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acute disease • cervicitis, salpingitis, endometritis, myometritis, peritonitis • pelvic cellulitis • tubo-ovarian abscess • pelvic abscess chronic disease • constant pelvic pain • dyspareunia • palpable mass • often due to Chlamydia • very difficult to treat, may require surgery

Differential Diagnosis (see Common Gynecological Complaints Section)

Investigations Gram stain • Gram-negative intracellular diplococci (GC) cervical culture • aerobic and anaerobic bacteria as well as Chlamydia (obligate intracellular parasite) ultrasound • may be normal • fluid in cul-de-sac • pelvic or tubo-ovarian abscess • hydrosalpinx laparoscopy • for definitive diagnosis • for tubal cultures and endometrial biopsy

Diagnosis must have • lower abdominal pain • cervical motion tenderness • adnexal tenderness plus one or more of the following • temperature > 38.0ºC • WBC > 10.5 • mucopurulent cervicitis or pus on culdocentesis (rarely done) • pelvic abscess or inflammatory mass on US or bimanual • elevated ESR or C-reactive protein (not commonly used) • positive culture for N. gonorrhea, C. trachomatis, E. coli or other vaginal flora • high risk partner • elevated ESR or C-reactive protein (not commonly used)

C o n s e q u e n c e s o f U n t r e a t e d P I D c h r o n i c p e l v i c p a i n a b s c e s s , p e r i t o n i t i s a d h e s i o n f o r m a t i o n e c t o p i c p r e g n a n c y i n f e r t i l i t y 1 e p i s o d e o f P I D > 1 3 % i n f e r t i l i t y 2 e p i s o d e s o f P I D > 3 6 % i n f e r t i l i t y b a c t e r e m i a • septic arthritis, endocarditis

Treatment must treat with polymicrobial coverage inpatient if: • atypical infection • adnexal mass, tubo-ovarian or pelvic abscess • moderate to severe illness • unable to tolerate oral antibiotics • immunocompromised • pregnant • surgical emergency cannot be excluded • PID is secondary to instrumentation • recommended treatment • cefoxitin 2 g IV q6h or cefotetan 2 g IV q12h + doxycycline 100 mg IV q12h, or • clindamycin + gentamicin + doxycycline

Gynecology 30

MCCQE 2000 Review Notes and Lecture Series

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