Genital Tract Infections Flashcards

Question

What are the investigations for chlamydia?

Answer 1

***Nucleic acid amplification tests*** (NAAT) are used to diagnose chlamydia. This can involve a: * Vulvovaginal swab * Endocervical swab * First-catch urine sample (in women or men) * Urethral swab in men * Rectal swab (after anal sex) * Pharyngeal swab (after oral sex)

Answer 2

* First-line for uncomplicated chlamydia infection is ***doxycycline 100mg twice a day for 7 days***. * Doxycycline is contraindicated in pregnancy and breastfeeding. Alternatives options listed in the BASHH guidelines (always check guidelines) for treatment in pregnant or breastfeeding women are: * Azithromycin 1g stat then 500mg once a day for 2 days * Erythromycin 500mg four times daily for 7 days * Erythromycin 500mg twice daily for 14 days * Amoxicillin 500mg three times daily for 7 days Other factors to consider are: * Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection * Refer all patients to ***genitourinary medicine*** (***GUM***) for contact tracing and notification of sexual partners * Test for and treat any other sexually transmitted infections * Provide advice about ways to prevent future infection * Consider safeguarding issues and sexual abuse in children and young people

Answer 3

* Pelvic inflammatory disease * Chronic pelvic pain * Infertility * Ectopic pregnancy * Epididymo-orchitis * Conjunctivitis * Lymphogranuloma venereum * Reactive arthritis

Answer 4

* Preterm delivery * Premature rupture of membranes * Low birth weight * Postpartum endometritis * Neonatal infection (conjunctivitis and pneumonia)

Answer 5

***Neisseria gonorrhoeae*** is a ***Gram-negative diplococcus*** bacteria. It infects ***mucous membranes*** with a ***columnar epithelium***, such as the ***endocervix*** in women, ***urethra***, ***rectum***, ***conjunctiva*** and ***pharynx***. It spreads via contact with mucous secretions from infected areas.

Answer 6

Gonorrhoea is a ***sexually transmitted infection***. RFs * young * sexually active * having multiple partners * Having other sexually transmitted infections, such as chlamydia or HIV, also increases the risk.

Answer 7

Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. 90% of men and 50% of women are symptomatic. The presentation will vary depending on the site. Female genital infections can present with: * Odourless purulent discharge, possibly green or yellow * Dysuria * Pelvic pain Male genital infections can present with: * Odourless purulent discharge, possibly green or yellow * Dysuria * Testicular pain or swelling (***epididymo-orchitis***) ***Rectal infection*** may cause anal or rectal discomfort and discharge, but is often asymptomatic. ***Pharyngeal infection*** may cause a sore throat, but is often asymptomatic. ***Prostatitis*** causes perineal pain, urinary symptoms and prostate tenderness on examination. ***Conjunctivitis*** causes erythema and a purulent discharge.

Answer 8

***Nucleic acid amplification testing*** (***NATT***) is use to detect the ***RNA*** or ***DNA*** of gonorrhoea. Genital infection can be diagnosed with ***endocervical***, ***vulvovaginal*** or ***urethral*** swabs, or in a ***first-catch urine*** sample. ***Rectal*** and ***pharyngeal*** swab are recommended in all ***men who have sex with men*** (***MSM***), and in those with risk factors (e.g. anal and oral sex) or symptoms of infection in these areas. A standard charcoal ***endocervical swab*** should be taken for ***microscopy***, ***culture*** and ***antibiotic sensitivities*** before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

Answer 9

Patients should be referred to GUM clinics (or local equivalent) to ***coordinate testing***, ***treatment*** and ***contact tracing***. Management depends on whether antibiotic sensitivities are known. For uncomplicated gonococcal infections: * A single dose of ***intramuscular ceftriaxone*** 1g if the sensitivities are NOT known * A single dose of ***oral ciprofloxacin*** 500mg if the sensitivities ARE known Different regimes are recommended for complicated infections, infections in other sites and pregnant women. Most regimes involve a single dose of intramuscular ceftriaxone. All patients should have a follow up “***test of cure***” given the high antibiotic resistance. This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure **at least**: * 72 hours after treatment for culture * 7 days after treatment for RNA NATT * 14 days after treatment for DNA NATT Other factors to consider are: * Abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection * Test for and treat any other sexually transmitted infections * Provide advice about ways to prevent future infection * Consider safeguarding issues and sexual abuse in children and young people

Answer 10

* Pelvic inflammatory disease * Chronic pelvic pain * Infertility * Epididymo-orchitis (men) * Prostatitis (men) * Conjunctivitis * Urethral strictures * Disseminated gonococcal infection * Skin lesions * Fitz-Hugh-Curtis syndrome * Septic arthritis * Endocarditis A key complication to remember is ***gonococcal*** ***conjunctivitis*** in a neonate. Gonococcal infection is contracted from the mother during birth. Neonatal conjunctivitis is called ***ophthalmia neonatorum***. This is a medical emergency and is associated with sepsis, perforation of the eye and blindness.

Answer 11

Appearances vary o Tiny flat patches on vulval skin o Small papilliform (cauliflower) swellings o Usually multiple

Answer 12

* No treatment — treatment is not always indicated, as in about 30% of people, warts disappear spontaneously within 6 months. * Self-applied treatments * Podophyllotoxin 0.5% solution * Imiquimod 5% cream * Sinecatechins 10% ointment * Specialist application — trichloroacetic acid (TCA) 80-90% solution. * Ablative methods (such as cryotherapy, excision, and electrocautery): consider if appropriately trained and resourced. These may be better for people with a small number of low-volume warts (regardless of type). Refer to GUM services. * Inform the person that active treatments: * May take 1–6 months to work. * Have significant failure rates. * Have significant relapse rates (because they do not eliminate the human papillomavirus). * Often involve discomfort and skin reactions. * Advise women that no changes are recommended in the screening intervals of cervical cytology. * Recommend condom use and smoking cessation to improve response to treatment. * However, explain that latex condoms may be weakened if in contact with imiquimod. * If psychological distress is an issue, explain that psychological counselling is available. * If asked, reassure that the presence of anogenital warts does not always imply recent partner infidelity because human papillomavirus is thought to have a long latency period (3 weeks to 8 months). * Suggest that, with consent, the person's current sexual partner may benefit from assessment for undetected genital warts or other undetected sexually transmitted infections, or for explanation and advice about the disease process in their par

Answer 13

The ***herpes simplex virus*** (***HSV***) ## Footnote ***HSV-1*** is most associated with ***cold sores***. It is often contracted initially in childhood (before five years), remains dormant in the ***trigeminal nerve ganglion*** and reactivates as cold sores, particularly in times of stress. ***Genital herpes*** caused by HSV-1 is usually contracted through ***oro-genital sex***, where the virus spreads from a person with an oral infection to the person that develops a genital infection. ***HSV-2*** typically causes ***genital herpes*** and is mostly a ***sexually transmitted infection***. It can also cause lesions in the mouth. The herpes simplex virus is spread through direct contact with affected ***mucous membranes*** or ***viral shedding*** in ***mucous secretions***. The virus can be shed even when no symptoms are present, meaning it can be contracted from asymptomatic individuals. Asymptomatic shedding is more common in the first 12 months of infection and where recurrent symptoms are present.

Answer 14

Patients affected by herpes simplex may display no symptoms, or develop symptoms months or years after an initial infection when the latent virus is reactivated. The symptoms of an initial infection with genital herpes _usually appear within two weeks_. The initial episode is often the most severe, and recurrent episodes are milder. Signs and symptoms include: * ***Ulcers*** or ***blistering lesions*** affecting the genital area * ***Neuropathic*** type pain (tingling, burning or shooting) * ***Flu-like*** symptoms (e.g. fatigue and headaches) * ***Dysuria*** (painful urination) * ***Inguinal lymphadenopathy*** Symptoms can last three weeks in a primary infection. Recurrent episodes are usually milder and resolve more quickly.

Answer 15

The diagnosis can be made ***clinically*** based on the history and examination findings. A ***viral PCR*** swab from a lesion can confirm the diagnosis and causative organism.

Answer 16

Where appropriate, patients should be referred to a ***genitourinary medicine*** (***GUM***) specialist service. ***Aciclovir*** is used to treat genital herpes. There are various aciclovir regimes listed in the BNF, depending on the individual circumstances. Alternatives are valaciclovir and famciclovir. Additional measures, including to manage the symptoms include: * Paracetamol * Topical lidocaine 2% gel (e.g. ***Instillagel***) * Cleaning with warm salt water * Topical vaseline * Additional oral fluids * Wear loose clothing * Avoid intercourse with symptoms

Answer 17

Syphilis is caused by bacteria called ***Treponema pallidum***. This bacteria is a ***spirochete***, a type of ***spiral-shaped*** bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a ***sexually transmitted infection***. The incubation period between the initial infection and symptoms is 21 days on average.

Answer 18

* ***Oral***, ***vaginal*** or ***anal sex*** involving direct contact with an infected area * ***Vertical transmission*** from mother to baby during pregnancy * ***Intravenous drug use*** * ***Blood transfusions*** and ***other transplants*** (although this is rare due to screening of blood products)

Answer 19

***Primary syphilis*** involves a ***painless ulcer*** called a ***chancre*** at the original site of infection (usually on the genitals). ***Secondary syphilis*** involves systemic symptoms, particularly of the skin and mucous membranes. These symptoms can resolve after 3 – 12 weeks and the patient can enter the ***latent stage***. ***Latent syphilis*** occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. ***Early latent syphilis*** occurs within two years of the initial infection, and ***late latent syphilis*** occurs from two years after the initial infection onwards. ***Tertiary syphilis*** can occur many years after the initial infection and affect many organs of the body, particularly with the development of ***gummas*** and cardiovascular and neurological complications. ***Neurosyphilis*** occurs if the infection involves the ***central nervous system***, presenting with neurological symptoms.

Answer 20

* A painless genital ulcer (***chancre***). This tends to resolve over 3 – 8 weeks. * Local lymphadenopathy

Answer 21

***Secondary syphilis*** typically starts after the chancre has healed, with symptoms of: * Maculopapular rash * ***Condylomata lata*** (grey wart-like lesions around the genitals and anus) * Low-grade fever * Lymphadenopathy * Alopecia (localised hair loss) * Oral lesions

Answer 22

***Tertiary syphilis*** can present with several symptoms depending on the affected organs. Key features to be aware of are: * ***Gummatous lesions*** (***gummas*** are granulomatous lesions that can affect the skin, organs and bones) * Aortic aneurysms * Neurosyphilis

Answer 23

***Neurosyphilis*** can occur at any stage if the infection reaches the central nervous system, and present with symptoms of: * Headache * Altered behaviour * Dementia * ***Tabes dorsalis*** (demyelination affecting the spinal cord posterior columns) * ***Ocular syphilis*** (affecting the eyes) * Paralysis * Sensory impairment

Answer 24

***Antibody testing*** for antibodies to the ***T. pallidum*** bacteria can be used as a screening test for syphilis. Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing. Samples from sites of infection can be tested to confirm the presence of ***T. pallidum*** with: * ***Dark field microscopy*** * ***Polymerase chain reaction*** (***PCR***) The ***rapid plasma reagin*** (***RPR***) and ***venereal disease research laboratory*** (***VDRL***) tests are two ***non-specific*** but ***sensitive*** tests used to assess for active syphilis infection. These tests assess the ***quantity of antibodies*** being produced by the body to an infection with syphilis. A higher number indicates a greater chance of active disease. These tests involve introducing a sample of serum to a solution containing antigens and assessing the reaction. A more significant reaction suggests a higher quantity of antibodies. The tests are ***non-specific***, meaning they often produce ***false-positive*** results. There is a skill to both performing and interpreting the results of these tests.

Answer 25

All patients should be managed and followed up by a specialist service, such as GUM. As with all sexually transmitted infections, patients need: * Full screening for other STIs * Advice about avoiding sexual activity until treated * Contact tracing * Prevention of future infections A single ***deep*** ***intramuscular*** dose of ***benzathine benzylpenicillin*** (penicillin) is the standard treatment for syphilis. Alternative regimes and types of penicillin are used in different scenarios, for example, late syphilis and neurosyphilis. Ceftriaxone, amoxicillin and doxycycline are alternatives.

Answer 26

* ***Trichomonas vaginalis*** is a type of parasite spread through sexual intercourse. * Trichomonas is classed as a ***protozoan***, and is a single-celled organism with ***flagella***. * Flagella are appendages stretching from the body, similar to limbs. * Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism. * The flagella are used for movement, attaching to tissues and causing damage. Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.

Answer 27

* ***Contracting HIV*** by damaging the vaginal mucosa * ***Bacterial vaginosis*** * ***Cervical cancer*** * ***Pelvic inflammatory disease*** * ***Pregnancy-related complications*** such as preterm delivery.

Answer 28

Up to 50% of cases of trichomoniasis are asymptomatic. When symptoms occur, they are non-specific: * Vaginal discharge * Itching * Dysuria (painful urination) * Dyspareunia (painful sex) * Balanitis (inflammation to the glans penis) The typical description of the vaginal discharge is ***frothy*** and ***yellow-green***, although this can vary significantly. It may have a ***fishy smell***. Examination of the cervix can reveal a characteristic “***strawberry cervix***” (also called ***colpitis macularis***). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.

Answer 29

The diagnosis can be confirmed with a standard ***charcoal swab*** with ***microscopy*** (examination under a microscope). Swabs should be taken from the ***posterior fornix of the vagina*** (behind the cervix) in women. A ***self-taken low vaginal swab*** may be used as an alternative. A ***urethral swab*** or ***first-catch urine*** is used in men. vaginal pH - above 4.5 - similar to bacterial vaginosis

Answer 30

Patients should be referred to a ***genitourinary medicine*** (***GUM***) specialist service for diagnosis, treatment and ***contact tracing***. Treatment is with ***metronidazole***.

Answer 31

HIV refers to the ***human immunodeficiency virus***. Being infected with HIV is referred to as being ***HIV positive***. ***AIDS*** refers to ***acquired immunodeficiency syndrome***. AIDS occurs as an HIV infection progresses, and the person becomes ***immunodeficient***. This immunodeficiency leads to opportunistic infections and several ***AIDS-defining illnesses***, such as ***Kaposi’s sarcoma***. AIDS is now mostly referred to as ***late-stage HIV***.

Answer 32

HIV is not transmitted through day-to-day activities, including kissing. It is spread through: * Unprotected anal, vaginal or oral sexual activity * Mother to child at any stage of pregnancy, birth or breastfeeding (called ***vertical transmission***) * Mucous membrane, blood or open wound exposure to infected ***blood*** or ***bodily fluids***, for example, through sharing needles, needle-stick injuries or blood splashed in an eye

Answer 33

***Antibody testing*** is the typical screening test for HIV. This is a simple blood test. Patients can request an antibody testing kit online for ***self sampling*** at home, which they post to the lab for testing. Testing for the ***p24 antigen***, checking directly for this specific HIV antigen in the blood. This can give a positive result earlier in the infection compared with the antibody test. ***PCR testing*** for the ***HIV RNA*** levels tests directly for the number of ***viral copies*** in the blood, giving a ***viral load***.

Answer 34

**CD4 Count** The CD4 count is the number of CD4 cells in the blood. These are the cells destroyed by the virus. The lower the count, the higher the risk of opportunistic infection: * 500-1200 cells/mm3 is the normal range * Under 200 cells/mm3 is considered ***end-stage HIV*** (AIDS) and puts the patient at high risk of opportunistic infections **Viral Load (VL)** Viral load is the number of copies of ***HIV RNA*** per ml of blood. “***Undetectable***” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.

Answer 35

* Specialist ***HIV***, ***infectious disease*** or ***GUM*** centres manage patients with HIV. * Treatment involves a combination of ***antiretroviral therapy*** (***ART***) medications. * ART is offered to everyone with a diagnosis of HIV irrespective of ***viral load*** or ***CD4 count***. * Some regimes involve only a single combination tablet, taken once daily, with the potential to suppress the infection completely. * Specialist blood tests can establish the resistance of each HIV strain to different medications and help tailor treatment. * The ***BHIVA guidelines*** (2015) recommend a starting regime of two ***NRTIs*** (e.g. tenofovir and emtricitabine) plus a third agent. There are a number of classes of HAART medications that work slightly differently on the virus: * Protease inhibitors (PIs) * Integrase inhibitors (IIs) * Nucleoside reverse transcriptase inhibitors (NRTIs) * Non-nucleoside reverse transcriptase inhibitors (NNRTIs) * Entry inhibitors (EIs)

Answer 36

***Prophylactic co-trimoxazole*** (***Septrin***) is given to patients with a CD4 under 200/mm3 to protect against ***pneumocystis jirovecii pneumonia*** (***PCP***). HIV infection increases the risk of developing ***cardiovascular disease***. Patients with HIV have close monitoring of cardiovascular risk factors and blood lipids. Appropriate treatment (e.g. statins) may be required to reduce their risk of developing cardiovascular disease. Yearly ***cervical smears*** are required for women with HIV. HIV predisposes to developing ***human papillomavirus*** (***HPV***) infection and ***cervical cancer***, so female patients need close monitoring to ensure early detection of these complications. ***Vaccinations*** should be up to date, including influenza, pneumococcal, hepatitis A and B, tetanus, diphtheria and polio vaccines. Patients should avoid ***live vaccines***.

Answer 37

Advise condoms for vaginal and anal sex and dams for oral sex, even when both partners are HIV positive. If the viral load is ***undetectable***, transmission through unprotected sex is unheard of, even in extensive studies, although infection is not impossible. Partners should have regular HIV tests. Where the affected partner has an undetectable viral load, unprotected sex and pregnancy may be considered. It is also possible to conceive safely through techniques like ***sperm washing*** and ***IVF***.

Answer 38

***Post-exposure prophylaxis*** (***PEP***) can be used after exposure to HIV to reduce the risk of transmission. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours). The sooner it is started, the better. A risk assessment of the probability of developing HIV should be balanced against the side effects of PEP. PEP involves a combination of ***ART therapy***. The current regime is ***Truvada*** (emtricitabine and tenofovir) and ***raltegravir*** for 28 days. HIV tests are done ***immediately*** and also a minimum of ***three months*** after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.

Answer 39

**Endometritis** refers to infection or inflammation of the endometrium, the inner lining of the uterus. It can be divided into pregnancy-related (obstetric) or non-obstetric.

Answer 40

* Acute endometritis is characterised by the presence of more than five neutrophils in a 400 power field in the endometrial glands. * Chronic endometritis is characterised by the presence of more than one plasma cell, (and lymphocytes) in a 120 power field in the endometrial stroma.

Answer 41

There is usually a mix of 2-3 organisms involved; some will be found in normal vaginal flora. It is often a mixed aerobic and anaerobic infection. There is rarely microbiological confirmation of the cause, as an uncontaminated endometrial sample or positive blood culture would be required. Causative organisms include: * Gram-positive cocci - *Staphylococcus* spp., Group A and B *Streptococcus* spp. * Gram-negative - *Escherichia coli*, *Klebsiella* spp., *Chlamydia trachomatis, Proteus* spp., *Enterobacter* spp., *Gardnerella vaginalis*, *Neisseria* spp. * Anaerobes - *Bacteroides* spp., *Peptostreptococcus* spp. * Others - *Mycoplasma* spp., *Ureaplasma* spp., tuberculosis.

Answer 42

Result of o Instrumentation of the uterus o Complication of pregnancy o BothResult of o Instrumentation of the uterus o Complication of pregnancy o Both

Answer 43

Result of o Instrumentation of the uterus o Complication of pregnancy o Both

Answer 44

Number and severity of symptoms can vary markedly from patient to patient but usually include: * Fever. * Abdominal pain. * Offensive-smelling lochia. * Abnormal vaginal bleeding - postpartum haemorrhage. * Abnormal vaginal discharge. * Dyspareunia. * Dysuria. * General malaise. **Signs** * Raised temperature. * Pain and uterine tenderness, which may radiate to the adnexae. * Tachycardia.

Answer 45

* Blood cultures should be performed. * FBC may reveal a raised white cell count. * Check midstream urine. * High vaginal swab, including swab for gonorrhoea/chlamydia. * Endometrial biopsy is diagnostic, although rarely appropriate. Ultrasound is unhelpful in this situatio

Answer 46

* Abx * Consider admission → tx on admission

Answer 47

Combination of clindamycin and gentamicin as the optimal first-line antibiotic treatment Abdominal pain, fever (\>38°C) and tachycardia (\>90 bpm) are indications for admission for intravenous antibiotics

Answer 48

If sepsis is suspected in the community, urgent referral to hospital is indicated where 'red flag' signs and symptoms are present: * If the woman appears seriously unwell, transfer by emergency ambulance^[[⁶](https://patient.info/doctor/postpartum-endometritis-pro#ref-6)^]: * Pyrexia \>38°C. * Sustained tachycardia (more than 90 bpm). * Breathlessness (respiratory rate \>20 breaths per minute - a serious symptom). * Abdominal or chest pain. * Diarrhoea and/or vomiting. * Uterine or renal angle pain and tenderness. * The woman is generally unwell or seems unduly anxious/distressed. * Intravenous (IV) antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Most women are best managed in a hospital environment. * The Royal College of Obstetricians and Gynaecologists (RCOG) guideline for sepsis following pregnancy recommends **IV piperacillin/tazobactam** or a **carbapenem plus clindamycin for severe sepsis**. Other options for **less severe infections** include co-**amoxiclav, metronidazole and gentamicin.** However, i_t stresses guidelines based on local resistance should be followed._

Answer 49

* Spectrum of inflammatory disease comprising of the upper female genital tract including combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis

Answer 50

Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections: * ***Neisseria gonorrhoeae*** tends to produce more severe PID * ***Chlamydia trachomatis*** * ***Mycoplasma genitalium*** Pelvic inflammatory disease can less commonly be caused by non-sexually transmitted infections, such as: * ***Gardnerella vaginalis*** (associated with ***bacterial vaginosis***) * ***Haemophilus influenzae*** (a bacteria often associated with respiratory infections) * ***Escherichia coli*** (an enteric bacteria commonly associated with urinary tract infections)

Answer 51

* Not using barrier contraception * Multiple sexual partners * Younger age * Existing sexually transmitted infections * Previous pelvic inflammatory disease * Intrauterine device (e.g. copper coil)

Answer 52

Women may present with symptoms of: * Pelvic or lower abdominal pain * Abnormal vaginal discharge * Abnormal bleeding (intermenstrual or postcoital) * Pain during sex (dyspareunia) * Fever * Dysuria Examination findings may reveal: * Pelvic tenderness * Cervical motion tenderness (cervical excitation) * Inflamed cervix (cervicitis) * Purulent discharge Patients may have a fever and other signs of sepsis. Oishi infertility, chronic pelvic pain, fever, vomiting, back pain, dyspareunia, bilateral abdominal pain, lower genital tract infection, itching, bleeding or discharge

Answer 53

Patients with pelvic inflammatory disease should have testing for causative organisms and other sexually transmitted infections: * NAAT swabs for gonorrhoea and chlamydia * NAAT swabs for Mycoplasma genitalium if available * HIV test * Syphilis test A ***high vaginal swab*** can be used to look for ***bacterial vaginosis***, ***candidiasis*** and ***trichomoniasis***. A microscope can be used to look for ***pus cells*** on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID. A ***pregnancy test*** should be performed on sexually active women presenting with lower abdominal pain to exclude an ***ectopic pregnancy***. ***Inflammatory markers*** (CRP and ESR) are raised in PID and can help support the diagnosis. **HIV serology** **USS**: tubo-ovarian abscess (TVUS)- You would see increased tubal wall thickness

Answer 54

Consider removal of IUD if it is *in situ* o Usually if the patient has failed to respond to treatment after 72hours **Outpatient Antibiotic Regimen** o **Ceftriaxone** 1g IM (single dose) - covers gonorrhoea o **Doxycycline** 100 mg BD (oral) for 14 days - covers chlamydia and mycoplasma genitalium o **Metronidazole** 400 mg BD (oral) for 14 days - cover anaerobes such as Gardnerella vaginalis **Alternative**: ofloxacin + metronidazole for 14 days **If pyrexial or oral management has failed** o **1st line: IV cefoxitin + doxycycline -** covers other bacteria including H.influenzae and E.coli o 2nd line: IV clindamycin + gentamicin **STI screening and contact tracing** o Chlamydia and gonorrhoea tests should be offered o Current and recent partners (within last 6 months) should be contacted and offered advice, screening and treatment Advise about barrier contraception Counsel about the small risk of subfertility (increased risk with recurrence) More severe cases, particularly where there are signs of sepsis or the patient is pregnant, require admission to hospital for IV antibiotics. Where a pelvic abscess develops, this may need drainage by interventional radiology or surgery. Follow-up

Answer 55

If managed as outpatients, should be seen **within 72 hours** to assess response If no improvement, admit for IV antibiotics Further follow-up at **2-4 weeks** to: o Ensure resolution o Reiterate importance of STIs o Reassure that if compliant, fertility is not affected Complications: o Infertility o Ectopic pregnancy o Chronic pelvic pain

Answer 56

* Sepsis * Abscess * Infertility * Chronic pelvic pain * Ectopic pregnancy * Fitz-Hugh-Curtis syndrome

Answer 57

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the ***liver capsule*** (***Glisson’s capsule***), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood. Fitz-Hugh-Curtis syndrome results in ***right upper quadrant pain*** that can be referred to the right shoulder tip if there is diaphragmatic irritation. ***Laparoscopy*** can be used to visualise and also treat the adhesions by ***adhesiolysis***.