HOW TO TREAT 23
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Figure 10 . Schematic illustration of Mycoplasma genitalium .
Isseki Yu et al . Biomolecular interactions modulate macromolecular structure and dynamics in atomistic model of a bacterial cytoplasm / CC BY-SA / bit . ly / 3Abr5XG
The GP confirms that Sara has no drug allergies and advises her that treatment involves an IM antibiotic injection immediately and a twoweek course of oral antibiotics . Sara asks whether it is safe to keep the IUD in place , and the GP advises that if her symptoms are improving in three days , there is no need to remove it , but if they are not improving or worsening , the IUD needs to be removed . Sara consents to the medications and agrees to fill the prescription at the pharmacy and return straight away so the practice nurse can administer the injection . The GP
1 . Which ONE is not a consequence of untreated PID ? a Tubal factor infertility . b Chronic pelvic pain . c Menorrhagia . dEctopic pregnancy .
2 . Which THREE statements regarding the pathogens causing PID are correct ? a A pathogen is identified in most cases of PID . b Chlamydia trachomatis and Neisseria gonorrhoeae are well known PID pathogens . c About 15 % of new chlamydia infections in women will progress to symptomatic PID . d Many women with PID also have bacterial vaginosis .
3 . Which TWO are risk factors for PID ? a Menopause . b A current STI . c Recent uterine instrumentation . d Oral contraceptive pill use .
4 . Which THREE are clinical features of mild to moderate PID ? a Recent onset mild to moderate gives Sara a printed information sheet about PID and its management , and advises her to have no penetrative vaginal intercourse until treatment completion or until she is symptomatically better . Sara is also advised that her recent partners should be treated with doxycycline .
Sara is no longer seeing her most recent partner but agrees to send him a message about the need for antibiotic treatment via the Let Them Know website ( letthemknow . org . au ).
On follow-up three days later , Sara is feeling much better , with reduced pelvic pain , and tolerating
How to Treat Quiz .
low abdominal pain . b Deep dyspareunia . c Fever , nausea , vomiting . d Abnormal vaginal discharge .
5 . Which THREE are enough , on their own , to diagnose PID ? a Uterine tenderness plus recent onset pelvic pain where no other cause is identified . b Lower genital tract chlamydia , gonorrhoea or M . genitalium infection . c Cervical motion tenderness plus recent onset pelvic pain where no other cause is identified . d Adnexal tenderness plus recent onset pelvic pain where no other cause is identified .
6 . Which THREE differential diagnoses need to be excluded prior to a presumptive diagnosis of PID ? a Ectopic pregnancy . the antibiotics well . All her tests were negative , but her response to the antibiotics indicates the provisional diagnosis of PID is correct . Transabdominal examination confirms Sara only has mild tenderness , and the GP advises that it is appropriate to keep the IUD in place if she so chooses .
Sara reports that she sent a message to her recent partner regarding treatment . The GP reconfirms that Sara knows to avoid sex until treatment is complete or symptoms have resolved . At two-week follow-up , Sara ’ s symptoms have completely disappeared . She is very grateful for the
PELVIC INFLAMMATORY DISEASE
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b Urinary tract infection . c Appendicitis . d Rupture or torsion of an ovarian cyst .
7 . Which TWO findings on speculum examination support the diagnosis of PID ? a Cervical motion tenderness . b Bleeding from the cervix . c Cervical polyp . d Inflamed , erythematous and friable cervix .
8 . Which THREE routine investigations below are appropriate in a woman with suspected PID ? a Pregnancy test . b Endocervical swabs for chlamydia , gonorrhoea and M . genitalium . c A clean catch urine sample for leucocytes , nitrates , microscopy and culture . d FBC , LFTs and amylase .
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GP ’ s care and appreciates the discussion about safe sex .
CONCLUSION
GPs play a crucial role in the timely diagnosis and management of PID , thereby reducing the likelihood of progression to adverse reproductive sequalae . It is essential to routinely consider a diagnosis of PID in all women of reproductive age who present with recent onset lower abdominal pain , following exclusion of emergency differential diagnoses .
In most cases of PID , a pathogen is never identified . Antibiotic treatment
9 . Which ONE antibiotic regimen is recommended for mild to moderate PID ? a Ceftriaxone 500mg stat IV or IM plus oral metronidazole 400mg bd 14 days plus azithromycin 1g PO stat plus azithromycin 1g PO , stat , one week later . b Ceftriaxone 500mg stat IV or IM and wait for laboratory results before choosing the other antibiotic / s . c Ceftriaxone 500mg stat IV or IM plus oral metronidazole 400mg bd for 14 days plus oral doxycycline 100mg bd for 14 days . d Ceftriaxone 2g IV plus azithromycin 500mg IV daily plus metronidazole 500mg IV bd .
10 . Which THREE are part of the management of mild to moderate PID ? a Education , including written information . b Notifying and treating sexual contacts . c Review 2-3 days after antibiotic initiation and on completion of treatment . d Immediate removal of IUD . with ceftriaxone , doxycycline and metronidazole is started as soon as a clinical diagnosis of PID is made and without waiting for STI test results . A rapid response to treatment confirms a diagnosis of PID .
Advise women with PID that their sexual partners require treatment , and provide patients with information about preventing repeated infections through use of condoms when with new sexual partners .
RESOURCES
• Australian Sexual health Alliance — Australian STI management guidelines for use in primary care bit . ly / 3peWnYv
— NSW Government STI Programs Unit
— Acute abdominal pain in women bit . ly / 3pcnmUH
— STI / HIV testing tool ( includes guidance for contact tracing ) bit . ly / 3pbx4a3
— GP speculum and bimanual examination bit . ly / 3pfnv9V
• Coombe J , et al . New best practice guidance for general practice to reduce chlamydiaassociated reproductive complications in women . Aust J Gen Pract 2021 ; 50 ( 1-2 ): 50-54 bit . ly / 3E70e0d
• Let Them Know ( partner notification website ) bit . ly / 3I4yn2W
• Better to know ( STI information and partner notification website ) bit . ly / 3E6APDX
• Australian Government Department of Health Australasian Society for HIV , Viral Hepatitis and Sexual Health Medicine ( ASHM ) Australasian Contact Tracing guidelines bit . ly / 3G31NwP
• Monash University What ’ s Going on Down There bit . ly / 3I5zbEJ
References available on request from howtotreat @ adg . com . au