Pelvic (GU)


Dysuria

Rapid Review

Pearls

Deep Dive



Hematuria

Rapid Review

  • Differentials
    • Urinary tract infection
    • Nephrolithiasis
    • Bladder/Kidney cancer
    • Nephropathy
    • Foreign Body
    • BPH
  • History
    • Ingestion of new foods or medications
      • Consider pseudohematuria
    • Clots
      • Consider nonglomerular etiology (bladder)
    • Beginning, middle, or end of stream
      • Helps identify source of bleeding
    • Recent procedures or trauma
      • Consider urethral injuries
  • Physical Exam
    • CVA tenderness
      • Suggests pyelonephritis or nephrolithiasis
    • Suprapubic tenderness
      • Suggests cystitis
    • External lesions/lacerations
      • Evidence of urethral injury
  • Work-Up
    • Labs
      • CBC, BMP, Coags, CK
      • Urinalysis 
      • Urine culture
    • Imaging
      • CT (may be useful for identifying pyelonephritis vs nephrolithiasis)

Pearls

Video Credit: Strong Medicine


Testicular/Scrotal Pain

Rapid Review

  • Differentials
    • Testicular
      • Testicular torsion
      • Orchitis
      • Epididymitis
      • Neoplasm
      • Testicular rupture
    • Scrotal
      • Hydrocele
      • Fournier gangrene
      • Scrotal abscess
    • Abdominal/Renal
      • Abdominal aortic aneurysm
      • Nephrolithiasis
      • Inguinal hernia
  • History
    • Onset of pain
      • Surgery typically required within 12 hours of testicular torsion
    • Fever
      • Consider infectious causes
    • Recent strain or exercise
      • Consider hernia or testicular torsion
    • New sexual partners
      • Consider epididymitis
    • History of renal colic
      • Pain may be referred to testicular region
  • Physical Exam
    • Absent cremasteric reflex or horizontal lie of testicle
      • Suggests testicular torsion
    • CVA tenderness
      • Consider renal colic
    • Urethral discharge
      • Consider gonorrhea/chlamydia
    • Scrotal mass
      • Consider hernia
    • Transilluminated mass
      • Consider hydrocele
  • Work-up
    • Labs
      • Urinalysis, STI testing
    • Imaging
      • Testicular ultrasound
        • Evaluate for torsion
      • CT abdomen/pelvis
        • If concern for nephrolithiasis

Pearls

Video Credit: Dr. ER.tv


Urinary Retention

Rapid Review

  • Differentials
    • Urethral obstruction
      • Pelvic organ prolapse
      • Foreign body
      • Stricture
    • Prostatic obstruction
      • Benign prostatic hypertrophy (BPH)
      • Prostate cancer
      • Prostatitis
      • Prostate avulsion
    • Bladder obstruction
      • Calculi
      • Clots
      • Cancer
    • Neurogenic
      • Multiple sclerosis
      • Cauda equina syndrome
      • Diabetic neurogenic bladder
      • Spinal cord compression
    • Medications
      • Anticholinergics
      • Antihistamines
      • Nifedipine
      • Sympathomimetics
  • History
    • Time since last urination
      • Evaluate severity
    • Fever/chills
      • Consider infection
    • Family Hx of cancer
      • Consider prostate or bladder cancer 
    • Neurologic symptoms
      • Consider cauda equina, MS, cord compression
    • Medication list
      • Several medications may cause retention
  • Physical Exam
    • Abdominal exam
      • Palpate for masses
    • Pelvic exam
      • Evaluate for organ prolapse
    • Neurologic exam
      • Decreased strength/sensation in lower extremities or saddle region suggests cauda equina
  • Work-up
    • Labs
      • CBC (if suspect infection/hematuria), BMP
      • Urinalysis and urine cultures
    • Imaging
      • Bedside ultrasound
        • Confirm urinary retention
      • CT abdomen/pelvis
        • If concerned for malignancy, bladder calculi, mass
      • MRI/spinal imaging
        • If concern for cauda equina

Pearls

Video Credit: DR VIC


Vaginal Bleeding (Non-Pregnant)

Rapid Review

  • Differentials
    • Menstruation w/ coagulopathy
    • Uterine fibroids
    • Polyps
    • Breakthrough bleeding w/ OCPs
    • Atrophic vaginitis
    • Foreign Body
    • Endometrial/Cervical cancer
  • History
    • Amount of blood (in pads or tampons)
      • Helps quantify severity of bleeding
    • Recently started contraceptives
      • Consider breakthrough bleeding
    • Family history of malignancy
      • Consider endometrial or cervical cancer
    • Abdominal/Pelvic pain
      • Consider ectopic pregnancy
  • Physical Exam
    • Signs of trauma
      • Consider vaginal or uterine injury
    • Abdominal/Pelvic tenderness
      • Consider ectopic pregnancy or ovarian cyst
  • Work-Up
    • Labs
      • CBC, CMP, Type and Cross
      • Beta-hCG
      • DIC panel (fibrinogen, coags, reticulocyte count, d dimer)
    • Imaging
      • Transvaginal ultrasound

Pearls

Video Credit: Lecturio


Vaginal Bleeding (Pregnant)

Rapid Review

  • Differentials
    • Early pregnancy (<20 weeks)
      • Ectopic pregnancy
      • Abortion (threatened, complete, incomplete)
      • Trauma
      • Post-Couital bleeding
    • Later pregnancy (>20 weeks)
      • Placental abruption
      • Placenta previa
      • Cervical/vaginal trauma
      • Bloody show (cervical insufficiency or labor)
      • Vasa previa
  • History
    • Amount of bleeding
      • > 1 pad/hour is severe
    • Painful vs painless bleeding
      • Ectopic pregnancy and placental abruption are classically painful
    • Fever/chills
      • Consider cervicitis, septic abortion
    • Passage of tissue
      • Consider miscarriage
    • Recent sexual intercourse in past 24 hours
      • Consider post-coital bleeding
  • Physical Exam
    • Abnormal vitals (hypotension, tachycardia)
      • Consider ectopic pregnancy, placental abruption
    • Abdominal exam
      • Estimate gestation (20 weeks at umbilicus)
      • Tenderness suggests abruption
    • Pelvic exam
      • Evaluate source of bleeding
      • Determine if os is open or closed
  • Work-up
    • Labs
      • CBC, type and screen, coagulation studies, quantitative hCG, urinalysis
    • Procedures
      • Fetal heart tones
        • Present > 10 weeks
        • Normal fetal HR is 120-160
    • Imaging
      • Transvaginal/Transabdominal
        • Confirm intrauterine pregnancy
        • “Snowstorm” appearance in gestational trophoblastic disease

Pearls

Video Credit: World Medical School
Brandon Simpson, PA-C
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  • Blog - 25 Feb 2021