LEARNING ISSUE: ADNEXAL PAIN 1.

Define adxenal pain (JEN BOON) Adnexal pain is the pain in the adnexa of uterus, usually in the ovary or fallopian tube. List common cause of adnexal pain (JEN BOON) Surgical, Procedure Complication Pelvic surgery Retained ovary syndrome Infectious Disorders (Specific Agent) Chlamydia pelvic inflammatory disease Gonorrhea Infected organ, Abscesses Acute PID/Salpingitis Oophoritis Puerperal pelvic cellulitis/sepsis Pelvic inflammatory disease Chronic pelvic inflammatory disease Abortion, septic Ovarian abscess/Tubo-ovarian abscess Perioophoritis (Inflammation of the peritoneal covering of the ovary) Pelvic abscess Neoplastic Disorders Ovarian Cancer/Carcinoma Ovarian neoplasm Fallopian tube carcinoma Ovarian clear cell carcinoma Ovarian teratocarcinoma Anatomic, Foreign Body, Structural Disorders Ectopic pregnancy Ectopic pregnancy hemorrhage Obstructed fallopian tube Ovarian cyst/Hemorrhagic cyst Ovarian follicular cyst Fallopian tube volvulus Ruptured ovarian cyst Arteriosclerotic, Vascular, Venous Disorders Pelvic thrombophlebitis(swelling (inflammation) of a vein caused by a blood clot) 3. Mechanism and side effect of OCP (ZUL AZUAN)

2.

Mechanism OCP prevent pregnancy (birth control) It is hormonal preparation that may contain combination of estrogen and progestin or progestin alone Estrogen + progestin prevent pregnancy by inhibiting the release LH and FSH (negative feedback) from the anterior pituitary gland

LH and FSH responsible for the development of the egg and preparation of the lining of the uterus for implantation of the embryo Progestin makes uterine mucus that surrounds the egg more difficult for sperm to penetrate and for fertilization to take place In some women, progestin inhibits ovulation

Side effect Nausea Headache Breast tenderness Weight gain Irregular bleeding Hypertension 4. Normal flora of female genetilia (ZUL AZUAN)

Lactobacilus responsible for producing the acid that keeps the pH of the adult womans vagina low, which inhibits the growth of organism such as Candida albicans, an important cause of vaginitis S.aureus (approx. 5% of women) predisposed women to toxic shock syndrome B.streptococci (about 15-20% of women of childbearing age group) can cause of sepsis and meningitis in the newborn and is acquired during passage thru birth canal other normal flora of female genitalia Bacteroides species Corynebacterium species E.coli Gardnerella vaginalis Staphylococcus epidermis Chlamydia trachomatis 5. Pathophysiology of mucopurulent vaginal discharge (JOHNNY) Mucopurulent discharge means the secretion of the fluid which contain both mucus and pus. It is the result of the inflammation. During the bacteria infection, the Neisseria gonorrhea in this case, the bacteria at the cervix or vagina trigger the cell inflammation. The macrophages start to release mediators such as histamines, cytokines which result in chemotaxis and hypersecretion of the glandular tissues. The pus contains mostly the dead neutrophils while the mucus contain mostly water. Both phenomenon are result of body trying to protect itself from bacteria infection. The chemotaxis attract the neutrophils infiltrate the infected region and engulf the bacteria. However, Neisseria gonorrhea have cytotoxin called leucocidin( leuco = WBC , cidin = kill) to kill the neutrophils. Dead neutrophils are then eliminated by the macrophages as pus or suppuration.

6. Risk factor of genital infection in female (IZZAT) Short urethra In the human female, the urethra is about 1.52 inches (45 cm) long and exits the body between the clitoris and the vagina, extending from the internal to the external urethral orifice.

Multiple sex partners -Increase the probability of having genital infection. Unprotected sex Having sexual intercourse without taking Oral contraceptive pills or using barrier contraceptives (diaphragm or cervical cap) can lead to genital infection. 7. Causes of tumor related to sex worker (IZWAN) Having sex at an early age Multiple sexual partners Poor economic status (may not be able to afford regular Pap smears) Sexual partners who have multiple partners or who participate in high-risk sexual activities Weakened immune system

8. Types and causes of vaginal discharge (normal and abnormal) (iZWAN) Vaginal Discharge Causes
The vaginal walls and uterine cervix contain glands that produce a small amount of fluid that helps to keep the vagina clean. This normal vaginal discharge is typically clear or milky white in color and does not have an unpleasant odor. A number of different infections can cause a change in the amount, consistency, color, or odor of vaginal discharge. These include: Bacterial vaginosis is a condition is caused by an imbalance in the growth of the bacteria that are normally present in the vagina. It is not known exactly why this imbalance in bacterial growth occurs. This condition was formerly known as Gardnerella vaginitis after one type of bacteria that commonly cause the infection. Trichomonas (trich, trichomoniasis) is infection by a single-celled parasite known as Trichomonas vaginalis. The infection is transmitted by sexual contact. Gonorrhea is the sexually-transmitted disease (STD) resulting from infection by the bacteria known as Neisseria gonorrhoeae. Chlamydia is another sexually-transmitted infection (STD) due to the bacteriaChlamydia trachomatis. Although infected women may not have symptoms, a vaginal discharge may occur. Yeast infection (candidiasis) occurs when there is an overgrowth of yeast in the vagina, often due to antibiotic use or other factors that affect the natural balance of bacteria in the vaginal area. Candida species are the type of yeast most commonly responsible. While Trichomonas, Gonorrhea, and Chlamydia are examples of sexually-transmitted diseases (STDs), bacterial vaginosis and yeast infection are not considered to be STDs. Vaginal bleeding is different from vaginal discharge. The infections listed above are causes of abnormal vaginal discharge without the presence of significant vaginal bleeding.

9.

Interpretation of PV examination (MANMEET)

Factors which may favor diagnosis of PID over appendicitis

no migration of pain bilateral abdominal tenderness (tender on the lower abdominal quadrants) absence of nausea and vomiting

Vaginal Examination:

No excoriation marks on the vulva - On visual examination, cervicitis due to noncandidial infection may be characterized by vulval erythema and oedema, excoriation marks in the vulva and vagina. Mucopurulent discharge (not foul smelling) -Purulent discharge: Vaginitis, cervicitis or endometritis(eg gonorrhea) Cervical motion tenderness(cervical excitation) - Unpleasant sensation or response elicited on pelvic examination with movement of the cervix by the clinician's gloved hand feeling tenderness on bimanual exam of cervix, uterus or adnexa (usually described as cervical motion tenderness or adnexal tenderness, usually indicative of inflammatory processes in the pelvic organs or of those adjacent organs that may be moved during such examination.

Other interpretation of Vaginal/Pelvic Examination Bloody vaginal discharge: Menstruation, cancer or cervical polyp or erosion. a) Dysuria may suggest candidiasis or trichomoniasis b) Presence of itching may also suggest trichomoniasis c) Cheesy" discharge increases likelihood of vaginal candidiasis while watery discharge decreases likelihood d) Inflammation of vulva and/or vagina (edema, erythema, fissures, excoriations) e) Vulvovaginal candidiasis - hyphae or pseudohyphae visible on wet mount or potassium oxide mount f) Bacterial vaginosis - vaginal Gram stain g) Trichomoniasis - culture on modified Diamonds' medium Diagnosis of trichomoniasis: o mobile trichomonads seen on microscopy, often with increased polymorphonuclear leukocytes, diagnoses trichomoniasis o pH 4.5 suggests bacterial vaginosis or trichomoniasis o rapid diagnostic tests using nucleic acid probes or immunochromatographic capillary flow dipstick technology are available Diagnosis of vulvovaginal candidiasis: o budding yeast and hyphae on microscopy diagnose vulvovaginal candidiasis o thick, curdy discharge associated with candidiasis o inflammation of vulva and/or vagina (edema, erythema, fissures, excoriations) associated with candidiasis Diagnosis of bacterial vaginosis: o Gram stain is gold standard laboratory method o Amsel's criteria for clinical diagnosis of bacterial vaginosis (3 of 4 findings) vaginal pH > 4.5 amine (fishy) odor on addition of 10% potassium hydroxide to discharge (positive "whiff test") presence of 20% clue cells (vaginal squamous epithelial cells with large numbers of coccobacilli) on wet mount or high dry magnification thin watery discharge
o

tests with possible clinical utility include

DNA probe test for high concentration of Gardnerella vaginalis (Affirm VP III) card test for proline aminopeptidase (Pip Activity TestCard) vaginal sialidase test (OSOM BVBlue test)

Vaginal pH: normal pH < 4.5

o o o

normal pH rules out bacterial vaginosis or trichomoniasis pH 4.5 suggests bacterial vaginosis or trichomoniasis vulvovaginal candidiasis infection associated with normal pH level

10. Interpretation of lab test (IHSAN) FBC: Hb 12.0g/dl : normal Hct 43% (38%-46%) : normal WBC 13 x 10^9/L : high due to response to infection (infectious diseases) normal range (4 - 11 x 10^9/L) other possible causes of high WBC (not related)
Anemia Bone marrow tumors Inflammatory disease (such as rheumatoid arthritis or allergy) Leukemia Severe emotional or physical stress Tissue damage (for example, burns)

platelets 250 x 10^9/L : normal

Urine analysis: normal, rule out diseases related to urinary system eg : UTI Urine pregnancy test: negative

Vaginal swab (endocervical swab): Wet mount: negative for motile trophozoites can rule out trichomoniasis (T. vaginalis) Gram-stain: shows intracellular gram-negative diplococcic indicate presence of diplococci bacteria (most likely is Neisseria gonorrhoeae, other eg are Moraxella catarrhalis, and Neisseria meningitidis) Direct immune-fluorescent test: positive for intracellular inclusion bodies Blood culture: negative to rule out systemic infection

11. Describe N.gonorrhea (IZWAN) N.gonorrhea (IZWAN)

 Neisseria are fastidious Gram-negative cocci that require nutrient supplementation to grow in laboratory cultures. Specifically, they grow on chocolate agarwith carbon dioxide. These cocci are facultatively intracellular and typically appear in pairs (diplococci), in the shape of coffee beans. Of the eleven species of Neisseria that colonize humans, only two are pathogens. N. gonorrhoeae is the causative agent of and is transmitted via sexual contact. Infection of the genitals can result in a purulent (or pus-like) discharge from the genitals which may be foul smelling. Symptoms may include inflammation, redness, swelling, and dysuria Infection of the genitals in females with N. gonorrhoeae can result in pelvic inflammatory disease if left untreated, which can result in infertility. Pelvic inflammatory disease results if N. gonorrhoeaetravels into the pelvic peritoneum (via. Infertility is a risk to 10 to 20% of the females infected with N. gonorrhoeae. Neisseria is found normally at the vagina, urethra, mouth, pharynx, nose and conjunctiva. Pelvic inflammatory disease (or disorder) (PID) is a generic term for inflammation of the uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. This may lead to infections. PID is a vague term and can refer to viral, fungal, parasitic, though most often bacterial infections. PID should be classified by affected organs, the stage of the infection, and the organism(s) causing it. Although an STI is often the cause, many other routes are possible, including lymphatic, postpartum, postabortal (either miscarriage or abortion) or intrauterine device (IUD) related, and hematogenous spread. Two thirds of patients with laparoscopic evidence of previous PID were not aware they had PID 12. Feature Chlamydia trachomatis and principle of direct fluorescent test (HAZIM) Features of chlamydia Is small and can pass through 0.45 micrometer filters. Once is considered as virus because it is small But has properties of bacteria like; 1) possess inner and outer membranes similar to those of gram-negative bacteria (2) contain both deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) (3) possess prokaryotic ribosomes (4) synthesize their own proteins, nucleic acids, and lipids (5) are susceptible to numerous antibacterial antibiotics. It infects nonciliated columnar, cuboidal and transitional epithelial cells The principle of direct fluorescence test is Antibodies that have been prepared against the cell wall or major outer membrane protein are used. Uses a single antibody that is chemically linked to a fluorophore. The antibody recognizes the target molecule and binds to it, and the fluorophore it carries can be detected via microscopy. 13. Describe PID (pelvic inflammatory disease) (ALIFF)
Untreated gonorrhea can cause serious and permanent health problems in both women and men.

What is PID?
Pelvic inflammatory disease (PID) refers to infection of the uterus (womb), fallopian tubes and other reproductive organs that causes symptoms such as lower abdominal pain.

It is a serious complication of some sexually transmitted diseases(especially chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. PID can lead to serious consequences including infertility, ectopic pregnancy, abscess formation, and chronic pelvic pain.

How do women get PID?

PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but many cases are associated with gonorrhea and chlamydia, two very common bacterial STDs. Sexually active women are most at risk, and those under age 25 are more likely to develop PID than those older than 25 because the cervix of teenage girls and young women is not fully matured, susceptibility to the STDs that are linked to PID.

What are the signs and symptoms of PID?

Symptoms of PID vary from mild to severe. lower abdominal pain. Fever. unusual vaginal discharge that may have a foul odor. painful intercourse. painful urination. irregular menstrual bleeding. pain in the right upper abdomen (rare).

What is the treatment for PID?

PID can be cured with several types of antibiotics. PID is usually treated with at least two antibiotics that are effective against a wide range of infectious agents. (Due to difficulty in identifying organisms infecting the internal reproductive organs and might be more than one organism) These antibiotics can be given by mouth or by injection.

Sources : Centers for disease control and prevention http://www.cdc.gov/std/pid/stdfact-pid.htm 14. Psychosocial and management (ZULFIQAR) Antibiotic Follow up Consent ethics

Treatment
I. Anaerobic bacteria have been isolated from the upper-reproductive tract of women who have PID, and data from in vitro studies have revealed that some anaerobes (e.g., Bacteroides fragilis) can cause tubal and epithelial destruction. BV also is present in many women who have PID. II. Until treatment regimens that do not adequately cover these microbes have been demonstrated to prevent long-term sequelae (e.g., infertility and ectopic pregnancy) as successfully as the regimens that are effective against these microbes, the use of regimens with anaerobic activity should be considered. Treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on early administration of appropriate antibiotics.

III.

IV.

When selecting a treatment regimen, health-care providers should consider availability, cost, patient acceptance, and antimicrobial susceptibility. In women with PID of mild or moderate clinical severity, outpatient therapy yields short- and longterm clinical outcomes similar to inpatient therapy. The decision of whether hospitalization is necessary should be based on the judgment of the provider and whether the patient meets any of the following suggested criteria: surgical emergencies (e.g., appendicitis) cannot be excluded; the patient is pregnant; the patient does not respond clinically to oral antimicrobial therapy; the patient is unable to follow or tolerate an outpatient oral regimen; the patient has severe illness, nausea and vomiting, or high fever; or the patient has a tubo-ovarian abscess. No evidence is available to suggest that adolescents benefit from hospitalization for treatment of PID. The decision to hospitalize adolescents with acute PID should be based on the same criteria used for older women. Younger women with mild-to-moderate acute PID have similar outcomes with either outpatient or inpatient therapy, and clinical response to outpatient treatment is similar among younger and older women.

Parenteral Treatment

For women with PID of mild or moderate severity, parenteral and oral therapies appear to have similar clinical efficacy. Many randomized trials have demonstrated the efficacy of both parenteral and oral regimens. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 2448 hours of clinical improvement. In women with tubo-ovarian abscesses, at least 24 hours of direct inpatient observation is recommended.

Recommended Parenteral Regimen A

Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours I. Because of the pain associated with intravenous infusion, doxycycline should be administered orally when possible. Oral and IV administration of doxycycline provide similar bioavailability. II. Parenteral therapy can be discontinued 24 hours after clinical improvement, but oral therapy with doxycycline (100 mg twice a day) should continue to complete 14 days of therapy. When tubo-ovarian abscess is present, clindamycin or metronidazole with doxycycline can be used for continued therapy rather than doxycycline alone because this regimen provides more effective anaerobic coverage. Limited data are available to support the use of other second- or third-generation cephalosporins (e.g., ceftizoxime, cefotaxime, and ceftriaxone), which also might be effective therapy for PID and could potentially replace cefotetan or cefoxitin. However, these cephalosporins are less active than cefotetan or cefoxitin against anaerobic bacteria.

Recommended Parenteral Regimen B

Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (35 mg/kg) can be substituted.

I. Although use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, it is efficacious in analogous situations. Parenteral therapy can be discontinued 24 hours after clinical improvement; ongoing oral therapy should consist of doxycycline 100 mg orally twice a day, or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy. When tubo-ovarian abscess is present, clindamycin should be continued rather than doxycycline, because clindamycin provides more effective anaerobic coverage.

Alternative Parenteral Regimens

Limited data are available to support the use of other parenteral regimens. The following regimen has been investigated in at least one clinical trial and has broad-spectrum coverage.

Alternative Parenteral Regimens

Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess. One trial demonstrated high short-term clinical cure rates with azithromycin, either as monotherapy for 1 week (500 mg IV for 1 or 2 doses followed by 250 mg orally for 56 days) or combined with a 12-day course of metronidazole.

Oral Treatment
Recommended Regimen
Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Follow-Up
I. Patients should demonstrate substantial clinical improvement (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy. II. Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and surgical intervention. III. If no clinical improvement has occurred within 72 hours after outpatient oral or parenteral therapy, further assessment should be performed. IV. Subsequent hospitalization and an assessment of the antimicrobial regimen and diagnostics (including the consideration of diagnostic laparoscopy for alternative diagnoses) are recommended in women without clinical improvement. V. Women with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months of treatment. Repeat testing of all women who have been diagnosed with chlamydia or gonorrhea is recommended 36 months after treatment, regardless of whether their sex partners were treated. All women diagnosed with acute PID should be offered HIV testing.

Management of Sex Partners

I. Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patients onset of symptoms. If a patients last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patients most recent sex partner should be treated. II. Patients should be instructed to abstain from sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms. Evaluation and treatment are imperative because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the sex partner. Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic. III. Sex partners should be treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman. Even in clinical settings in which only women are treated, arrangements should be made to provide care or appropriate referral for male sex partners of women who have PID. Expedited partner treatment and enhanced patient referral are alternative approaches to treating male partners of women who have chlamydia or gonococcal infections.

SOURCE: Centre for disease control.

Treatment
I.
Anaerobic bacteria have been isolated from the upper-reproductive tract of women who have PID, and data from in vitro studies have revealed that some anaerobes (e.g., Bacteroides fragilis) can cause tubal and epithelial destruction. BV also is present in many women who have PID. II. Until treatment regimens that do not adequately cover these microbes have been demonstrated to prevent long-term sequelae (e.g., infertility and ectopic pregnancy) as successfully as the regimens that are effective against these microbes, the use of regimens with anaerobic activity should be considered. III. Treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on early administration of appropriate

antibiotics. When selecting a treatment regimen, health-care providers should consider availability, cost, patient acceptance, and antimicrobial susceptibility. IV. In women with PID of mild or moderate clinical severity, outpatient therapy yields short- and long-term clinical outcomes similar to inpatient therapy. The decision of whether hospitalization is necessary should be based on the judgment of the provider and whether the patient meets any of the following suggested criteria:

surgical emergencies (e.g., appendicitis) cannot be excluded; the patient is pregnant; the patient does not respond clinically to oral antimicrobial therapy; the patient is unable to follow or tolerate an outpatient oral regimen; the patient has severe illness, nausea and vomiting, or high fever; or the patient has a tubo-ovarian abscess.
No evidence is available to suggest that adolescents benefit from hospitalization for treatment of PID. The decision to hospitalize adolescents with acute PID should be based on the same criteria used for older women. Younger women with mild-to-moderate acute PID have similar outcomes with either outpatient or inpatient therapy, and clinical response to outpatient treatment is similar among younger and older women.

Parenteral Treatment
For women with PID of mild or moderate severity, parenteral and oral therapies appear to have similar clinical efficacy. Many randomized trials have demonstrated the efficacy of both parenteral and oral regimens. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 2448 hours of clinical improvement. In women with tubo-ovarian abscesses, at least 24 hours of direct inpatient observation is recommended.

Recommended Parenteral Regimen A

Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours

I.

Because of the pain associated with intravenous infusion, doxycycline should be administered orally when possible. Oral and IV administration of doxycycline provide similar bioavailability.

II.

Parenteral therapy can be discontinued 24 hours after clinical improvement, but oral therapy with doxycycline (100 mg twice a day) should continue to complete 14 days of therapy. When tuboovarian abscess is present, clindamycin or metronidazole with doxycycline can be used for continued therapy rather than doxycycline alone because this regimen provides more effective anaerobic coverage. Limited data are available to support the use of other second- or third-generation cephalosporins (e.g., ceftizoxime, cefotaxime, and ceftriaxone), which also might be effective therapy for PID and could potentially replace cefotetan or cefoxitin. However, these cephalosporins are less active than cefotetan or cefoxitin against anaerobic bacteria.

Recommended Parenteral Regimen B

Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (35 mg/kg) can be substituted.

I.

Although use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, it is efficacious in analogous situations. Parenteral therapy can be discontinued 24 hours after clinical improvement; ongoing oral therapy should consist of doxycycline 100 mg orally twice a day, or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy. When tubo-ovarian abscess is present, clindamycin should be continued rather than doxycycline, because clindamycin provides more effective anaerobic coverage.

Alternative Parenteral Regimens

Limited data are available to support the use of other parenteral regimens. The following regimen has been investigated in at least one clinical trial and has broad-spectrum coverage.

Alternative Parenteral Regimens

Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess. One trial demonstrated high short-term clinical cure rates with azithromycin, either as monotherapy for 1 week (500 mg IV for 1 or 2 doses followed by 250 mg orally for 56 days) or combined with a 12-day course of metronidazole.

Oral Treatment
Recommended Regimen
Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days OR Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH or WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Follow-Up
I. Patients should demonstrate substantial clinical improvement (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy. II. Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and surgical intervention.

III.
IV.

If no clinical improvement has occurred within 72 hours after outpatient oral or parenteral therapy, further assessment should be performed. Subsequent hospitalization and an assessment of the antimicrobial regimen and diagnostics (including the consideration of diagnostic laparoscopy for alternative diagnoses) are recommended in women without clinical improvement.

V.

Women with documented chlamydial or gonococcal infections have a high rate of reinfection within 6 months of treatment. Repeat testing of all women who have been diagnosed with chlamydia or gonorrhea is recommended 36 months after treatment, regardless of whether their sex partners were treated. All women diagnosed with acute PID should be offered HIV testing.

Management of Sex Partners

I. Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patients onset of symptoms. If a patients last sexual intercourse was >60 days before onset of symptoms or diagnosis, the patients most recent sex partner should be treated.

II.

Patients should be instructed to abstain from sexual intercourse until therapy is completed and until they and their sex partners no longer have symptoms. Evaluation and treatment are imperative because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the sex partner. Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic.

III.

Sex partners should be treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman. Even in clinical settings in which only women are treated, arrangements should be made to provide care or appropriate referral for male sex partners of women who have PID. Expedited partner treatment and enhanced patient referral are alternative approaches to treating male partners of women who have chlamydia or gonococcal infections.