Acute pelvic pain + PID

Question 1

Give 3 non-pregnant gynaecological causes of acute pelvic pain

Answer 1

Torsion of ovarian cyst
Degeneration of uterine fibroids
Flare of PID
Endometriosis
Ovarian hyperstimulation syndrome

Question 2

Give 3 PREGNANCY-related gynaecological causes of acute pelvic pain

Answer 2

Ectopic pregnancy
Molar pregnancy // Gestational trophoblastic disease
Miscarriage
Placental abruption

+non-gynaecological causes:
Torsion of ovarian cyst
Degeneration of uterine fibroids
Flare of PID

Question 3

Give 3 non-gynaecological causes of acute pelvic pain (think surgical + medical)

Answer 3

Medical:
Diverticulosis
IBS
Constipation
UTI
Interstitial cystitis

Surgical:
Appendicitis
Ureteric calculi
Intestinal obstruction
GI malignancy
Cholecystitis

Question 4

What are the examination findings for Ovarian cyst accidents? (give 4)

Answer 4

Tenderness on palpation
Abdominal guarding

On vaginal examination:
Cervical excitation
Adnexal tenderness
Adnexal mass [remember for ?ectopic pregnancy dont feel for masses]

Question 5

What is Fibroid degeneration?

Answer 5

Degeneration due to excessive fibroid growth that outmatches blood supply or mechanical compression of feeder arteries

Question 6

What are the 2 most common types of Fibroid degeneration

Answer 6

Hyaline degeneration (65%)
Myxomatous degeneration (13%)

Question 7

What is the management for Fibroid degeneration?

Answer 7

Conservative (esp in pregnancy) = Analgesia, Hydration, Antibiotics (if needed)

Emergency surgery for Pedunculated Fibroid Torsion

If suspicion of sarcoma = Hysterectomy

Question 8

What are the common organisms for Acute PID?

Answer 8

Chlamydia trachomatis
Neisseria gonorrhoea
Escherichia Coli

(+Gardnerella vaginalis, Mycoplasma genitalium)

Question 9

What is the presentation for Acute PID?

Answer 9

Lower abdominal pain
Dyspareunia (typically DEEP)
Post-coital bleeding + Intermenstraul bleeding
Vaginal discharge (yellow or green)
Fever

Question 10

What are the investigations for acute PID?

Answer 10

Pregnancy test (exclude PID)

Bloods (FBC, WCC, CRP)

Triple swabs:
NAAT (endocervical or vulvovaginal)
High vaginal charcoal swab
Endocervical charcoal swab

USG - Pelvis/Abdomen (imaging of limited value)

Diagnostic laparotomy

Question 11

What organisms does the Endocervical NAAT swab detect?

Answer 11

Chlamydia trachomatis
Neisseria gonorrhoea

Question 12

What organisms does the High vaginal charcoal swab detect?

Answer 12

Bacteria vaginalis (Gardnerella vaginalis)
Trichomonas vaginalis
Candidiasis trachomatis
Group B Streptococcus

Question 13

What are the complications associated with PID?

Answer 13

Chronic pelvic pain
Recurrent PID
Tubo-ovarian abscess
Ectopic pregnancy
Infertility // Subfertility (from tubal blockage)
Fitz-Hugh Curtis syndrome (Perihepatitis)

Intra-abdominal complications include&raquo_space; Peritonitis

Question 14

What is the outpatient treatment for PID?

Answer 14

IM Ceftriaxone 500mg single dose
PO Doxycycline 100mg BD for 14 days
PO Metronidazole BD for 14 days

Remember analgesia + Partner notification + Abstain from sexual intercourse + Follow-up

Question 15

What is the inpatient treatment for PID?

Answer 15

IV Ceftriaxone 2g daily + IV Doxycycline 100mg BD

Followed by Oral Doxycycline 100mg BD + Oral Metronidazole 400mg BD for 14 days

Remember analgesia + Partner notification + Abstain from sexual intercourse + Follow-up

Question 16

In addition to drug management for PID what other steps are necessary?

Answer 16

Surgical treatment = Laparoscopy / Laparotomy for drainage may be needed

Counselling (for risk of ectopic pregnancies / subfertility)

Partner notification + treatment

Follow-up

Question 17

Give 4 risk factors for PID

Answer 17

Unprotected sexual intercourse
Multiple sexual partners
Earlier age at first sexual intercourse // Age <25
Previous PID
Immunocompromised
Diabetes
Co-existing endometriosis

Question 18

What are the signs elicited in PID patients?

Answer 18

Lower abdominal tenderness (often bilaterally)
Abnormal / purulent discharge
Cervical motion tenderness
Adnexal tenderness
Fever >38

Question 19

What is the follow-up for PID?

Answer 19

Review after 72 hours > if no / minimal improvement:
- Remove IUC if in-situ
- Consider IV therapy

Review after 2-4 weeks > ensure symptoms resolved. Check compliance with Abx. Ensure sexual contacts have been screened + treated.