Gynecologic Emergencies

Vulvovaginits
Clinical Presentation
Generally presents with vaginal discharge of varying types depending on the underlying etiologic agent.

  • The color, odor and consistency of vaginal discharge should be noted during examination as should the presence of any erythema, ulcerations, blistering or edema.
  • Historical items which should be elicited include any associated history of vaginal itching or irritation, any changes in contraception methods, any changes in sexual activity or partners, any recent use of antibiotics, any previous episodes of vaginitis and pregnancy /menstrual history.
  • Vaginal cultures should be obtained including those for gonorrhea and Chlamydia. A wet mount and KOH preparation should be obtained.
  • Examination should include identifying the presence of any cervical motion tenderness or adnexal/uterine tenderness or masses.
  • A urinalysis and urine HCG should be obtained also as part of the evaluation.

acterial Vaginosis (BV)

    Gynecologic Emergencies
  • This is the most common cause of vaginitis and is caused by overgrowth of mixed bacterial flora causing a disturbance in the vaginal mucosal ecosystem. There is no single infectious agent that is responsible.
  • Vulvar/vaginal pruritis or irritation is relatively rare in this type of vaginitis.
  • The vaginal discharge is classically described as having a fishy odor and is usually gray in coloration. The discharge is thin and is noted to adhere to the vaginal mucosa.
  • There is minimal inflammation of the vaginal mucosa.
  • BV is diagnosed by noting an elevated vaginal pH >4.5. Also if a 10% solution of KOH is added to a sample of the discharge, it causes the release of a strong fishy odor.Microscopic examination of the discharge reveals the presence of clue cells. Clue cells consist of vaginal epithelial cells with clusters bacteria adhering to the cell membranes.

Treatment

  • Topical
  • Metronidazole gel 0.75%, one applicator full applied twice a day X 5 days
  • Clindamycin cream 2%, one applicator full applied at bedtime X 7 days
  • Oral
  • Metronidazole 500 mg PO twice a day X 7 days. Metronidazole can also administered as a one time dosage of 2.0 g which also delivers effective initial treatment but has a higher recurrence rate.

Candida Vaginitis

  • This is the second most commonly diagnosed cause for vaginitis. The most frequent presenting complaint is vulvar/vaginal pruritis and discharge which, when it is present, is minimal. The discharge is classically described as cottage cheese-like in appearance, and there is no significant odor. The patient may complain of dyspareunia. The pelvic examination generally shows erythema and edema of the mucosal surfaces. The patient who is immunocompromised or diabetic is at increased risk.
  • Candida vaginitis is diagnosed in large part based on the patient�s history and physical examination. Obtaining a wet mount and KOH preparation will demonstrate the presence of hyphal elements and yeast cells confirming the diagnosis.

Treatment

  • Topical
  • Clotrimazole 1% cream applied QHS for 7-14 days (OTC)
  • Miconazole 2% cream applied QHS for 7-14 days(OTC)
  • Butaconazole 2% cream applied QHS for 3 days
  • Miconazole 200 mg vaginal suppository inserted QHS for 3 days
  • Clotrimazole 500 mg tablet inserted vaginally QHS once
  • Oral
  • Fluconazole 150 mg tablet PO once

Trichomonas Vaginitis

  • The causative agent is the protozoan Trichomonas vaginalis and should be considered a sexually transmitted disease (STD).
  • The presenting signs and symptoms include yellow/gray frothy discharge which may be malodorous. Dysuria and dyspareunia may be present. The vaginal mucosa is typically erythematous, and the patient typically complains of pruritis. Punctate hemorrhages occur on the cervix (strawberry cervix) less than 20% of the time.
  • The diagnosis of Trichomonas vaginitis is confirmed by the visualization of pear-shaped flagellated trichomonads on wet mount. Leukocytes may also be visualized on microscopic examination. The pH of vaginal secretions is increased and is >4.5.
  • The treatment of Trichomonas vaginalis consists of the oral administration of Metronidazole either as a single dose of 2.0 g or 500 mg PO bid for 7 days. It is important that the patient�s sexual partner be treated also to prevent further reoccurrence and further spread. Topical metronidazole treatment is generally not recommended because of the inability to eradicate the organism from the urethra and skenes glands leading to reoccurrence. and obstetric emergencies.

Atrophic Vaginiti

  • Usually occurs in postmenopausal women due to diminished levels of circulating estrogens. Presents with vaginal and vulvar itching and discomfort. Physical examination usually demonstrates a pale, thin vaginal mucosa that is often friable. Wet mount, KOH evaluation and vaginal cultures are all found to be negative. A pap smear should be obtained at the time of the examination.
  • Appropriate emergency department treatment is to prescribe estrogen replacement therapy either orally or in the form of a vaginal cream and to arrange gynecological follow-up.

Contact Vulvovaginitis

  • This occurs secondary to a localized allergic reaction or chemical irritation after exposure to various substances. Common etiologies are soaps, deodorants, douches, tampons, panty hose, toilet paper and underwear. The patient presents with vaginal irritation, itching and discomfort. The physical examination reveals erythema and edema of varying degrees. Infectious etiologies are eliminated by the wet mount, KOH and cultures. The treatment consists of eliminating further contact with the causative agent, the use of sitz baths, topical steroids, oral antihistamines and gynecologic follow-up.

Genital Herpes

  • Symptoms of primary vaginal infection include vulvovaginal discomfort but may be accompanied by systemic symptoms such as fever and malaise.
  • Genital herpes is considered an STD and occurs most frequently in the young adult and adolescent patient populations.
  • Physical examination demonstrates fluid filled vesicles on the mucosal surfaces that may eventually progress on to painful ulcerations.

    Table The differential diagnosis of acute PID
  • Acute appendicitis
    		•
  • Ectopic pregnancy
    		•
  • Ovarian torsion
    		•
  • Urinary tract infection (UTI)
    		•
  • Ovarian cyst/ruptured ovarian cyst
    		•
  • Endometriosis
    		•
  • Urolithiasis
    		•
  • Gastroenteritis
    		•
  • Diverticulitis
    		•

  • The initial episode lasts for approximately 2-4 wk. The herpes virus continues to live in the dorsal root ganglia after the initial episode has resolved and predisposes the patient to chronic recurrent episodes.
  • The diagnosis is initially made by history and noting vesicular lesions/ulceration on physical examination. Confirmation of the diagnosis can be made by viral cultures and/or by finding multinucleated giant cells on a Tzanck smear.
  • The treatment of genital herpes is not curative but is aimed at shortening the course of episodes and decreasing the frequency of reoccurrence.
  • Antiviral therapy for the initial episode consists of the use of acyclovir (Zovirax) 400 mg 5x/day for 7-10 days or valocyclovir (Valtrex) 1 g PO BID for 7-10 days.
  • Analgesic agents and sitz baths may also be used to help alleviate the patients discomfort.
  • Patients with severe systemic symptomatology may need to be admitted for intravenous antiviral therapy.

Vaginal Foreign Bodies

  • Foreign bodies left in place either intentionally or accidentally for >24 h may lead to overgrowth of vaginal flora leading to foul smelling vaginal discharge. This frequently occurs in the pediatric population but may occur in adults when forgotten tampons or diaphragms are left in place.
  • The treatment consists of removal of the foreign body.

Pelvic Inflammatory Disease

  • This disease process represents an infection of the upper female reproductive tract that is sexually transmitted and starts as an ascending infection from the cervix and vagina.
  • This disorder is the most common gynecological cause for hospitalization in reproductive age women.
  • Most cases of PID are polymicrobial.
  • In approximately 50% of cases Chlamydia trachomatis and N. gonorrhea are isolated and represent the primary pathogens.
  • Pathogens that are also responsible less frequently include Bacteroides, Peptostreptococcus, E. coli, Haemophilus influenzae and Gardnerella vaginalis.
  • Risk factors for PID include sexual activity with multiple sexual partners, adolescence or young adulthood, douching, presence of an IUD and a prior history of other STDs.

Clinical Presentation

  • Initial presentation frequently includes a complaint of lower abdominal/pelvic pain but may include complaints of vaginal discharge, fever, malaise, nausea and vomiting.
  • The minimal criteria for diagnosing PID per the CDC are lower abdominal tenderness, adnexal tenderness and cervical motion tenderness.

    Table Current indications for inpatient therapy in PID
  • Uncertain diagnosis
    		•
  • Tuboovarian abscess
    		•
  • Simultaneous pregnancy
    		•
  • Adolescence
    		•
  • The immunocompromised patient (HIV)
    		•
  • Clinically toxic-appearing patient
    		•
  • Inability to maintain adequate PO intake/ persistent nausea and vomiting
    		•
  • Failure of attempted outpatient treatment
    		•
  • Unreliable patient/ inability to provide adequate follow-up
    		•

  • Other more minor determinants that increase the clinical suspicion of PID are fever, abnormal cervical or vaginal discharge, systemic signs, an increased ESR or CRP, and dyspareunia.
  • Fitz-Hugh-Curtis syndrome is one of the serious sequelae of PID and presents with right upper quadrant pain secondary to liver capsule inflammation and perihepatitis.
  • Appropriate laboratory evaluation for PID should include CBC, qualitative HCG, urinalysis, GC and Chlamydia cultures or DNA probe and screening for other common STDs.
  • Ultrasound evaluation is generally not indicated unless there is suspicion of a possible tuboovarian abscess or an associated pregnancy.

Emergency Department Management

  • The diagnosis of PID is based on clinical evaluation as early treatment is necessary in order to minimize the possibility of serious complications.
  • Patients with PID can be treated as inpatients (Table 7B.2) or outpatients depending on the severity of their symptoms.
  • Male sexual partners of patients with PID should be evaluated for STDs and treated for GC and Chlamydia

Inpatient Therapy

  • Cefotetan 2 g IV Q12H or Cefoxitin 2 g IV Q6H plus Doxycycline 100 mg IV Q12H
  • Alternative Treatment-Clindamycin 900 mg IV Q8H plus Gentamycin 2 mg/kg IV load and then 1.5 mg/kg Q8H IV

Outpatient Therapy

  • Ceftrioxone 250 mg IM plus Doxycycline 100 mg PO BID x 14 days Alternative Treatment-Ofloxin 400 mg PO BID x 14 days
    plus

    Metronidazole 500 mg PO BID x 14 days
  • At discharge patients may also be given analgesics as indicated by the severity of their symptoms. They should be educated about the importance of preventing STD spread and reinfection by having their male partners evaluated and treated appropriately.

Tuboovarian Abscess (TOA)

  • This occurs in approximately 5% of patients diagnosed with PID and the constellation of symptoms and etiology of TOA is similar to that discussed previously with PID.
  • Lower abdominal pain, cervical motion tenderness, adnexal tenderness and a palpable adnexal mass are present. Ultrasound is the imaging tool of choice in confirming the diagnosis of TOA.
  • Gynecologic consultation should be obtained.
  • In most cases IV antibiotic therapy is the sole necessary treatment.
  • However 20-40% of cases do require surgical intervention for successful treatment.

Pediculosis Pubis

  • Pediculosis pubis is a cutaneous infestation with the louse, Phthirus pubis. Found in the area of pubic hair after contact with an infected individual, it is frequently transmitted through sexual contact.
  • The adult form is approximately 1-2 mm in length and the nits, small 0.5 mm ova, are found at the base of pubic hair shafts.
  • Patients present with the complaint of severe itching in the pubic area and the diagnosis is confirmed by direct visualization of either the adult or nit form.
  • The most effective treatment is Permethrin cream applied to the involved area.
  • Lindane shampoo can be used as an alternative treatment but is contraindicated in pregnancy or lactation.
  • All clothing and bed linens should be cleaned to eliminate sources of reinfection.
  • All recent sexual contacts should be informed and subsequently treated.

Pubic Scabies

  • This represents a highly contagious infestation by the mite Sarcopetes scabiei. The female mite which is approximately 0.2-0.4 mm long burrows into the patients skin to deposit eggs.
  • Transmission usually occurs from intimate contact with an infected individual or with infested clothing.
  • The clinical presentation is that of severe pruritis in the pubic area.
  • Physical examination may show the presence of burrows which are noted as small (less than 1 cm) raised threadlike structures.
  • Further confirmation of the diagnosis can be made by microscopic evaluation of skin scrapings to identify mites, eggs or fecal material.
  • The most effective treatment is the topical application of Permethrin 5% cream from the neck down which is subsequently washed off 8 h later.
  • Machine washing of all clothing and bed linens in hot water reduces the incidence of reinfection.
  • Antihistamines may be given for control of pruritis and the patient should be warned that this pruritis may persist for several weeks after treatment because of residual skin inflammatory response.
  • Topical application of corticosteroids can help alleviate residual pruritis.

Bartholin Abscess

  • A Bartholin abscess is a polymicrobial infection of a Bartholin duct cyst; E. coli being the organism found most frequently (N. gonorrhea can be found as the etiologic agent in less than 10% of cases).
  • These abscesses occur most frequently in women of reproductive age and present with a painful lump on the labia.
  • The abscess is palpable as a tender fluctuant mass over the vulva on the involved side and are usually unilateral.
  • Incision and drainage of the abscess using local anesthetic is the treatment of choice.
  • The area of the abscess is locally infiltrated with 1% lidocaine and an incision is made on the mucosal surface of the abscess parallel to the hymenal ring.
  • The appearance of purulent drainage indicates successful penetration of the abscess wall.
  • The abscess should be irrigated with normal saline and a Word catheter should be inserted to allow further drainage.
  • The patient should be discharged on antibiotic therapy and be given gynecologic follow-up in two days for packing removal and further evaluation.
  • Amoxicillin/clavulanic acid 875 mg PO BID for 5 days plus Metronidazole 500 mg PO BID for 5 days offers excellent coverage.
  • Alternatively Ciprofloxacin 500 mg PO BID plud Metronidazole 500 mg PO BID can be used.
  • Most patients can be treated as outpatients. Patients that require admission are usually septic or have severe cellulitis/necrotizing fasciitis.
       
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