upper genital tract STI + Acute Pelvic Pain

Question 1

Infections causing vaginitis or ectocervicitis

Answer 1

candida, trichomonas, HSV, BV

Question 2

upper genital tract infections

Answer 2

chlamydia + gonorrhea

Question 3

signs of cervicitis

Answer 3

mucopurulent cervical discharge, cervical friability, vaginal discharge, strawberry cervix

Question 4

work-up for cervicitis

Answer 4

endocervical swabs for gram staining, gonorrhea culture, and chlamydia NAAT

gram stain >20 PMNs per HPF –> chlamydial and or gonorrhea (not sensitive or specific)

vaginal swabs for wet mount + gram stain (for trich, BV)

note on cervical swab:

• vaginal swab if pre-pubertal
• if hysterectomy: urine NAAT or vaginal swab for NAAT (can be used for G, C, and trich)

Question 5

how to perform cervical + vaginal swab

Answer 5

cervical: rotate 180 degrees in endocervix
vaginal: swab pooled secretions or posterior fornix

Question 6

chlamydia testing

Answer 6

NAAT - best

urine, urethral or cervical swab
use urine if asymptomatic + pelvic exam not needed

effected by blood + mucous

test-of-cure unnescessary

culture only for legal - assault

Question 7

Gonorrhoea testing

Answer 7

urethral or endocervical swab for gram

gram-neg diplococci inside PMNs = predictive (outside is non-specific)

culture for sensitivities (sex assault, treatment failure), may be neg <48hrs from exposure

NAAT: cervical, urethral, urine, +/- vaginal. Use if no cervix or not want exam

Question 8

trichomonas testing

Answer 8

whiff neg - no bad odour

vaginal pH >4.5

microscopy (but not sensitive), culture if available (urethral, vaginal swabs, prostate fluid, urine sediment)

Question 9

candida testing

Answer 9

pH normal, whiff neg

wet-mount prep /w KOH shows budding or branching pseudohyphae

Question 10

BV testing

Answer 10

pH >4.5, whiff positive

gram stain: less gram positive rods (lactobacilli), more coccobacili and clue cells

Question 11

PID definition

Answer 11

infection involving endometrium, fallopian tubes, pelvic peritoneum, and/or adjacent structures

Question 12

organisms that cause PID

Answer 12

STI: C + G

Endogenous: genital mycoplasmas

anaerobes: bacertoides, peptostreptococcus, prevotella

facultative aerobes: E.Coli, gardnerella vaignalis, streptococcus, haemophilus influenza

Question 13

diagnostic criteria for PID

Answer 13

minimal diagnostic criteria:

1) lower abdo tenderness
2) adnexal tenderness
3) CMT

additional criteria:

1) oral T >38.3
2) leukocytosis
3) WBC on vag wet mount
4) elevated ESR
5) elevated CRP
6) +ve for G or C

definitive:

1) endo bx shows endometritis
2) TVUS: thickend fluid filled tubes +/- free fluid or TOA
3) gold standard: laparoscopy see erythema/exudates

Question 14

criteria for PID admission

Answer 14

1) can’t r/o other surg emergency
2) pregnancy
3) failure of outpatient tx
4) can’t tolerate/follow PO meds
5) severe illness, vomiting, fever
6) can’t follow-up after 72 hrs
7) adolescence
8) co-existing HIV/immune

Question 15

treatment overview

Answer 15

broad spectrum antibiotics

if parenteral: can stop after 24hrs if improve, then PO for 14 days

if no improvement: laparoscopy + alternative dx considered

Question 16

outpatient Tx for PID

Answer 16

1) ceftriaxone 250mg IM + doxycycline PO bid x 14 days

2) cefoxitin 2g IM +
probenecid 1g PO +
doxycyline 100mg PO bid x 14 days

3) other parental third gen cephalosporin (ceftizomine or cefotaxime) PLUS doxycylince 100mg PO bid x 14 days

1, 2, and 3 can add metronidazole 500mg PO bid for more anaerobes/BV

4) Ofloxacin 400mg PO bid x 14 days +/- metronidazole 500mg PO bid x14d
5) levofloxacin 500mg PO qd +/- metronidazole 500mg PO bid x14d

Question 17

CI antibiotics in preg + BFing

Answer 17

ofloxaxin, ciprofloxacin, levofloxacin, doxycycline

Question 18

In patient tx for PID

Answer 18

1) cefoxitin 2g IV q6h + doxycycline 100mg IV/PO q12h
2) Clindamycin 900mg IV q8h + gentamicin loading IV/IM 2mg/kg, then 1.5mg/kg q8hrs

Alternatives: ofloxacin or levofloxacin + metronidazole,

amplicillin + doxycycline

cirprofloxaxin + doxycycline + metronidazole

Question 19

chlamydia tx

Answer 19

treat if positive, if suspect and don’t want to wait for results, if sexual partner dx, if gonorrhoea is dx

test of cure at 3-4 wks only if: poor compliance, symptoms, re-exposure, alt regimen, pre-pubertal, pregnant

meds:
doxycycline 100mg PO bid x 7 days
OR
azithromycin 1g PO single dose

alts: ofloxacin, erythromycin, amoxicillin (if preg)

Question 20

gonorrhoea treatment

Answer 20

ceftriaxone 250mg IM

alt: cefixime 800mg PO x1

ok if pregnant

Question 21

reporting

Answer 21

G + C reportable to public health, partners from 60 days since onset contacted + treated

for trichomonas partners don’t need to be treated

Question 22

follow-up for G + C

Answer 22

repeat screen in 6 months, re-infection rate high

Question 23

Differential diagnosis for acute pelvic pain

Answer 23

preg: SA, septic abortion, ectopic
gyne: endometritis, PID/salpingitis, TOA, dsymenorrhea, fibroids, endometriosis, mittelschmerz, ovarian cyst (rupture/hemorrhage), torsion, cancer, ovarian hyperstim syndrome

non-gyne: appendicitis, bowel stuff, UTI, kidney, MSK, joints, hernia, aortic aneyrusm/dissection, prophyria

Question 24

workup for acute pelvic pain

Answer 24

hx + physical (abdo + pelvic exam)

labs

• BCHG
• Rh if preg
• urinalysis
• cervical + vag swabs
• CBC
• others PRN

Imaging

• US
• CT in specific cases (MRI if preg)

laparoscopy
- if can’t dx and are considering dangerous pathology (appendicitis, PID, torsion)