Diseases, Disorders information

Clinical evaluation
Assessment of acute pelvic pain should determine the patient’s age, obstetrical history, menstrual history, characteristics of pain onset, duration, and palliative or aggravating factors.
Associated symptoms may include urinary or gastrointestinal symptoms, fever, abnormal bleeding, or vaginal discharge.
Past medical history. Contraceptive history, surgical history, gynecologic history, history of pelvic inflammatory disease, ectopic pregnancy, sexually transmitted diseases should be determined. Current sexual activity and practices should be assessed.
Method of contraception
Sexual abstinence in the months preceding the onset of pain lessons the likelihood of pregnancy-related etiologies.
The risk of acute PID is reduced by 50% in patients taking oral contraceptives or using a barrier method of contraception. Patients taking oral contraceptives are at decreased risk for an ectopic pregnancy or ovarian cysts.
Risk factors for acute pelvic inflammatory disease. Age between 15-25 years, sexual partner with symptoms of urethritis, prior history of PID.

Physical examination
Fever, abdominal or pelvic tenderness, and peritoneal signs should be sought.
Vaginal discharge, cervical erythema and discharge, cervical and uterine motion tenderness, or adnexal masses or tenderness should be noted.

Laboratory tests
Pregnancy testing will identify pregnancy-related causes of pelvic pain. Serum beta-HCG becomes positive 7 days after conception. A negative test virtually excludes ectopic pregnancy.
Complete blood count. Leukocytosis suggest an inflammatory process; however, a normal white blood count occurs in 56% of patients with PID and 37% of patients with appendicitis.
Urinalysis. The finding of pyuria suggests urinary tract infection. Pyuria can also occur with an inflamed appendix or from contamination of the urine by vaginal discharge.
Testing for Neisseria gonorrhoeae and Chlamydia trachomatis are necessary if PID is a possibility.
Pelvic ultrasonography is of value in excluding the diagnosis of an ectopic pregnancy by demonstrating an intrauterine gestation. Sonography may reveal acute PID, torsion of the adnexa, or acute appendicitis.
Diagnostic laparoscopy is indicated when acute pelvic pain has an unclear diagnosis despite comprehensive evaluation.

Differential diagnosis of acute pelvic pain
Pregnancy-related causes. Ectopic pregnancy, spontaneous, threatened or incomplete abortion, intrauterine pregnancy with corpus luteum bleeding.
Gynecologic disorders. PID, endometriosis, ovarian cyst hemorrhage or rupture, adnexal torsion, Mittelschmerz, uterine leiomyoma torsion, primary dysmenorrhea, tumor.
Nonreproductive tract causes
Gastrointestinal. Appendicitis, inflammatory bowel disease, mesenteric adenitis, irritable bowel syndrome, diverticulitis.
Urinary tract. Urinary tract infection, renal calculus.

Diagnosis of ED: History

Detailed sexual and medical history, including:
Nature and frequency of ED
Risk factors for ED, eg:

Concurrent disease
Drug abuse
Psychiatric illness

Risk Factors for ED

Hypertension
Hyperlipidemia
Hypogonadism
Endocrine disorders
Smoking
Alcohol abuse
Trauma or surgery to the pelvis or spine
Depression
Drug abuse
Anemia
Vascular disease
Peyronie’s disease
Vascular surgery

Drugs Associated with ED

Alcohol
Estrogens
Antiandrogens
H2 receptor blockers
Anticholinergics
Ketoconazole
Antidepressants
Marijuana
Antihypertensives
Narcotics
ß-blockers
Psychotropics
Cigarettes
Cocaine
Spironolactone
Lipid-lowering agents
NSAIDs
Cytotoxic drugs
Diuretics

Diagnosis of ED: Physical Examination

Assessment of secondary male sexual characteristics
Femoral and lower extremity pulses
Focused neurologicexamination
Perianal sensation
Sphincter tone
Bulbocavernosus reflex
Examination of penile vasculature
Evaluation of prostate size by digital rectal exam
Detection of Peyronie’s plaques

Laboratory Tests

Morning serum testosterone specimen
Serum prolactin

Tests for other systemic disease:

Complete blood count
Urinalysis
Serum creatinine
Glucose
Lipid profile
Thyroid function tests

Special Tests: Indications

Vasoactive agent injection

Intracavernosal injection therapy
Penile prosthesis implantation
Vascular surgery

Nocturnal penile tumescence, eg, Snap-Gauge, Rigiscan

Screen for psychogenic vs organic ED

Duplex ultrasonography
Vascular surgery

Post Workup Patient Management

Patient education
Assessment of etiology and discussion of treatment options

Lifestyle modification: Diet and exercise; stress reduction; alcohol, smoking, and illicit drug use if an issue
Trial of chosen therapy

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