
  
• Tubo-ovarian abscess
  

TREATMENT

• Stabilize as needed.
  
• Pain control as necessary
  

• Treat hypotension or tachycardia from blood loss with isotonic IV fluids
  
• May need to transfuse packed red blood cells (PRBCs) if significant bleeding
  

• Analgesia
  
• Oral contraceptive (i.e., medroxyprogesterone acetate) or gonadotropin-releasing hormone agonist (i.e., leuprolide acetate) in consultation with gynecologist or primary care physician
  
• Gynecology consultation for significant bleeding, pain, or serious complication
  

• Ibuprofen: 400–800 mg PO q6–8h (max. 3.2 g/d)
  
• Acetaminophen: 325–650 mg PO q4–6h (max. 4 g/d)
  
• Ketorolac: 15–30 mg IV or 30–60 mg IM
  
• Morphine: 4–8 mg IM/IV or equivalent analgesic
  

• Ibuprofen: 400–800 mg PO q6–8h (max. 3.2 g/d)
  
• Acetaminophen: 325–650 mg PO q4–6h (max. 4 g/d)
  
• Ketorolac: 15–30 mg IV or 30–60 mg IM
  

FOLLOW-UP

• Intractable pain
  
• Significant bleeding
  
• Unclear diagnosis
  
• Need for further workup and treatment
  
• Peritoneal signs
  

Most patients with suspected endometriosis can be discharged with pain control and gynecology referral

Suspected cases of endometriosis should be referred to a gynecologist for evaluation and treatment

• Occurs in 6–10% of women of reproductive age
  
• Endometriosis frequently causes cyclical pelvic pain
  
• Rarely diagnosed initially in ED; delay between symptom onset and diagnosis frequently years
  
• Rule out other emergency medical conditions and treat symptoms as needed
  
• Endometriosis is a chronic condition that necessitates outpatient monitoring by a gynecologist or primary care physician
  

• Cirilli AR, Cipot SJ. Emergency evaluation and management of vaginal bleeding in the nonpregnant patient.
  Emerg Med Clin North Am
  . 2012;30:991–1006.
  
• Giudice LC. Clinical practice. Endometriosis.
  N Eng J Med.
  2010;362:2389–2398.
  
• McLeod BS, Retzloff MG. Epidemiology of endometriosis: An assessment of risk factors.
  Clin Obstet Gynecol
  . 2010;53:389–396.
  
• Vercellini P, Crosignani P, Somigliana E, et al. “Waiting for Godot”: A commonsense approach to the medical treatment of endometriosis.
  Hum Reprod.
  2011;26:3–13.
  

CODES

• 617.1 Endometriosis of ovary
  
• 617.3 Endometriosis of pelvic peritoneum
  
• 617.9 Endometriosis, site unspecified
  

BASICS

• Definition: Inflammation or infection of the epididymis
  
• Rare in prepubertal boys
  
• Pathogenesis:
  
  • Initial stages:
    
    • Cellular inflammation begins in vas deferens, descends to epididymis
      
  • Acute phase:
    
    • Epididymis is swollen and indurated in upper and lower poles.
      
    • Spermatic cord thickened
      
  • Testis may become edematous owing to passive congestion or inflammation.
    
  • Resolution:
    
    • May be complete without sequelae
      
    • Peritubular fibrosis may develop, occluding ductules.
      
• Complications:
  
  • 2/3 of men have atrophy due to partial vascular thrombosis of testicular artery.
    
  • Abscess and infarction rare (5%)
    
  • Incidence of infertility with unilateral epididymitis unknown:
    
    • 50% with bilateral epididymitis
      

• Definition: Inflammation or infection of the testicle:
  
  • Usually from direct extension of the same process within the epididymis
    
  • Isolated testicular infection is rare:
    
    • Can result from hematogenous spread of bacteria or following mumps infection
      
• Categories:
  
  • Pyogenic bacterial orchitis secondary to bacterial involvement of epididymis
    
  • Viral orchitis:
    
    • Most commonly due to mumps
      
    • Rare in prepubertal boys; occurs in 20–30% of postpubertal boys with mumps.
      
    • Occurs 4–6 days after parotitis but can occur without parotitis.
      
    • Unilateral in 70% of patients
      
    • Usually resolution in 6–10 days
      
    • 30–50% of testes involved have residual atrophy; rarely affects fertility
      
  • Granulomatous orchitis:
    
    • Syphilis
      
    • Mycobacterium and fungal diseases
      
    • Usually occurs in immunocompromised host
      

• Children:
  
  • Most common in children <1 yr or between the ages of 12–15 yr
    
  • Etiology identified in only 25% of prepubertal boys
    
  • Coliform or pseudomonal UTI
    
  • Sexually transmitted diseases rare in prepubertal males
    
  • Associated with predisposing abnormalities of lower urinary tract
    
• Young men, age <35 yr:
  
  • Usually sexually transmitted
    
  • Chlamydia trachomatis
    (28–88%) with severe inflammation with minimal destruction
    
  • Neisseria gonorrhea
    (3–28%)
    
  • Coliform bacteria (7–24%):
    
    • Highly destructive with tendency for abscess
      
    • Coliform bacteria more common in insertive partners in anal intercourse
      
  • Ureaplasma urealyticum
    (sole organism in only 6% of cases)
    
• Older men, age >35 yr:
  
  • Commonly associated with underlying urologic pathology (benign prostatic hypertrophy, prostate cancer, strictures)
    
  • May have acute or chronic bacterial prostatitis
    
  • Coliform bacteria more common (23–67%), especially after instrumentation
    
  • C. trachomatis
    (8–80%)
    
  • Klebsiella and Pseudomonas species
    
  • N. gonorrhea
    (15%)
    
  • Gram-positive cocci
    
• Drug related:
  
  • Amiodarone-induced epididymitis:
    
    • Usually with amiodarone levels > therapeutic levels
      
• Granulomatous:
  
  • Etiology maybe related to mycobacterial, syphilis, or fungal infections:
    
    • Mycobacterium tuberculosis
      is the most common cause of granulomatous disease affecting the epididymis
      
    • Suspect in HIV patients
      
    • Urine cultures often negative for
      M. tuberculosis
      
• Vasculitis:
  
  • Polyarteritis nodosa
    
  • Behcçet disease
    
  • Henoch–Schönlein purpura
    

• Pyogenic bacterial orchitis:
  
  • Escherichia coli
    
  • Klebsiella pneumoniae
    
  • Pseudomonas aeruginosa
    
  • Staphylococci
    
  • Streptococci
    
• Viral orchitis:
  
  • Mumps:
    
    • 20% may develop epididymo-orchitis.
      
    • Rarely associated with live-attenuated mumps vaccine
      
• Coxsackie A and lymphocytic choriomeningitis virus
  
• Granulomatous orchitis: Syphilis, mycobacterial and fungal diseases:
  
  • Suspect in HIV patients
    
• Fungal orchitis:
  
  • Blastomycosis in endemic regions
    
  • Invasive candidal infections in immunosuppressed hosts
    
• Post-traumatic orchitis: Inflammation