Pelvic Infections

Question 1

What are some investigations yoou would order for someone with suspected PID?

Answer 1

• MSU
• Urine +/- serum β-HCG
• endocervical swabs
  
  • MCS
  • PRC
    
    • trichomonas
    • mycoplasma genitalium
    • chlmydia
    • gonorrhoea
• FBE, CRP, UEC, LFT, lipase
• Other STI screen = HBV, HCV, HIV, syphilis
• Peliv US
  
  • free fluid in pouch of douglas (non-specific sign)
  • pyosalpinx (fallopain tube filled with pus)
  • tubo-ovarian abscess

Question 2

What is PID? What are some other differentials you should consider?

Answer 2

• upper genital tract inflammation = above cervix
  
  • endometritis
  • chorioamnionitis
  • salpingitis
  • tubo-ovarian abscess
  • oophoritis
  • pelvic cellulitis

Question 3

What is the acute presentation of PID? and how does it differ to a chronic infection? What are some risk factors for PID?

Answer 3

• asymptomatic in 2/3
• lower abdominal pain
  
  • uterine tenderness
  • cervical motion tenderness
  • back pain
  • deep dyspareunia
• fever
• vaginal discharge/odour
• itching
• N/V

Chronic:

• constant pelvic pain
• palpable mass
• deep dyspareunia
• usually due to chalmydia. hard to treat.

RFs

• <30
• STI RFs
  
  • prior infection with chalmydia/gonorrhoea
  • unprotected intercourse multiple partners
  • new sexual partners
• IUD inserted <10d
• instrumentation
• Hx PID
• vaginal douching

Question 4

What are some causes of PID?

Answer 4

• usually a polymicrobial ascending infection

Sexually Transmitted:

• Chlamydia - most common (10% symptomatic and progress)
• Gonorrhoea 0.4%
• mycoplasma genitalium 6%
• Trichomonas - most common STI but usually only vaginitis

Non-sexually transmitted:

• vaginal flora
  
  • anaerobic
  • mycoplasma hominis
• Other
  
  • CMV
  • actinomyces (IUD insertion prolonged >5years) - add actinomyces culture
    
    • remove IUD
    • consult specialist

Question 5

What is Trichomonas? How does it present?

Answer 5

• most common STI worldwide
• yellow-green frothy discharge (fishy smell)
• pH>4.5
• diagnose with
  
  • microscopy (clue cells)
  • PCR
  • treat partner + test for other STIs

Question 6

What is thrush? What is the treatment?

Answer 6

• cause of vaginitis
• RFs: high oestrogen state (change HRT/OCP?)
• often caused by albicans - (other candida species can cause it too)
• treatment:
  
  • oral fluconazole OTC single dose
  • caneston cream single dose
  • if chronic (>4episodes/year) - vulva involved
• non-albicans - might need a boric acid vaginal pessary

Question 7

What is the treatment for PID?

Answer 7

Mild-Moderate:

• ceftriaxone 500mg IM
• metronidazole 400mg bd for 14days
• azithromycin 1g oral or doxycyclin 100mg oral 12hrly 14days

Severe:

• the same but with IV

Question 8

What bacteria is related to IUDs? What is a complication related to this?

Answer 8

• treat similar if presenting with PID, but need to cover acintomyces:
  
  • Gram + bacillus
  • normal enteric + vaginal flora
  • increased colonisation
• complication
  
  • tubulo-ovarian abscess (+/- monitor if <3cm + clinically well)
  • otherwise:
    
    • US guidance drainage
    • laproscopic drainage
  • DDx between hydrosalpinx (flow back into uterine environment - fertility).
• test for chlamydia and vaginosis before insertion.