The main approach to nonpregnant patients with pelvic pain or established vaginal bleeding is to determine whether the condition requires general (e.g., resuscitation) or specific ED-based evaluation or intervention. In patients who present primarily with vaginal bleeding, the main issue is to determine whether there has been significant blood loss, and whether a condition exists (such as traumatic injury or bleeding dyscrasia) that places the patient at risk for uncontrolled or significant bleeding. If the bleeding has not led to hemodynamic compromise (and is unlikely to), then, after pregnancy has been ruled out, the only diagnoses that need to be absolutely established in the ED are trauma (including sexual abuse and assault), bleeding dyscrasia, and infection. Foreign bodies may also need to be considered in the prepubescent (particularly young child) and the elderly (e.g., retained pessary). Otherwise, patients can be referred for outpatient investigation, with the timing based on the urgency.
The approach to pelvic pain is similar. Assuming pregnancy has been excluded, acute infectious etiologies, torsion of adnexal anatomy, and nonpelvic surgical etiologies need to be considered for acute ED-based intervention and treatment. Rarely, a ruptured cyst may cause significant internal bleeding, but this is likely evident on evaluation and from the patient's level of pain. If infection is not strongly within the diagnostic possibilities, then the degree of pain may dictate further ED workup. Ultrasound and computed tomography are the most likely useful adjuncts, depending on the diagnoses remaining within consideration. Some patients with significant pain may be observed in an ED that has the capacity and capability for such activities. Reliable patients with moderate pain may be sent home on analgesics with appropriate instructions and a return visit or follow-up arranged within 12 to 24 h. Patients with mild to moderate pain of longer standing (in whom the foregoing considerations have been excluded) may be referred for further outpatient diagnostic evaluation.
The need for inpatient management is self-evident. Significant blood loss or risk thereof, or significant pathology, will usually warrant at least an immediate consultation and likely admission or a further non-ED-based procedure. Patients with intractable pain, or in whom significant pathology cannot be excluded, should be admitted for further evaluation.
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