CEN: Genitourinary, Gynecologic and Early-Pregnancy Emergencies

In depth

The one-page summary above is what the PDF prints. These sections go further.

Ectopic pregnancy in detail

About 2 in 100 diagnosed pregnancies are ectopic, and rupture usually comes between about 6 and 16 weeks (Merck). Risk factors are a previous ectopic, tubal surgery or damage, PID or chlamydia, infertility and assisted reproduction, smoking, and pregnancy with an IUD in place, but about half of patients have none (Hendriks 2020). Symptoms can be absent until rupture, then sudden severe pain, shoulder pain from blood under the diaphragm, syncope and shock. A urine pregnancy test is about 99% sensitive. Hendriks 2020 found no evidence that palpation during the pelvic examination raises the risk of rupture.

hCG and ultrasound are read together. Most intrauterine pregnancies are visible by 1,500 mIU/mL, and for a desired pregnancy a conservative discriminatory level of up to 3,500 mIU/mL avoids harming a viable pregnancy (Hendriks 2020; Merck also uses 3,500). In a viable pregnancy hCG rises at least 49% in 48 h from a start below 1,500, at least 40% from 1,500 to 3,000, and at least 33% above 3,000; a fall of at least 21% in 48 h suggests a failing intrauterine pregnancy. Below the discriminatory level with an empty uterus, a stable patient with a desired pregnancy is followed with serial hCG, repeat ultrasound and return precautions.

Methotrexate works in about 90%, and about 9% of patients have a complication needing admission (Merck). hCG often rises from day 1 to day 4, and mild pain in the first days is common, but rupture stays possible until hCG is undetectable. Discharge teaching: avoid folic acid and NSAIDs (they blunt the drug), alcohol and opioids (they mask rupture), intercourse and vigorous exercise, and sun exposure; return at once for severe pain, dizziness or fainting; wait at least one ovulatory cycle after hCG is undetectable before trying to conceive (Hendriks 2020).

Early pregnancy loss, Rh and hyperemesis

About 10 to 15% of confirmed pregnancies end in spontaneous loss, over 80% of them in the first trimester (Merck). Fetal cardiac activity is usually seen at about 5.5 to 6 weeks; a crown-rump length of 7 mm or more without a heartbeat, or a mean sac diameter of 25 mm or more without an embryo, is diagnostic of failure. Expectant care completes about 80% within 8 weeks; misoprostol 800 mcg vaginally is common, and mifepristone 200 mg orally 24 h earlier improves success; suction aspiration is urgent for hemorrhage, instability or infection. Septic abortion shows fever, constant pain, purulent discharge and uterine tenderness.

Rh: ACOG's 2024 clinical practice update (Obstet Gynecol 2024;144(6):e140-e143; a UMEM pearl dated 10/10/2024 cites the September 2024 posting) suggests forgoing routine Rh testing and Rh D immune globulin after abortion or pregnancy loss before 12 0/7 weeks, because alloimmunization is very unlikely, with testing and anti-D still possible by shared decision. The acog.org page returned HTTP 402, so this wording comes from ACEP Now, UMEM and a search summary that quotes ACOG; ACEP Now notes that 50 mcg is the proper first-trimester dose, though 300 mcg vials are easier to find. Merck still says all Rh-negative patients with ectopic pregnancy receive anti-D, and none of the sources opened says whether ACOG's update, written for abortion and loss, covers ectopic or molar pregnancy, so this page keeps anti-D for ectopic pregnancy and does not attribute that to ACOG. Local policy may differ; Obstetric Emergencies covers anti-D later in pregnancy.

Hyperemesis gravidarum is vomiting with dehydration, ketosis and weight loss over 5%; ordinary nausea starts near 5 weeks, peaks near 9 and settles by 16 to 18 (Merck). Work-up: urine ketones, electrolytes, kidney and liver tests, magnesium, phosphorus, TSH, and an ultrasound for twins or molar pregnancy. Treatment: nothing by mouth at first, 2 L of lactated Ringer's over 3 h aiming for urine over 100 mL/h, thiamine 100 mg IV before any dextrose and daily for 3 days (Wernicke encephalopathy), potassium, magnesium and phosphorus replaced, and sodium corrected slowly. Antiemetics named by Merck: doxylamine 12.5 mg with pyridoxine 10 to 25 mg, promethazine 12.5 to 25 mg, metoclopramide 5 to 10 mg, prochlorperazine 5 to 10 mg, and ondansetron 8 mg every 12 h (before 10 weeks only after weighing the risk of birth defects). Methylprednisolone is a last resort and avoided during organogenesis.

Adnexal torsion, ruptured cysts, PID and abscess

Adnexal torsion twists the ovary, often with the tube, and cuts off its blood supply. The main risk is an ovary over 4 cm (benign cyst or tumor), plus ovulation induction, pregnancy with a large corpus luteum cyst and a previous torsion (Merck). Pain is sudden and severe, may come and go for days, and is often out of proportion to the examination; nausea and vomiting are usual. ACOG Committee Opinion 783 (adolescents): up to 46% of torsed ovaries in young patients have no mass, no clinical or imaging criteria confirm torsion before surgery, and Doppler flow alone should not guide decisions (the 46% figure and these points come from the Europe PMC abstract and secondary summaries; the full text was not opened). The aim of surgery is to untwist and conserve the ovary, with removal for tissue that cannot be saved (Merck). In an adolescent girl with right lower quadrant pain, appendicitis, torsion, ectopic pregnancy and PID are all on the list, which is why hCG comes first and laparoscopy can settle more than one of them.

A ruptured or bleeding ovarian cyst causes sudden pain, sometimes with vomiting and lightheadedness. Pregnancy is excluded first. Mild cases without ongoing bleeding are managed with analgesia and observation; hemoglobin is followed, and rising heart rate, falling hemoglobin, orthostatic symptoms or growing hemoperitoneum mean surgery (Mantecon 2022, a single case report; no guideline was opened for this condition).

Supportive criteria for PID include oral temperature over 38.3 C, mucopurulent discharge, white cells on vaginal fluid microscopy, raised ESR or CRP and documented gonorrhea or chlamydia. Improvement is expected within 3 days; no improvement within 72 h means admission and reassessment. An IUD does not need removal (consider it if no improvement in 48 to 72 h). Test for HIV and syphilis, treat partners from the 60 days before symptoms, retest at 3 months after gonococcal or chlamydial PID. Pregnant patients with suspected PID are admitted for IV therapy. About 15% of patients with salpingitis develop a tubo-ovarian abscess (Merck); it needs at least 24 h of inpatient observation (CDC), drainage is considered if it is over 7 cm or responds poorly, and suspected rupture means immediate surgery. Later complications include Fitz-Hugh-Curtis perihepatitis (right upper quadrant pain), chronic pain, infertility and ectopic pregnancy.

Urethritis, gonorrhea and epididymitis

After gonorrhea treatment: no sex for 7 days and until partners are treated, partners from the past 60 days evaluated, and a retest at 3 months because reinfection is common. Epididymitis care adds bed rest, scrotal elevation and NSAIDs; a man who is not better within 72 h is re-evaluated, and torsion must be considered in every case, especially in adolescents and when there is no sign of inflammation (CDC). Ultrasound mainly rules out torsion.

The acute scrotum

Testicular torsion peaks between 12 and 18 years, with a second peak in infancy, and rests on the bell-clapper anomaly (present in about 5 to 16% of males), which leaves the testis free to rotate (Merck). Pain is rapid and severe with nausea and vomiting, then swelling; the cremasteric reflex is usually absent. A clear clinical picture goes straight to surgery; color Doppler is the preferred study when imaging is needed. Salvage is 80 to 100% at 6 to 8 h and near zero at 12 h. If surgery is not immediately available, manual detorsion rotates the testis outward, like opening a book (the left testis turns clockwise viewed from the front); surgery still follows, and the other testis is fixed at the same time.

TWIST (Testicular Workup for Ischemia and Suspected Torsion) adds testicular swelling 2, a hard testis 2, absent cremasteric reflex 1, nausea or vomiting 1 and a high-riding testis 1 (Cassaro 2025). Scores of 0 to 2 are low risk, 3 to 4 intermediate and 5 to 7 high (Tobu 2025); intermediate scores go to Doppler and high scores support going straight to surgery. The score supports judgment, so urology is called early.

Torsion of the appendix testis affects younger boys than cord torsion. A tender nodule at the upper pole and a blue dot seen through the skin suggest it. In Fujita's series (70 patients) the median age was 11 years against 16 for cord torsion, and the few boys scanned with Doppler showed reduced flow only with cord torsion, but ultrasound depends on the operator and does not settle the question alone. Analgesics, cooling and reduced activity treat most cases (Fujita 2017). If the diagnosis is uncertain, urology still evaluates for torsion.

Priapism and Fournier gangrene

Priapism is an erection lasting more than 4 h without sexual stimulation; over 95% are ischemic (low flow, rigid, painful) (Alnajjar 2022). Causes include intracavernosal or oral erectile drugs in adults and hematologic disease, mainly sickle cell disease, in children (Merck). Nonischemic priapism comes from high arterial inflow, usually after penile or perineal trauma, is typically painless and does not cause necrosis; conservative care is usual (Alnajjar, Merck). In ischemic priapism, corporal blood is aspirated (up to 50 mL) after a penile block and sent for a blood gas, which shows hypoxia and acidosis. ACEP Now's summary of the AUA/SMSNA guideline (2024) gives intracavernosal phenylephrine 100 to 500 mcg every 3 to 5 min, with aspiration, irrigation or the drug used singly or together; it states no maximum dose, reports retrospective totals from a median of 1,000 to 1,500 mcg up to 12,000 mcg, and names premixed 500 or 1,000 mcg/mL solutions. Alnajjar asks for continuous blood pressure and heart rate monitoring because alpha agonists can cause cardiovascular events, and the dose is adjusted in significant heart disease and in children. A distal shunt follows if this fails; beyond about 36 h fibrosis and erectile dysfunction are expected (Alnajjar), and Merck uses a shunt for priapism over 48 h.

Sickle cell disease: early hematology input goes alongside the ischemic-priapism pathway (Alnajjar). Merck notes that sickle-related priapism often settles as the crisis is treated, but a rigid erection beyond 4 h is ischemic priapism and urology is called for aspiration and phenylephrine; Merck lists sildenafil and Alnajjar hydroxyurea and exchange transfusion only for the stuttering (recurrent) form.

Fournier gangrene is a rapidly progressive necrotizing fasciitis of the perineum, scrotum and genitals, usually polymicrobial from urinary, bowel or skin sources; and mortality is about 40% (StatPearls, as quoted in a search summary; the StatPearls text was not opened). Predisposing factors are diabetes, alcohol use, immune suppression, and kidney or liver disease; in the 24-patient series the source was bowel in 42%, skin in 21% and urinary tract in 17% (Ioannidis 2017). In one 24-patient series, crepitus was felt in about 21% (19 to 64% in the literature), soft-tissue air showed on plain films in 75%, and mortality was about 21%; treatment rests on early, aggressive debridement of all necrotic tissue, broad-spectrum antibiotics and resuscitation, often with repeat debridement (Ioannidis 2017). The ED nurse's job is recognition, sepsis resuscitation and an early surgical call.

Stones: pain, imaging, who stays

Colic comes in waves of about 20 to 60 min with nausea and vomiting; the radiation suggests the level: flank across the abdomen for upper ureter or pelvis, into the groin or genitals for lower ureter, urgency and frequency for a stone at the bladder (Merck). Noncontrast CT is the usual first study and also shows mimics such as aortic aneurysm; low-dose CT cuts radiation. EAU 2026: ultrasound first in children (then KUB or low-dose CT) and in pregnancy (then MRI, low-dose CT last). Merck says to consider aortic aneurysm or dissection in older patients (see Aortic Emergencies).

Merck: patients with stones under 1 cm, no infection or obstruction, controlled pain and oral intake can go home; stones not passed in 6 to 8 weeks are usually removed; extra fluid does not speed passage. Tamsulosin (FDA label): 0.4 mg once daily about 30 min after the same meal, not crushed, chewed or opened; dizziness, orthostatic hypotension and syncope; rare priapism; floppy iris syndrome during cataract or glaucoma surgery. Return precautions: fever, vomiting that stops oral intake, pain the prescribed analgesic does not control.

Urinary retention and post-obstructive diuresis

Benign prostatic hyperplasia caused retention in about half of men in one series, and drugs tip a narrow outlet into retention: anticholinergics weaken the detrusor and decongestants raise alpha tone at the bladder neck and prostate; NSAID users had about twice the risk (Selius 2008). A post-void residual under 50 mL is normal and under 100 mL usually acceptable over 65 (Merck). Treatment is immediate, complete decompression; there is no evidence that gradual draining or clamping prevents hematuria, hypotension or diuresis (Selius 2008; Halbgewachs 2015). If a urethral catheter will not pass, do not force it: a coude or suprapubic catheter is placed by someone skilled. Starting an alpha blocker for about 3 days before a voiding trial helps; up to 70% of men retain again within a week if the bladder is simply drained (Selius 2008).

Post-obstructive diuresis (Halbgewachs 2015) is urine over 200 mL/h for 2 consecutive hours or over 3 L in 24 h after relief of obstruction, watched for after bladder outlet obstruction, bilateral ureteral obstruction or obstruction of a single kidney. The physiologic form clears retained salt and water and settles in about 24 h; a pathologic form runs past 48 h, and urine sodium over 40 mEq/L suggests tubular injury. Record output every 2 h, vital signs every 6 to 8 h, electrolytes, magnesium, phosphate and creatinine every 12 to 24 h, daily weight. Replace part of the output (for example 75% of the previous hour), orally if the patient can drink, 0.45% saline IV if not; replacing every milliliter keeps the diuresis going. The ICU side is on Acute Kidney Injury.

UTI, pyelonephritis and special groups

Urinalysis (Merck): pyuria is 8 or more white cells per microliter; nitrite is specific but not sensitive, and unreliable if the urine stands; white cell casts mean inflammation in the kidney (pyelonephritis, interstitial nephritis, glomerulonephritis). A culture of more than 10,000 CFU/mL is significant in a symptomatic patient. Pyelonephritis brings fever, chills, flank pain and costovertebral angle tenderness; only about a third have dysuria and frequency.

Asymptomatic bacteriuria (IDSA 2019): screen and treat only in pregnancy (4 to 7 days) and before urologic procedures that breach the mucosa. Do not treat it in diabetes, spinal cord injury, catheterized patients, kidney transplant beyond 1 month, or older adults with a fall or delirium and no urinary or systemic signs: look for another cause and observe. In pregnancy it is screened at 12 to 16 weeks or the first prenatal visit (Merck).

Pyelonephritis in pregnancy is treated as an inpatient with an IV cephalosporin, aztreonam or ampicillin with gentamicin; fluoroquinolones and TMP-SMX are avoided (Merck). Most improve within about 72 h; persistent fever suggests obstruction or abscess. Endotoxin can injure the alveolar-capillary membrane: in Cunningham 1987, respiratory insufficiency appeared 24 to 48 h after admission, was not explained by fluid overload, and three of 15 women needed ventilation. Watch respiratory rate, SpO2 and fluid balance, and keep fetal and contraction monitoring going.

Infants and young children (Merck): about 4 to 10% of febrile infants without a source have a UTI. Culture urine is obtained by catheterization (suprapubic aspiration for boys with marked phimosis); bagged specimens are unreliable and are not used for diagnosis. Blood cultures go with a UTI in infants, and a first febrile UTI under 3 years earns a kidney and bladder ultrasound.

Exam pearls

• The pregnancy test comes before the ultrasound, the CBC or the urinalysis in pelvic pain, whatever the history.
• Normal blood pressure does not mean a stable ectopic: tachycardia and dizziness on standing already mean hemorrhage.
• Preserved Doppler flow does not exclude ovarian or testicular torsion.
• Gradual scrotal pain with dysuria or discharge favors epididymitis; sudden pain with vomiting favors torsion.
• Priapism over 4 h is a urology procedure, not oral terbutaline and a wait.
• Renal colic with fever is an emergency drainage problem, not an analgesia problem.
• Drain retention completely; replace post-obstructive diuresis partly.
• Bacteriuria without symptoms is treated in pregnancy and almost nowhere else.