A 26-year-old female presents to your department because of dull aches in the lower abdomen and pelvic area for the past 2 weeks. She rates the pain as 4/10 in intensity and is accompanied with mild fever. She tried acetaminophen but it has not helped much. She denies bleeding, weight gain, constipation, and amenorrhea. She has had multiple sexual partners over the last 6 months and does not use condoms consistently.
Her vitals are BP 110/65 mmHg, pulse 80/min, respirations 14/min, temperature is 38.5°C. An abdominal exam shows suprapubic tenderness without rebound or guarding. Pelvic exam is positive for cervical motion tenderness, but negative for any bleeding, masses, or abnormal discharge. Pregnancy test is positive.
Which of the following would be the most appropriate next step in management of this patient?
Correct Answer E:
This patient’s clinical presentation points to pelvic inflammatory disease (PID). This is suggested by a history of unprotected sexual intercourse with multiple partners, symptoms of fever, lower abdominal pain, and findings of suprapubic tenderness and cervical motion tenderness on physical examination. While majority of patients with PID are managed as outpatients, hospitalization is recommended in pregnant women, patients found to have pelvic abscess on ultrasonography, uncertain diagnosis, compromised immunity, and failure to improve after 72 hours of outpatient treatment. This patient’s pregnancy test is positive, therefore she should be hospitalized.
For inpatient management, currently two regimens are recommended:
→ Treat her with penicillin as outpatient (choice A) is incorrect. Syphilis is treated with penicillin. The most common causes of PID are Chlamydia and Gonorrhea.
→ Admit the patient and treat with levofloxacin and doxycycline (choice B) is incorrect. Doxycycline should not be used in a patient who has just tested positive for pregnancy.
→ Admit the patient for laparoscopy (choice C) is incorrect. Laparoscopy is used if tubo-ovarian abscesses are suspected, the diagnosis of PID is in doubt, or when the patient’s condition doesn’t improve despite appropriate standard treatment.
→ Treat her with IM ceftriaxone and azithromycin as outpatient (choice D) is incorrect. Pregnant patients should be admitted to be treated PID.
Key Point:
PID in a pregnant patient should be managed in the hospital with intravenous cefoxitin or cefotetan and azithromycin 1 gram orally.
A 32-year-old woman comes to the emergency department complaining of fever, nausea, and vomiting for the past week. She has already vomited three times in the morning at home and one more time in the hospital. She also has some tenderness the pelvic region. Her last menstrual period was six weeks ago. She states that she has had many sexual partners in the past year. Past medical history includes an infection in the genital area that was treated with antibiotics two years ago. Vital signs indicate a temperature of 39°C, heart rate of 82 bpm, blood pressure of 92/59 mmHg, and respiratory rate of 24 bpm. Physical examination of the abdomen and pelvic area shows rebound tenderness. Ultrasound shows abscess in the pelvic region.
What is next best step in management of this patient?
Correct Answer E: Pelvic inflammatory disease (PID) presents with infection and inflammation of the upper genital tract in women including the uterus, fallopian tubes, and/or ovaries. Risk factors for PID are the same as those for acquiring sexually transmitted infections: multiple sexual partners, young age, smoking, and illicit drug use. Neisseria gonorrhoeae and Chlamydia trachomatis are pathogens most commonly associated with PID though other pathogens including vaginal anaerobes may account for up to 23% in women. Criteria for diagnosis include cervical motion, uterine, or adnexal tenderness along with fever, vaginal/cervical discharge, leukocytosis, positive cultures and elevated C-reactive protein. Salpingitis and endometritis are also associated with PID and severe cases increase risk of ectopic pregnancy and infertility.
Patients suspected of PID that are pregnant, non-responsive to oral antibiotic therapy for 72 hours, non-compliant to outpatient management, severe fever/nausea/vomiting and have tubo-ovarian abscess should be admitted for further evaluation and treatment. Commonly used inpatient therapeutic agents include IV 3rd generation cephalosporin and doxycycline followed by PO doxycycline for a total of 14 days. Outpatient therapy includes single dose IM ceftriaxone/cefoxitin and PO doxycycline for 14 days. This patient shows symptoms of acute PID and possible acute abdomen/sepsis therefore should be prepared for emergent surgery (choice E). Patients with tubo-ovarian abscess (TOA) larger than 10 cm should consider surgery. Surgical exploration is indicated in any patient with symptoms of acute abdomen (e.g. rebound tenderness, fever) and signs of sepsis (e.g. hypotension, tachypnea) shown in this patient.
→ Admit and give IV cefoxitin and doxycycline (choice A) is not correct. The patient should normally be admitted and given IV antimicrobials if the patient has severe symptoms and non-compliant or unresponsive to outpatient therapy. However, if the patient shows severe symptoms along with signs of sepsis, acute abdomen or ovarian rupture, she should undergo surgery right away.
→ Admit and give IM ceftriaxone and PO doxycycline (choice B) is not correct. IM ceftriaxone and PO doxycycline is commonly prescribed as outpatient therapy for PID patients.
→ Discharge the patient and advise follow-up in one week (choice C) is not correct. Since the patient presents with severe symptoms, she should not be discharged.
→ Discharge the patient and prescribe IM cefoxitin and PO doxycycline (choice D) is not correct. Since the patient presents with severe symptoms, she should not be discharged. Also, the antibiotics listed are typically used for outpatient therapy.
Key point:
Pelvic inflammatory disease presents with infection (commonly gonococcal and chlamydial) and inflammation of the upper genital tract in women including the uterus, fallopian tubes, and/or ovaries associated with salpingitis and endometritis. If the patient presents with symptoms of sepsis, acute abdomen or tubal ovarian rupture, surgical intervention is warranted.
The definition of vaginismus is:
Correct Answer A:
Vaginismus is vaginal tightness causing discomfort, burning, pain, penetration problems, or complete inability to have intercourse.
The other choices b), c) and d) are definitions for dyspareunia, dysmenorrhea and imperforate hymen respectively.
Which one of the following best describes vaginismus?
Correct Answer C:
Vaginismus is a psychogenic phenomenon which produces spasms of the vaginal muscles. These spasms may produce only a slight contraction at the beginning of intercourse, but at the other extreme they can cause severe pain and contractions so strong that even a fingertip cannot be inserted into the vagina. Most women who suffer from vaginismus believe that their vagina is simply too small, but it is actually normal. True vaginal spasms cannot be produced voluntarily, and in fact many women with vaginismus are sexually responsive, are orgasmic on clitoral stimulation, and may enjoy sexual play without intercourse.
A woman who reports two previous miscarriages and family history of neural tube defects (anencephaly) is planning a pregnancy within next 6 months.
What is the best advice you would give?
Insufficient folic acid (folate) in the diet increases the chance that a fetus will develop spina bifida (in which the spine does not completely enclose the spinal cord) and anencephaly (in which a large part of the brain and skull is missing) or other abnormalities of the brain or spinal cord known as neural tube defects.
Prenatal diagnosis by amniocentesis and ultrasonography is recommended for couples who have at least a 1% risk of having a baby with a neural tube defect.
The risk of having a baby with a neural tube defect is increased by having a family history (including the couple's own children) of such defects. For couples who have had a baby with spina bifida or anencephaly, the risk of having another baby with one of these defects is 2 to 3%.
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