Gynecology

8.1 Bartholin Cyst Abscess

Brit J Clin Pract 1978;32:101

Epidem: 80% of acute episodes associated with Neisseria gonorrheae, and may also be associated with Chlamydia trachomatis, Escherichia coli, or mixed flora. Seen predominantly in Hispanic or black women 20-29 yr of age, with multi-gravid and multiparity as protective (South Med J 1994;87:26).

Pathophys: Obstruction of Bartholin duct with abscess formation.

Sx: Labial pain and swelling.

Si: Usually unilateral lower labial swelling with erythema, warmth, and tenderness.

Crs: Recurrence may be treated/prevented with marsupialization of cyst.

Cmplc: Work-up and treat as with other STDs—see p 153.

Lab: Gram stain of abscess contents, gc/chlamydia from cervix (urine for chlamydia could be considered), test for syphilis (RPR, VDRL, etc), consider HIV and partner testing.

Emergency Management:

Iv access if procedural sedation with parenteral narcotics and/or midazolam necessary for procedure.
Lithotomy position, prep with Betadine, then drape.
Anesthetize with 1-2% lidocaine buffered with bicarb.
Incise on mucosal surface, and place gauze packing or Word catheter (South Med J 1968;61:514); the Word catheter works by placing needle on syringe filled with 3-5 cc of saline through the rubber on the flat end of the catheter so that the needle tip now sits inside the closed “balloon,” and once incision is cross-hatched, place the curved end of the balloon into the wound and inject approximately 3 cc of saline into balloon so that it does not come out and keeps the wound open—remove 1 cc q wk until this heals from inside out.
To marsupialize, cross hatch on mucosal surface and carry cross hatch down to the cyst. The four corners of the incised cyst will be sewn to the superficial mucosal surface, so that the cyst cannot reocclude, and will heal by secondary intention.
Consider silver nitrate for sclerosis (Eur J Obstet Gynecol Reprod Biol 1995;63:61).
Sitz baths.
Refer to STD section for specific STD treatments.

8.2 Ovarian Cyst Rupture

Cause: Rupture of cyst, which may be physiologic, benign or malignant. Some examples are follicular cysts, mucinous or serous cystadenomas, endometriomas, or cystic teratomas—usually benign.

Epidem: 2-5% in prepubertal females (Obgyn 1993;81:434)

Pathophys: The size of the unruptured cyst does not correlate with physical symptoms, and a ruptured cyst of any size may cause significant pelvic pain.

Sx: Pelvic pain of sudden onset, nausea.

Si: Abdominal exam may be non-specific, pelvic exam may disclose localized tenderness with or without a mass, cervical motion tenderness (Chandelier sign) should be lacking, but not 100%.

Crs: Most will be self-limited and respond to pain treatment and others will be recurrent. Cysts > 5 cm or complex need further evaluation, or if other concerning aspects are noted during a patients evaluation—eg, ectopic tooth.

Cmplc: Hemoperitoneum (hemorrhage) (Abdom Imaging 1999;24:304), peritonitis.

Diff Dx: Ectopic pregnancy [pseudo-ectopic pregnancy (W V Med J 1989;85:488)], appendicitis, tubo-ovarian abscess, ovarian torsion, PID, nephrolithiasis, UTI, endometriosis, or Mittelschmerz.

Endometriosis is difficult to qualify as to whether it is an individual’s cause for pelvic pain. It may be found gross or microscopically in either women with chronic pelvic pain or found incidentally during other procedures without correlation to pain hx (Hum Reprod 1996;11:387).

Lab: Urine pregnancy test—serum quantitative if positive; UA, CBC with diff if considering infectious etiology, gc/chlamydia for all women of childbearing age and/or if cervix inflamed or chandelier sign.

X-ray: This discussion is for a non-pregnant patient. If unsure of diagnosis or if palpable mass, US may show a cyst coincident with pain locale, or free fluid with no other lesions which may be consistent with a ruptured cyst. US may also define simple vs complex cysts. Hemorrhagic ovarian cyst may be better elucidated with transvaginal ultrasound (Gynecol Endocrinol 1991;5:123). Right-sided pain may not be easily explained with free fluid but no other lesions noted—this may be consistent with appendicitis, as well.

Emergency Management: If patient is pregnant, go to Ectopic Pregnancy, p 292. If not, then:

If patient afebrile, and left-sided pain, may elect to treat with NSAIDs and narcotics for breakthrough pain—US as outpt with referral to primary care physician or gynecologist.
If pain is right-sided, must consider appendicitis. Using Bayseian reasoning, consider the H&P and CBC with diff (UA and urine pregnancy test should both be unremarkable, although ureteral irritation sometimes occurs) to decide whether diagnosis needs to be made immediately, or have the patient return in 6-8 hr for a recheck. Abdominal CT for cases with high index of suspicion for appendicitis—do not rely on US to r/o appendicitis although it may rule it in (not as good as CT). Iv medications for pain control (narcotics) and nausea/vomiting are OK.
Cysts > 5 cm refer for gyn follow-up, for either aspiration (Brit J Obstet Gynaecol 1989;96:1035), laparoscopy or laparotomy.

8.3 Ovarian Torsion

Ann EM 2001;38:156

Cause: Enlarged ovary (cyst) that twists on itself usually in a woman of childbearing age; perhaps Tamoxifen a risk (Gynecol Obstet Invest 1999;48:200); rarely due to leiomyomatosis peritonealis disseminata (Abdom Imaging 1998;23:640).

Epidem: Incidence approximately 7%; more common on the right side and in pregnancy (Int J Gynaecol Obstet 1989;28:21) and with h/o ovarian cyst or pelvic surgery.

Pathophys: The enlarged ovary will asymmetrically grow in relation to its position in the meso-ovarium. This will allow it to twist on its axis, and this will threaten its blood supply, which may cause necrosis to the ovary.

Sx: Pelvic pain, nausea, vomiting.

Si: Pain upon palpation, palpable mass (80%).

Crs: Necrosis with non-viable ovary if not repositioned, with 50% gangrenous in operating theater.

Cmplc: Loss of ovary.

Lab: Check urine pregnancy test, and consider CBC with diff and UA.

X-ray: US with large and eccentric ovary > 5 cm, perhaps with Doppler to determine viability (Ultrasound Obstet Gynecol 1995;5:129); may also be seen with CT (J Reprod Med 1998;43:827).

Emergency Management:

Iv access for parenteral anti-emetics and narcotics, if necessary.
Gynecologic consult.

8.4 Pelvic Inflammatory Disease

Mmwr 1998;47:1

Cause: Chlamydia causes over half of mild cases (Ann IM 1981;95:685); Neisseria gonococcus in 13-20% of cases (Am J Obgyn 1980;138:909); anaerobes (Clin Infect Dis 1999;28:S29); cytomegalovirus; mycoplasma. All via sexual intercourse, especially with multiple partners. IUD use previously thought to increase risk, but this is equivocal—presenting with febrile PID is probably higher in those with IUDs (Jama 1976;235:1851).

Epidem: Approximately 1 million cases/yr in U.S.; associated in those with induced abortion and harboring chlamydia or bacterial vaginosis (Am J Obgyn 1980;138:868), specific prophylaxis is helpful (Am J Obgyn 1992;166:100; Infection 1994;22:242).

Pathophys: Lower genital tract infections ascend cervical canal, usually just before or during menses, with infection spreading to tubes and ovaries.

Sx: Pain in lower abdomen; nausea; vomiting; anorexia; dyspareunia; dysuria; tenesmus; dysmenorrhea.

Si: Adnexal mass (20%) and tenderness; cervical motion tenderness—Chandelier sign; fever; cervical discharge; mild cases have no specific clinical criteria to aid in diagnosis (Sex Transm Dis 1986;13:119).

Crs: Bilateral tubal ligation is not protective (Ann EM 1991;20:344), but perhaps milder course (Am J Emerg Med 1997;15:271). Pregnancy is not protective in adolescents (J Ped Adolesc Gynecol 1996;9:129).

Cmplc: Infertility—15+% with each episode; ectopic pregnancy; pelvic abscess; septic thrombophlebitis; surgical excision of reproductive organs. No difference in outcomes for reproductive abilities in those with mild-moderate disease when comparing inpatient and outpt treatment (Am J Obgyn 2002;186:929).

Diff Dx: Ectopic pregnancy; appendicitis—presentation to the ER in the latter 2 wk of the menstrual cycle (Am J Emerg Med 1993;11:569), within 2 d of symptom onset, and with both nausea and vomiting may favor appendicitis (Am J Surg 1985;150:90); septic abortion; endometriosis; adenomyosis.

Lab: CBC with diff, UA, urine pregnancy test, gc and chlamydia screens, test for syphilis (Jacep 1978;7:93), consider HIV testing; consider ESR or CRP to follow for resolution (Arch Gynecol Obstet 1987;241:177) if there is a concern.

X-ray: Pelvic ultrasound or CT scan for abscess if clinically suspected.

Emergency Management: Initiate treatment based on pain and tenderness.

Outpatients

First: Cefoxitin 2 gm im + probenecid 1 gm po, or ceftriaxone 250 mg im; then tetracycline 500 mg po qid or doxycycline 100 mg po bid for 14 d.
Second: Ofloxacin 400 mg po bid + clindamycin 450 mg po qid or metronidazole 500 mg po bid for 2 wk.

Inpatients

Hospitalize if: