swab used during the examination due to cervical friability Testing for etiology is essential as it is difficult to determine based on examination findings alone There are, however, several characteristic findings that may aid the diagnosis Edema in the zone of ectopy may suggest gonorrhea or chlamydia; ulcerations or vesicles are characteristic of HSV; and punctate hemorrhages are seen in T vaginalis As many adolescent patients, particularly those in the ED setting, can be assessed without a speculum examination, the diagnosis can be made based on the clinical picture After determining the patient has cervicitis based on physical examination findings of cervical discharge or endocervical friability, or based on vaginal discharge in a patient at risk for a sexually transmitted disease, testing should be performed for gonorrhea, chlamydia, bacterial vaginosis, trichomoniasis, and Mycoplasma genitalium Testing for gonorrhea and chlamydia can be performed with a nucleic acid amplification test (NAAT) using urine, a vaginal sample, or an endocervical sample (least preferred, and not necessary if the speculum examination is not indicated) Trichomonas can also be detected using NAAT Testing for bacterial vaginosis generally requires wet prep and vaginal pH testing (see bacterial vaginitis discussion) M genitalium testing is available through a recently approved NAAT; testing and treatment is controversial It is important to remember that the diagnosis of one sexually transmitted infection does not exclude other infections In addition to laboratory tests, the clinician should perform a bimanual examination to assess for concurrent PID Management Patients with acute cervicitis should receive empiric therapy for gonorrhea and chlamydia while awaiting test results This can be treated with ceftriaxone (250 mg intramuscularly or intravenously; lidocaine hydrochloride can be used as diluent to decrease discomfort) and azithromycin (1 g orally), or doxycycline (100 mg orally twice a day for days) Treatment of trichomonas, bacterial vaginosis, and herpes simplex virus (HSV) are discussed in the corresponding sections Patients should be counseled to abstain from sexual activities for days following treatment PELVIC INFLAMMATORY DISEASE Goals of Treatment The goals of treatment of PID are early recognition, initiation of appropriate antimicrobial treatment, and detection of complications CLINICAL PEARLS AND PITFALLS One in eight sexually active adolescent girls will develop PID PID can lead to chronic pelvic pain, ectopic pregnancy, and infertility Acute presentation of PID is variable and patients may be well appearing despite serious consequences of untreated disease Current Evidence PID is a polymicrobial inflammatory condition of the female upper genital tract caused by an ascending sexually transmitted infection that variably involves the endometrium, fallopian tubes, ovaries, adjacent structures, and pelvic peritoneum An estimated one in eight sexually active adolescent girls develops PID before reaching 20 years of age Young age, a large number of sexual partners, and nonbarrier contraceptive methods are risk factors for infection with N gonorrhoeae and C trachomatis, the microorganisms responsible for initiating most cases of acute PID Other risk factors include cigarette smoking, recent douching, bacterial vaginosis, previous gynecologic surgery, and HIV infection Patients with PID are at risk of serious acute and chronic complications such as tuboovarian abscesses, infertility, and chronic pelvic pain It has been estimated that 20% of women with PID will have chronic pelvic pain Half of all ectopic pregnancies are thought to be the result of tubal damage produced by PID Women with a history of PID have a 10-fold risk of infertility with repeated bouts substantially increasing the likelihood of infertility Clinical Considerations Clinical Recognition Although the constellation of symptoms and signs associated with PID— abdominal pain, irregular uterine bleeding, abnormal vaginal discharge, and lower abdominal and pelvic tenderness—is well known, no single symptom or sign or a combination of symptoms and signs is both sensitive and specific Clinical findings that improve the specificity of the diagnosis of PID (i.e., increase the likelihood that the diagnosis is correct) so only at the expense of sensitivity (i.e., exclude patients who in fact have PID) Criteria for the diagnosis of PID suggested by the CDC are shown in Table 92.2 Because the diagnosis of PID is imprecise, and the potential for damage to the reproductive health of the patient is great, providers should maintain a low threshold for the diagnosis of PID TABLE 92.2 DIAGNOSTIC CRITERIA FOR PELVIC INFLAMMATORY DISEASE Minimum criteria Additional criteria Specific criteria Sexually active patient with pelvic or lower abdominal pain, no cause other than PID identified, and one of the following: Cervical motion tenderness or Uterine tenderness or Adnexal tenderness These findings enhance the specificity of the minimum criteria and support a diagnosis of PID: Oral temperature >101°F (>38.3°C) Abnormal cervical or vaginal mucopurulent discharge Abundant numbers of white blood cell on saline microscopy of vaginal secretions Erythrocyte sedimentation rate >15 mm/hr Elevated C-reactive protein Documented gonococcal or chlamydial cervical infection These findings offer a definitive diagnosis of PID: Endometrial biopsy with histopathologic evidence of endometritis Laparoscopic abnormalities consistent with PID Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes or tuboovarian complex, or Doppler studies showing tubal hyperemia PID, pelvic inflammatory disease Adapted from Workowski KA, Berman S; Centers for Disease Control and Prevention Sexually transmitted diseases treatment guidelines, 2010 MMWR Recomm Rep 2010;59(RR-12):1–110 Triage Considerations The majority of patients with PID will be stable However, patients presenting with an ill appearance or peritonitis require prompt treatment and surgical consultation These findings may suggest a complication such as a perforated tuboovarian abscess Clinical Assessment The emergency physician should focus on identifying patients with relatively mild illness; the CDC encourages clinicians to err on the side of providing rather than withholding antibiotic treatment Additionally, the EM practitioner should identify women with relatively severe illness, through additional diagnostics, focusing on the consideration of major competing diagnoses Many patients with PID will have negative cultures, which does not exclude the diagnosis, as PID is a polymicrobial clinical syndrome rather than a specific bacterial infection FIGURE 92.3 Strategy for diagnosis of pelvic inflammatory disease (PID) Minimal laboratory evaluation should include tests for gonococcal and chlamydial cervicitis Expanded laboratory investigation may include, in addition to the minimal evaluation, complete blood cell count, Creactive protein or erythrocyte sedimentation rate, and pelvic or transvaginal ultrasonography (Adapted from Kahn JG, Walker CK, Washington AE, et al Diagnosing pelvic inflammatory disease A comprehensive analysis and considerations for developing a new model JAMA 1991;266:2594–2604.) An important pathophysiologic irony is the observation that tubal occlusion is associated more often with a relatively unimpressive clinical presentation of PID (i.e., long duration of symptoms, no signs of peritonitis, normal peripheral leukocyte count) than with a “hot” clinical disease (i.e., short duration of symptoms, fever, peritoneal signs, leukocytosis) Similarly, chlamydial PID is associated with both a longer duration of pain at patient presentation and a higher risk of infertility than is gonococcal PID Thus, if the diagnosis of PID is allowed to depend substantially on patients’ appearance—as either “well” or “sick”— clinicians may be tempted to reject the diagnosis of PID and to withhold ... findings may suggest a complication such as a perforated tuboovarian abscess Clinical Assessment The emergency physician should focus on identifying patients with relatively mild illness; the CDC encourages