Pelvic (GU)

Rapid Review

Pearls

Deep Dive

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

Deep Dive

• Evaluation and Management of Hematuria in the Emergency Department (emDocs)

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

Deep Dive

• Scrotal Pain: Evaluation and Management (PubMed)

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

Deep Dive

• Doc I Can’t Pee, What Could it Be? Evaluation and Management of Acute Urinary Retention in the Emergency Department (emDocs)

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

Deep Dive

• Vaginal Bleeding in the Non-Pregnant Patient (emDocs)

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

Deep Dive

• Vaginal Bleeding in Early Pregnancy (EM Cases)