Pelvic Inflammatory Disease (PID)/STDs Flashcards
What are the management options for PID (& organisms)
-IM 1g Ceftriaxone (gonorrhoea)
-100g Doxycycline (BD, PO) for 14 days (chlamydia and mycoplasma genitalium)
-400g Metronidazole (BD, PO) for 14 days (anaerobes eg Gardnerella vaginalis which causes BV)
What are management options for penicillin allergy?
PO ofloxacin and metronidazole for 14 days (400mg, BD)
What are some organisms that cause PID (severe,3, vs less common,3,)
Severe:
1.Chlamydia trachomatis (most common, C>G)
2. Neisseria gonorrhoea
3. Mycoplasma genitalium
Less common:
1. Gardnerella vaginalis (BV)
2. Haemophilus influenza
2. Escherichia coli
What are some investigations for PID?
Bedside:
-Basic obs (signs of shock)
-Abdominal exam (tenderness, masses eg tuboovarian abscess)
-Bimanual exam (cervical motion tenderness)
-Speculum
-NAAT swabs
-pregnancy test
Bloods:
-FBC (WCC)
-CRP
-Blood culture
Imaging:
-TVUSS (eg for tuboovarian abscess, perihepatitis)
-Laporoscopy (gold standard for Fitz-Hugh-Curtis syndrome)
What are other considerations for patients?
- contact tracing
- STI screen
- Consider IUD removal
- Counsel about subfertility/contraception
what is normal vaginal pH?
The vaginal pH is normal in such patients (around 4.0-4.5 in women of reproductive age, although this can vary slightly)
how is vaginal PH affected by BV?
the vaginal pH would be raised (> 4.5).
how is recurrent thrush defined?
> 4 episodes a year
what is the induction/maintenance regime for thrush?
-induction: oral fluconazole every 3 days for 3 doses (150mg once on day 1, 150mg once on day 4, 150mg once on day 7)
-maintenance: oral fluconazole weekly for 6 months
what is the criteria for BV diagnosis?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
1. thin, white homogenous discharge
2. clue cells on microscopy: stippled vaginal epithelial cells
3. vaginal pH > 4.5
4. positive whiff test (addition of potassium hydroxide results in fishy odour)
what is the criteria for BV diagnosis?
Amsel’s criteria for diagnosis of bacterial vaginosis - 3 of the following 4 points should be present:
1. thin, white homogenous discharge
2. clue cells on microscopy: stippled vaginal epithelial cells (loss of lactobacilli)
3. vaginal pH > 4.5
4. positive whiff test (addition of potassium hydroxide results in fishy odour)
vaginal discharge most common causes
what % of men and women are asymptomatic for chlamydia?
In women, 80% have no symptoms – hence screening is important. In men approximately 50% are asymptomatic.
what swabs should be done for STDS?
-A high vaginal Amies swab for bacterial and fungal culture (NAAT for chlamydia and gonorrhoea) should be performed
-endocervical culture for gonorrhoea (due to increasing rates of resistance to first line cephalosporin therapies).
what % of PID are organisms detected? what are the most common organisms?
50% (50% no organism)
-the majority will be due to Chlamydia trachomatis and Neisseria gonorrhoeae.
what is alternative treatment for gonorrhoea (if all sites of exposure are cultured and found to be sensitive)
ciprofloxacin (alternative to IM 1g STAT ceftriaxone)
what is used to treat chlamydia in pregnant women?
-Azithromycin 1g STAT, followed by 500mg OD for 2 days is first line therapy in pregnancy.
-Erythromycin 500mg QDS for 7 days is an acceptable second line therapy as per BASHH Guidelines 2017 for Chlamydia management
what are some non-STD causes of vaginal discharge?
-Allergies to soaps and spermicides e.g.nonoxynol-9 can also cause vaginal discharge
-Lichen sclerosis if severe
Bacteria present in BV (bacterial vaginosis):
Gardnerella vaginalis
organism that causes syphilis:
Treponema pallidum
symptoms & treatment of syphilis:
chancre (painless hard ulcer in genital area)
-1st line = IM stat benzylpenicillin or doxycycline BD for 14 days.
syphilis stages
Management of severe PID:
IV ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 d)
complications of PID:
Chronic pelvic pain (40%)
Infertility (15%)
Ectopic pregnancy (1%)
Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm, on a background of pelvic inflammatory disease. Liver function tests are often normal. An abdominal ultrasound should be used to exclude stones. Laparoscopy is required for a definitive diagnosis and treatment involves the use of antibiotics.
