Iv access if procedural sedation with parenteral narcotics and/or midazolam necessary for procedure.

Lithotomy position, prep with Betadine, then drape.

Anesthetize with 1-2% lidocaine buffered with bicarb.

Incise on mucosal surface, and place gauze packing or Word catheter (South Med J 1968;61:514); the Word catheter works by placing needle on syringe filled with 3-5 cc of saline through the rubber on the flat end of the catheter so that the needle tip now sits inside the closed “balloon,” and once incision is cross-hatched, place the curved end of the balloon into the wound and inject approximately 3 cc of saline into balloon so that it does not come out and keeps the wound open—remove 1 cc q wk until this heals from inside out.

To marsupialize, cross hatch on mucosal surface and carry cross hatch down to the cyst. The four corners of the incised cyst will be sewn to the superficial mucosal surface, so that the cyst cannot reocclude, and will heal by secondary intention.

Consider silver nitrate for sclerosis (Eur J Obstet Gynecol Reprod Biol 1995;63:61).

Sitz baths.

Refer to STD section for specific STD treatments.

X-ray: This discussion is for a non-pregnant patient. If unsure of diagnosis or if palpable mass, US may show a cyst coincident with pain locale, or free fluid with no other lesions which may be consistent with a ruptured cyst. US may also define simple vs complex cysts. Hemorrhagic ovarian cyst may be better elucidated with transvaginal ultrasound (Gynecol Endocrinol 1991;5:123). Right-sided pain may not be easily explained with free fluid but no other lesions noted—this may be consistent with appendicitis, as well.

If patient afebrile, and left-sided pain, may elect to treat with NSAIDs and narcotics for breakthrough pain—US as outpt with referral to primary care physician or gynecologist.

If pain is right-sided, must consider appendicitis. Using Bayseian reasoning, consider the H&P and CBC with diff (UA and urine pregnancy test should both be unremarkable, although ureteral irritation sometimes occurs) to decide whether diagnosis needs to be made immediately, or have the patient return in 6-8 hr for a recheck. Abdominal CT for cases with high index of suspicion for appendicitis—do not rely on US to r/o appendicitis although it may rule it in (not as good as CT). Iv medications for pain control (narcotics) and nausea/vomiting are OK.

Cysts > 5 cm refer for gyn follow-up, for either aspiration (Brit J Obstet Gynaecol 1989;96:1035), laparoscopy or laparotomy.

X-ray: US with large and eccentric ovary > 5 cm, perhaps with Doppler to determine viability (Ultrasound Obstet Gynecol 1995;5:129); may also be seen with CT (J Reprod Med 1998;43:827).

Iv access for parenteral anti-emetics and narcotics, if necessary.

Gynecologic consult.

X-ray: Pelvic ultrasound or CT scan for abscess if clinically suspected.

First: Cefoxitin 2 gm im + probenecid 1 gm po, or ceftriaxone 250 mg im; then tetracycline 500 mg po qid or doxycycline 100 mg po bid for 14 d.

Second: Ofloxacin 400 mg po bid + clindamycin 450 mg po qid or metronidazole 500 mg po bid for 2 wk.

Dx uncertain, gyn consult for laparoscopy (J Reprod Med 1993:53).

Mass is present.

Unable to keep po meds down.