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)