Pelvic Inflammatory Disease

Question 1

“A 30-year-old female presents with 7-day history of pelvic pain and dyspareunia. On examination, she had a temp of 38.5 C and a tender left adnexal mass. What is your provisional diagnosis and management?

2020 stem: PID. Husband had one night stand. How would you manage this (what changes if she has a tubo-ovarian abscess)?”

Answer 1

Impression
Given pelvic pain with fevers and adnexal mass, am concerned about pelvic inflammatory disease complicated be tube-ovarian abscess (TOA).

Ddx to consider include:

• other gynaecological: ectopic pregnancy, ovarian cyst rupture, endometriosis
• non-gynaecological: pyelonephritis, cystitis, appendicitis

Question 2

PID - History

Answer 2

History

• sx: vaginal discharge, urinary changes, bowel changes, fevers, pain SOCRATES,
• complications: RUQ pain (fitz-hugh-curtis syndrome), infertility
• sexual history: contraception, sexual partners, STI screening
• gynaecological history: Cervical screening
• obstetric + menstrual history
• SNAP

Question 3

PID - Examination

Answer 3

Examination

• general observation + vital signs
• abdominal examination: peritonitis, focal tenderness, masses, RUQ pain
• pelvic examination: speculum + opportunistic CST/STI, bimanual (cervical motion tenderness, adnexal mass, etc)

Question 4

PID - Investigations

Answer 4

Investigations
key/diagnostic:
- urine STI screen, high-vaginal swab, otherwise clinical diagnosis (however -ve STI screen does not exclude PID)

• Bedside: vital signs, endocervical swab -> STI/CST, UA and ß-HCG
• Bloods: FBC, UEC, ß-HCG, CRP/ESR, LFT, blood culture, lactate, HIV/syphilis screening
• imaging: TA/TV US, pelvic CT
• Other: laparoscopy (diagnostic and therapeutic for draining pus etc)

Question 5

PID - Management

Answer 5

Management
- consider ED management if concern about red flag differentials (ectopic pregnancy)

Supportive

• fluids
• analgesia, antipyretics, antiemetics are required
• contact tracing, notify PHU
• remove IUD if present
• patient education and counselling

Definitive

• Antibiotics: ceftriaxone + azithromycin + metronidazole. switch to directed therapies once results and sensitivities are returned.
• Surgical: laparoscopy and drainage of toA