A 20-year-old college student presents with lower abdominal pain and fever. Physical exam shows bilateral lower abdominal tenderness. Her vaginal exam shows tenderness with cervical mobilization. Her pregnant test is negative.
What is the most likely diagnosis?
Correct Answer A:
Pelvic inflammatory disease is infection of the upper female genital tract: the cervix, uterus, fallopian tubes, and ovaries; abscesses may occur. Common symptoms and signs include lower abdominal pain, cervical discharge, and irregular vaginal bleeding. Long-term complications include infertility, chronic pelvic pain, and ectopic pregnancy.
Pelvic inflammatory disease (PID) results from microorganisms ascending from the vagina and cervix into the endometrium and fallopian tubes. Infection of the cervix (cervicitis) causes mucopurulent discharge. Infection of the fallopian tubes (salpingitis) and uterus (endometritis) tend to occur together. If severe, infection can spread to the ovaries (oophoritis) and then the peritoneum (peritonitis). These infections are called salpingitis even though they involve other structures.
Diagnosis includes PCR of cervical specimens for Neisseria gonorrhoeae and Chlamydiae, microscopic examination of cervical discharge (usually), and ultrasonography or laparoscopy (occasionally). Treatment is with antibiotics.
A 16-year-old sexually active nulliparous white female complains of pelvic pain and vaginal discharge. On examination she is found to have a temperature of 39.8°C (102.0°F) pain with movement of the cervix, and tenderness and a mass in the right adnexa.
According to CDC guidelines, which one of the following treatments would be appropriate?
Correct Answer D:
Patients with PID and tubo-ovarian abscess and high fever should be hospitalized and treated for at least 24 hours with intravenous antibiotics (choice D).
→ Amoxicillin and penicillin G procaine are no longer recommended because of the increasing prevalence of penicillinase-producing and chromosomally-mediated resistant Neisseria gonorrhoeae.
→ If cefoxitin is used intra-muscularly for outpatient treatment, it should be combined with probenecid.
→ If ceftriaxone is used for outpatient treatment, probenecid is not required. Re-examination should be done within 3 days of initiation of therapy.
A 24-year-old female presents to your office with lower abdominal pain, dyspareunia, and a vaginal discharge. She has a history of multiple sex partners. Examination shows that the cervix is tender to manipulation and the uterus is tender and enlarged to the size expected at 6-8 weeks gestation. No adnexal masses are noted. She has no rebound tenderness on abdominal examination.
Which one of the following indicates that the patient should be hospitalized for parenteral therapy?
Correct Answer E:
The criteria for hospitalizing patients with pelvic inflammatory disease include failure to improve after 3 days of oral therapy, inability to tolerate antibiotics, suspicion that the patient will not comply with therapy, tubo-ovarian abscess, severe illness with high fever, vomiting, pain, pregnancy, and the underlying possibility of a surgical problem such as appendicitis.
Pelvic inflammatory disease is characterized by all of the following, except:
Pelvic inflammatory disease (PID) has a high association with gonorrhea and Chlamydia. After several days of inflammation, the bacterial flora is often polymicrobial. Pain, cervical motion tenderness, leucorrhea from the cervical os, fever, and leukocytosis are all common signs found when a patient presents with PID.
A. This is one of the criteria that is often used in making the diagnosis of pelvic inflammatory disease.
B. See answer to A.
C. See answer to A.
E. See answer to A. This is due to the inflammation of the tubes and peritoneum; moving the cervix from side to side will result in significant pain from the stretching of the inflamed peritoneum.
A 16-year-old female presents to the emergency room with a fever of 102°F (38.9°C) for 1 day, lower abdominal pain, and vaginal discharge. She admits to having unprotected sexual intercourse with a new male partner in the last 2 weeks. Her last menses was 1 week ago. She denies dysuria but complains of dyspareunia. Physical exam reveals bilateral lower abdominal tenderness, but no peritoneal signs. There is no suprapubic or costovertebral angle tenderness. On bimanual exam, she has right-sided adnexal tenderness, an erythematous, friable cervix with thick yellow discharge, and cervical motion tenderness. Her cervix is normal in size. A serum hCG is negative, urinalysis is unremarkable and a cervical swab gram stain reveals gram-negative diplococci.
Which of the following is the most likely diagnosis?
This adolescent has gonococcal pelvic inflammatory disease. She has evidence of cervicitis with systemic symptoms including fever and abdominal pain.
A. A normal urinalysis in the absence of dysuria, suprapubic tenderness, and cervical motion tenderness virtually excludes pyelonephritis.
B. No right lower quadrant pain or peritoneal signs on examination make this diagnosis unlikely. However, appendicitis should always be considered in patients with fever and lower abdominal pain.
C. With no adnexal mass and a negative serum HCG, it is an unlikely diagnosis.
D. Endometriosis causes chronic, intermittent pelvic and/or abdominal pain, but not fever and vaginal discharge.
Click to expand