HOW TO TREAT 19
19y old woman - Maya ( she , her )
Presenting complaint 48-hour history of lower abdominal pain
• Started during sexual intercourse with current partner
• Persisted , now a dull ache Post coital bleeding ( PCB ) 2 days ago Currently has white / yellow offensive vaginal discharge
Menstrual history
• LMP 2 months
• No previous irregular bleeding
Contraceptive history
• Tricycles COCP
• No missed pills
Examination Mild tenderness in lower abdomen on deep palpation but soft with no rebound tenderness
White discharge at introitus with amine-type odour
Photo by kaung minn kent on unsplash
Sexual health / STI history Male partner of 2 months duration Previous partner about 3 months ago Concerns re exclusivity Condom use ’ sometimes ’ No previous STI check
Features in Maya ’ s history that make the following causes less likely Pregnancy including ectopic : using effective contraception reliably UTI : no dysuria , no previous UTI Appendicitis : Pain did not start unilaterally , associated genital symptoms Ovarian cyst : No unilateral symptoms and taking COCP
Speculum examination Cervicitis and significant discharge
Vaginal examination Tender in both adenexae , no masses , normal sized uterus and also pain on moving cervix to both sides
Investigations Urine sample
• beta HCG to exclude pregnancy
Vaginal swabs
• Trichomonas vaginalis , bacterial vaginosis
• pH paper Cervical swabs
• Neisseria gonorrhoea , Chlamydia trachomatis , Mycoplasma genitalium
Presumptive diagnosis
• Pelvic inflammatory disease
Treatment Start treatment for PID immediately on basis of presumptive diagnosis
• Do not await test results
Per Australian guidelines
• Ceftriaxone 500 mg IM with 2 ml 1 % lignocaine stat dose
• Doxycycline 100 mg bd for 14 days
• Metronidazole 400 mg bd for 14 days
Advice to Maya
• Partner advised to be seen , tested and treated ASAP
• No unprotected sexual intercourse until completed treatment
• Review at 72 hours
• See earlier if symptoms worsening
Other information to give Maya Health promotion
• Prevention of repeat infection to reduce the risk of repeat PID and complications
Partner
• Contact tracing
Risk of complications is reduced due to prompt treatment
• Infertility
• Ectopic pregnancy
• Pain
Other considerations If test results do not identify a current STI
• does not exclude diagnosis of PID If test results identify Mycoplasma genitalium
• Need further treatment according to guidelines
Figure 5 . Documenting the clinical consultation for diagnosis and management of PID .
enables visualisation of the fallopian tubes and identification of upper genital tract pathogens , it is an invasive procedure that is generally limited to cases not responding to treatment . 1 , 19
Given the serious consequences of untreated PID , have a low threshold for diagnosis where pregnancy is excluded . Over-diagnosis is preferable to under-diagnosis as the risks of antibiotics are potentially less than the possible long-term complications of a missed diagnosis or delayed treatment . 19 A diagnosis of PID is further supported by a rapid response in symptoms to antibiotic treatment .
PID diagnostic criteria are provided in box 3 . The minimum criteria for a clinical diagnosis of PID are any one of uterine , cervical motion or adnexal tenderness in sexually active young or other women with recent onset pelvic pain and where no other cause is identified . 19 Several additional features may support a diagnosis if present with the minimum criteria and include a diagnosed chlamydia or gonorrhoea infection , cervical friability , and elevated inflammatory markers . 19
Exclusion of emergency differential diagnoses , including ectopic pregnancy , appendicitis , and rupture or torsion of an ovarian cyst , is essential when considering a diagnosis of PID . 3 , 19 If abdominal pain is severe and associated with copious vaginal bleeding and systemic features ( for example , hypotension , nausea , vomiting ), immediately refer the woman to ED . Other potential differential diagnoses include endometriosis , dysmenorrhoea , irritable bowel syndrome , urinary tract infection or pyelonephritis . 3 The NSW Government STI Programs Unit website offers an overview of the differential diagnoses and associated presentations for recent onset abdominal pain in women of reproductive age .
Taking a patient history
Taking an accurate history is essential to support or exclude a diagnosis
Figure 6 . Chlamydial mucopurulent cervicitis .
Table 1 . Features of the pelvic examination Examination and purpose Potential findings Interpretation
Bimanual examination to allow assessment of pelvic tenderness to check for any pelvic masses
Speculum examination to allow visual assessment of the cervix and if an IUD is present
of PID in females with new onset lower abdominal pain . 3 , 19 Given that PID can develop in the time between asymptomatic STI testing and recall for treatment , it is also essential to ask about possible symptoms of PID in any female patient attending for treatment of a chlamydia or gonorrhoea infection . 22
• Cervical motion tenderness : pain when the cervix is rocked back and forward
• Uterine tenderness when the uterus is felt between the examiner ’ s two hands
• Adnexal tenderness felt when palpating lateral to the uterus
• Bleeding from the cervical os
• Mucopurulent cervical discharge
• Inflamed , erythematous and friable cervix
• Vaginal discharge : thin and white
• pH greater than 4.5
• Amine odour
Ask about a detailed description of pelvic pain , its pattern and duration , and the presence of any deep dyspareunia . Pain from PID is generally bilateral , mild to moderate in intensity , may resemble menstrual pain , and has often been present for days to weeks . In contrast , pain associated with ectopic pregnancy or
One or more of these supports a diagnosis of PID
Note : Where cervical motion , uterine or adnexal tenderness are not present a diagnosis of PID is unlikely
Indicates cervicitis which supports the diagnosis of PID
Consistent with bacterial vaginosis that may contribute to development of PID
appendicitis is often more acute , unilateral ( ectopic pregnancy ) or radiates to the right iliac fossa ( appendicitis ). About 5 % of women with PID have right upper quadrant pain that resembles cholecystitis but may indicate perihepatic inflammation or Fitz-Hugh-Curtis syndrome . 1 , 19 The history includes the woman ’ s general medical history as well as a sexual , menstrual and contraception history to ascertain if a pregnancy is likely , the level of STI risk , or a recent IUD insertion or termination of pregnancy . It is important to ask about any postcoital bleeding and altered vaginal discharge which may suggest cervicitis ( see figure 6 ). 3
The physical examination
The physical assessment for PID begins with recording vital signs and abdominal palpation for tenderness or masses . If the woman verbally consents to a pelvic examination , conduct a bimanual and a speculum examination . Bimanual pelvic examination is recommended to check for uterine or adnexal masses and tenderness , and to assess for cervical motion tenderness ( also termed cervical excitation ), which is suggestive of pelvic inflammation . Speculum examination allows visualisation of the cervix and identification of cervicitis ( see figure 7 ) that further supports a diagnosis of PID . 3 , 19 , 23 Table 1 summarises the findings supporting a diagnosis of PID during a pelvic examination . The NSW Government STI Programs Unit offers a brief online guide to conducting and interpreting speculum and bimanual examinations when considering a diagnosis of PID .
Australian GPs have indicated hesitancy in conducting pelvic examinations , particularly bimanual examinations , because of lack of experience or confidence in conducting them and interpreting the findings , as well as barriers including patient health issues and time constraints . 24 Clear communication regarding the reasons for the examination is crucial to support patients in providing informed consent . Offering a chaperone may also help address barriers to pelvic examination in some situations . If a pelvic examination is not performed and a diagnosis of PID is likely based on the history , risk factors and abdominal palpation , then treatment for PID should be