Pelvic Problems MDM
MDM Templates
Ovarian Torsion
Patient presents with acute onset unilateral pelvic pain with nausea.
Presentation concerning for ovarian torsion given the acuity, severity, and adnexal tenderness on exam.
Ultrasound shows *** cm ovarian cyst with *** Doppler flow.
OBGYN consulted emergently regarding operative management.
Disposition: Admit to OBGYN for surgical exploration/detorsion.
Bartholin Abscess — I&D
Patient presents with painful vulvar mass consistent with Bartholin abscess.
No cellulitis or concerning features for necrotizing infection.
Plan: Bedside I&D with Word catheter placement (see procedure note).
Disposition: Discharge with OBGYN follow-up in 2-4 weeks for Word catheter removal.
Return for worsening pain, fever, or catheter dislodgement.
Ovarian Cyst — Rupture/Hemorrhagic
Patient presents with acute pelvic pain.
Ultrasound shows *** cm hemorrhagic ovarian cyst with free fluid.
Hemodynamically stable. Serial exams stable.
History and exam lower suspicion for ectopic pregnancy, ovarian torsion, appendicitis, TOA, or other surgical emergency.
Plan: Analgesics, serial exams.
Disposition: Discharge if stable with OBGYN follow-up.
Return for worsening pain, lightheadedness, or hemodynamic instability.
Ovarian Hyperstimulation Syndrome
Patient undergoing fertility treatment presents with abdominal distension, pain, and nausea consistent with ovarian hyperstimulation syndrome.
No evidence of severe complications (tense ascites, pleural effusion, renal failure, thromboembolism).
Plan: IV fluids, antiemetics. OBGYN/Reproductive Endocrinology and Infertility notified.
Disposition: discharge with close REI follow-up.
Procedure Notes
Bartholin Abscess Word Catheter Placement
Indication: Symptomatic Bartholin abscess, intact skin overlying cyst, desire for bedside drainage with subsequent epithelialization.
Technique: Clean skin with chlorhexidine or betadine. Anesthetize area with 1% lidocaine (intradermal and deeper into gland). Create small incision over abscess dome. Express purulent material. Insert Word catheter (14 French) into cavity with string end exiting vulva. Secure with Tegaderm or gauze. Instruct patient to keep area clean and dry; avoid tampon insertion. Word catheter typically self-expels after 2-4 weeks as epithelialization occurs.
Follow-up: OBGYN follow-up in 2-4 weeks for catheter removal or assessment for fall-out. Earlier follow-up if fever, increased pain, or signs of cellulitis.
Clinical Education
Ovarian Torsion Pearls
Ultrasound Sensitivity. Pelvic ultrasound is the first-line imaging but sensitivity for ovarian torsion is only approximately 85%[1]. Absent Doppler flow is not reassuring (may indicate complete torsion with strangulation) and preserved arterial flow does not rule out torsion (venous flow occludes first). Torsion remains a clinical diagnosis. When clinical suspicion is high (acute unilateral adnexal pain, risk factors such as enlarged ovary or cyst, nausea/vomiting), consult OBGYN emergently regardless of ultrasound findings.
Risk Factors and Presentation. Ovarian torsion occurs most commonly in reproductive-age women and in those with underlying ovarian pathology (cysts, enlarged ovary, PCOS)[1]. Onset is typically acute and often awakens patients from sleep. Associated symptoms include nausea, vomiting, and sometimes light vaginal bleeding.
Operative Intervention. Ovarian conservation is the goal in reproductive-age women even if tissue appears nonviable, as some salvage is possible with reperfusion[1]. Emergent surgical exploration is indicated for confirmed or highly suspected torsion.
Bartholin Abscess Management
Diagnosis and Presentation. Bartholin abscesses present as unilateral vulvar mass with pain, often with a history of prior cyst. Some patients report fever or systemic symptoms. The cyst is located at the 4 or 8 o’clock position on the vulva.[2]
Word Catheter Technique. Word catheter placement is the preferred first-line treatment for non-diabetic patients and those without signs of necrotizing infection. The technique allows simultaneous drainage and re-epithelialization and has low recurrence rates (5-10%). Marsupialization is reserved for recurrent abscesses (2+ episodes) and provides more permanent resolution but may have slightly higher morbidity.
Age Consideration. Women >40 years presenting with a presumed Bartholin cyst should undergo biopsy or imaging to rule out Bartholin gland carcinoma, even if initially appearing as simple abscess or cyst. Malignancy risk increases substantially with age.
Ruptured Ovarian Cyst
Hemorrhagic Cyst Management. A hemorrhagic ovarian cyst that ruptures typically causes acute pelvic pain but often resolves with conservative management. Hemodynamically stable patients with stable serial exams are candidates for discharge with expectant management (analgesia, reassurance). Serial hemoglobin should be checked if hemorrhage is significant or if patient is symptomatic with hemodynamic changes.
Free Fluid Interpretation. Small amounts of free fluid on ultrasound (typically <1 cm layering or minimal) are common and not automatically concerning. Larger volumes, especially with hemodynamic instability, should prompt consideration of active hemorrhage or other pathology. Contrast-enhanced CT may clarify if diagnosis unclear and bleeding appears substantial.
Differential Diagnosis. Acute pelvic pain with imaging finding of cyst and free fluid requires exclusion of ectopic pregnancy rupture, appendicitis, mesenteric ischemia, and other surgical emergencies. Clinical history, beta-hCG, and careful examination are essential.
Ovarian Hyperstimulation Syndrome
Classification. Ovarian hyperstimulation syndrome (OHSS) is classified as mild, moderate, or severe based on symptom severity and imaging findings. Mild OHSS presents with abdominal pain and nausea with mild distension. Moderate OHSS includes significant pain with mild to moderate ascites on imaging. Severe OHSS involves tense ascites, potential pleural effusion, oliguria, or laboratory abnormalities (elevated hematocrit, elevated liver enzymes)[3].
Pathophysiology and Risk. OHSS results from exaggerated ovarian response to gonadotropins used in fertility treatment. It occurs in 1-2% of IVF cycles but is mostly mild. Severe OHSS carries risk of thromboembolism (3-5% of severe cases), acute kidney injury, and rarely death. Polycystic ovary syndrome and young age are risk factors for severe disease.
Management Strategy. Mild and moderate OHSS are managed conservatively with IV hydration, antiemetics, analgesia, and close outpatient follow-up with fertility team. Severe OHSS typically requires admission for IV hydration, monitoring of urine output and lab values (renal function, electrolytes, hemoglobin), and rarely paracentesis if respiratory compromise or organ dysfunction develops. Anticoagulation may be considered for thrombosis prophylaxis in severe cases.
Pelvic Pain Differential
Ectopic Pregnancy Consideration. In any reproductive-age woman (menarche to menopause) presenting with pelvic pain, ectopic pregnancy rupture must be ruled out until proven otherwise. Obtain serum beta-hCG in all menstruating-age women regardless of reported contraceptive use or sexual history. A negative pregnancy test is reassuring; a positive test requires pelvic ultrasound for location and viability assessment.
Appendicitis Mimicry. Appendicitis frequently presents with right lower quadrant pain and can mimic ovarian torsion or cyst rupture. Rebound tenderness, fever, or leukocytosis may be more pronounced with appendicitis. CT imaging is sensitive (95%+) and should be obtained if diagnosis remains unclear after ultrasound and clinical assessment.
References
- Moore AM, Katz VL. Ovarian torsion. In: UpToDate. Accessed March 2026.
- Leungwattanakij S, Behr B. Bartholin gland and duct problems. In: UpToDate. Accessed March 2026.
- Youssef MA, El-Khayat W. Ovarian hyperstimulation syndrome. In: UpToDate. Accessed March 2026.
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