Ep 183 STIs: Pelvic Inflammatory Disease and Genital Lesions – HSV, Syphilis and LVG

In this part 2 of our 2-part series on STIs with Dr. Catherine Varner and Dr. Robyn Shafer we answer such questions as: Why should we care about making the diagnosis of pelvic inflammatory disease (PID) in the ED? What combination of clinical features and lab tests should trigger a presumptive diagnosis and empiric treatment of PID? Which patients with PID require admission to hospital? What are the test characteristics of ultrasound for the diagnosis of PID and for Fitz-Hugh-Curtis Syndrome? When and how should we work up  patients for syphilis in the ED? When should we suspect and empirically treat for lymphogranuloma venereum and granuloma inguinale? does an IUD need to be removed in patients with PID? and many more...

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Hanna Jalali and  Anton Helman May, 2023

Cite this podcast as: Helman, A. Varner, C. Shafer, R. Episode 183 - STIs: Pelvic Inflammatory Disease and Genital Ulcers - HSV, Syphilis and LGV. Emergency Medicine Cases. May, 2023. https://emergencymedicinecases.com/stis-pid-genital-lesions-hsv-syphilis-lgv. Accessed May 30, 2024

Résumés EM CasesPelvic Inflammatory Disease (PID) - an often elusive diagnosis

PID encompasses a wide spectrum of upper genital tract infections including endometritis, salpingitis, oophoritis, myometritis, tubo-ovarian abscess, and perihepatitis (Fitz-Hugh Curtis syndrome) and ranges in clinical presentation from acutely severely ill patients with intra-abdominal sepsis to those with mild abdominal pain and more indolent presentations over weeks to months.

Why should we care about making the diagnosis of pelvic inflammatory disease (PID) in the ED?

The long-term consequences of untreated PID include:

* Infertility

* Chronic pelvic pain

* Ectopic pregnancy (10% risk)

The diagnosis of PID is frequently missed in the ED due to:

* Sometimes vague and indolent presentation with mild or nonspecific symptoms or signs (e.g., abnormal bleeding, dyspareunia, and vaginal discharge)

* Poor accuracy of laboratory testing and imaging

* Unrecognized organisms besides gonorrhea and chlamydia (which comprise only 50% of PID cases) such as mycoplasma genitalium

* Increasing multi-drug resistant gonorrhoea with incomplete treatment

Pelvic Inflammatory Disease (PID) diagnostic criteria

PID should be considered in all sexually active females presenting with abdominal/pelvic pain where other causes have been excluded plus one or more of the following minimum diagnostic criteria:

* Adnexal tenderness

* Cervical motion tenderness

* Lower abdominal tenderness

A presumptive diagnosis should be made and treatment initiated with any one of the above present after other causes of abdominal/pelvic pain are ruled out.

Additional diagnostic criteria can increase specificity for PID including:

* Fever

* Abnormal cervical mucopurulent discharge or cervical friability on pelvic exam

* Elevated ESR/CRP

* Laboratory documentation of cervical/vaginal infection with gonorrhea or chlamydia

Definitive diagnosis is made with:

* Transvaginal ultrasound findings in keeping with PID including tubo-ovarian abscess

* Biopsy

* Laparoscopy

In summary, there is not one historical feature, physical exam or lab test that definitively rules in the diagnosis of PID. A low threshold for presumptive diagnosis should be employed in sexually active women with unexplained abdominal/pelvic pain and significant tenderness on pel...