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Toronto Notes 2019 Gynecological Infections Gynecology GY31 Treatment
• musttreatwithpolymicrobialcoverage
Table 16. Inpatient and Outpatient Management Options for Pelvic Inflammatory Disease
Indications
Antibiotic Regimen
Inpatient
Moderate to severe illness
Atypical infection
Adnexal mass, tubo-ovarian mass, or pelvic abscess
Unable to tolerate oral antibiotics or failed oral therapy
Immunocompromised
Pregnant
Adolescent – first episode
Surgical emergency cannot be excluded (e.g. ovarian torsion)
PID is secondary to instrumentation
Cefoxitin 2g IV q6h + doxycycline 100mg PO/IV q12h or
Clindamycin 900mg IV q8h + gentamycin 2mg/kg IV/IM loading dose then gentamycin 1.5mg/kg q8h maintenance dose
Continue IV antibiotics for 24 h after symptoms have improved then doxycycline 100 mg PO bid to complete 14 d
Percutaneous drainage of abscess under U/S guidance
When no response to treatment, laparoscopic drainage
If failure, treatment is surgical (salpingectomy, TAH/BSO)
Outpatient
Typical findings
Mild to moderate illness
Oral antibiotics tolerated
Compliance ensured
Follow-up within 48-72 h (to ensure symptoms not worsening)
1st line: Ceftriaxone 250 mg IM x 1 + doxycycline 100 mg PO bid x 14 d OR cefoxitin 2 g IM x1 + probenecid 1g PO + doxycycline 100 mg PO BID ± metronidazole 500 mg PO bid x 14 d
2nd line: ofloxacin 400 mg PO BID x14 d OR levofloxacin 500mg PO OD x 14 d ± metronidazole 500 mg PO bid x 14 d
Consider removing IUD after a minimum of 24 h of treatment
Reportable disease
Treat partners
Consider re-testing for C. trachomatis and N. gonorrhoeae 4-6 wk after treatment if documented infection
Complications of Untreated PID
• chronicpelvicpain • abscess, peritonitis • adhesionformation • ectopicpregnancy • infertility
■ 1episodeofPID→13%infertility
■ 2episodesofPID→36%infertility • bacteremia
• septicarthritis,endocarditis
Gynecological
Acute
Non-gynecological
Pelvic Pain
Pregnancy- related Labour Ectopic pregnancy Spontaneous abortion Placental abruption
Chronic
GI
Appendicitis Mesenteric adenitis Diverticulitis IBD
GU
UTI (e.g. cystitis, pyelonephritis) Renal colic
Gynecological
Chronic PID Endometriosis Adenomyosis Adhesions Dysmenorrhea Ovarian cyst Pelvic congestion syndrome Ovarian remnant syndrome Fibroid (rare) Uterine prolapse (rare)
Non-gynecological
Referred pain Urinary retention Urethral syndrome Interstitial cystitis GI neoplasm IBS
IBD Constipation Partial bowel obstruction Diverticulitis Hernia formation Nerve entrapment Sexual/physical/ psychological abuse Depression Anxiety Somatization
Adnexal
Mittelschmerz Ruptured ovarian cyst Ruptured ectopic pregnancy Hemorrhage into cyst/neoplasm Ovarian/tubal torsion
Uterine
Fibroid degeneration Torsion of pedunculated fibroid Pyometra/ hematometra
Infectious
Acute PID Endometritis
Figure 15. Approach to pelvic pain