Sexual health for PLAB 1

A 19 year old woman has had bilateral lower abdominal pain and deep dyspareunia for three days, with an offensive vaginal discharge. Her temperature is 38.4°C. Vaginal examination shows marked cervical motion tenderness. A urinary pregnancy test is negative. What is the SINGLE most likely diagnosis?

1. Ectopic pregnancy Must be excluded in any woman of reproductive age with pelvic pain. A pregnancy test is mandatory. Bilateral pain with cervical motion tenderness and a negative pregnancy test does not exclude it by itself.
2. Pelvic inflammatory disease correct Correct. Bilateral lower abdominal pain, deep dyspareunia, offensive discharge, fever and cervical motion tenderness in a sexually active young woman. Cervical excitation is the sign that moves this from a urinary or bowel cause to an ascending genital tract infection.
3. Appendicitis Migratory right iliac fossa pain with anorexia and localised peritonism. Bilateral pain with cervical motion tenderness and a negative pregnancy test makes a gynaecological cause far more likely.
4. Ovarian torsion Sudden severe unilateral pain with vomiting and an adnexal mass. Bilateral pain with cervical motion tenderness and a negative pregnancy test does not fit that pattern.
5. Endometriosis Cyclical pain and dyspareunia over months to years, without fever or discharge. Bilateral pain with cervical motion tenderness and a negative pregnancy test is too acute.

The point: PID is a clinical diagnosis and the threshold to treat is deliberately low, because the cost of missing it is infertility, ectopic pregnancy and chronic pelvic pain. Treat empirically before swabs return, cover gonorrhoea, chlamydia and anaerobes, remove nothing, and trace contacts.

Source: NICE CKS — Pelvic inflammatory disease NICE · tier 1, national regulator or guidance

A 19 year old woman has had bilateral lower abdominal pain and deep dyspareunia for three days, with an offensive vaginal discharge. Her temperature is 38.4°C. Vaginal examination shows marked cervical motion tenderness. A urinary pregnancy test is negative. What is the SINGLE most appropriate initial investigation?

1. Endocervical swabs for gonorrhoea and chlamydia correct Correct. Nucleic acid amplification testing identifies the organism and enables partner notification, which is what stops reinfection. It does not delay anything, because treatment is started at the same visit before the result returns.
2. High vaginal swab Detects bacterial vaginosis and candida, neither of which is the target here. Bilateral pain with cervical motion tenderness and a negative pregnancy test calls for endocervical sampling.
3. Urinary pregnancy test Mandatory in every woman of reproductive age with pelvic pain, because ectopic pregnancy is the diagnosis that kills. Bilateral pain with cervical motion tenderness and a negative pregnancy test does nothing to exclude it.
4. Laparoscopy The reference standard but not a first-line test, reserved for diagnostic doubt or failed treatment. Bilateral pain with cervical motion tenderness and a negative pregnancy test does not warrant it.
5. Pelvic ultrasound Looks for a tubo-ovarian abscess rather than confirming PID itself. Bilateral pain with cervical motion tenderness and a negative pregnancy test makes an abscess worth excluding.

The point: PID is a clinical diagnosis and the threshold to treat is deliberately low, because the cost of missing it is infertility, ectopic pregnancy and chronic pelvic pain. Treat empirically before swabs return, cover gonorrhoea, chlamydia and anaerobes, remove nothing, and trace contacts.

Source: NICE CKS — Pelvic inflammatory disease NICE · tier 1, national regulator or guidance

A 19 year old woman has had bilateral lower abdominal pain and deep dyspareunia for three days, with an offensive vaginal discharge. Her temperature is 38.4°C. Vaginal examination shows marked cervical motion tenderness. A urinary pregnancy test is negative. What is the SINGLE most appropriate immediate management?

1. Ceftriaxone, doxycycline and metronidazole correct Correct. Empirical triple cover: ceftriaxone for gonorrhoea, doxycycline for chlamydia, metronidazole for anaerobes. All three are needed because the swab cannot be waited for and coinfection is common.
2. Metronidazole alone Covers anaerobes only. Bilateral pain with cervical motion tenderness and a negative pregnancy test requires broader treatment than that.
3. Admit for intravenous antibiotics For pregnancy, severe systemic illness, a tubo-ovarian abscess, or failure of oral treatment. Bilateral pain with cervical motion tenderness and a negative pregnancy test meets that threshold.
4. Await swab results before treating The single most harmful option. Delay is what causes tubal damage, and bilateral pain with cervical motion tenderness and a negative pregnancy test makes the diagnosis clinically clear enough to act on.
5. Remove the intrauterine device Not routine. The device can usually stay unless there is no improvement at 72 hours. Bilateral pain with cervical motion tenderness and a negative pregnancy test does not change that.

The point: PID is a clinical diagnosis and the threshold to treat is deliberately low, because the cost of missing it is infertility, ectopic pregnancy and chronic pelvic pain. Treat empirically before swabs return, cover gonorrhoea, chlamydia and anaerobes, remove nothing, and trace contacts.

Source: NICE CKS — Pelvic inflammatory disease NICE · tier 1, national regulator or guidance