Pelvic inflammatory disease & tubo-ovarian abscess — structured SAQ (15 marks)

(a) CDC 2021 minimum criteria and threshold (3 marks)

One mark for the principle, one for the criteria, one for the threshold. ^[1]

• Empirically treat a sexually active at-risk woman with pelvic or lower abdominal pain, when no other cause is identified, and one or more of these minimum criteria is present:
• Cervical motion tenderness, OR uterine tenderness, OR adnexal tenderness.
• This woman meets the threshold (cervical motion and adnexal tenderness) — treat now; do not wait for NAAT results.^[1]

(b) CDC 2021 outpatient regimen and counselling (4 marks)

One mark per drug (3), one for counselling. ^[1]

• Ceftriaxone 500 mg IM in a single dose (1 g if body weight over 150 kg), PLUS
• Doxycycline 100 mg orally twice daily for 14 days, WITH
• Metronidazole 500 mg orally twice daily for 14 days.
• Counselling (either): doxycycline — sun protection, avoid in pregnancy, take with water away from milk/antacids; OR metronidazole — covers anaerobes and is now routine (not optional) in the 2021 update.^[1]

(c) CDC 2021 admission criteria — four of (4 marks)

One mark each, maximum four. ^[1]

Any four of:

• A surgical emergency (e.g. appendicitis) cannot be excluded.
• Tubo-ovarian abscess.
• Pregnancy.
• Severe illness, nausea and vomiting, or oral temperature over 38.5 C.
• Unable to follow or tolerate an outpatient oral regimen.
• No clinical response to oral antimicrobial therapy.^[1]

(d) Long-term sequelae and Westrom data (4 marks)

One mark per sequela/number, maximum four. ^[2][3]

• Tubal-factor infertility: approximately 12% after one laparoscopically-verified PID episode (versus under 1% in controls).
• Risk rises steeply with the number of episodes (relative risks 1.0 / 7.0 / 16.2 / 28.3 for 0 / 1 / 2 / 3-plus), and with severity and delayed care.
• Ectopic pregnancy: the first pregnancy after PID is ectopic in about 8% (versus 1 to 2% in controls).
• Chronic pelvic pain in about a third, from adhesions and nerve injury — and subclinical PID inflicts the same damage, which is why empirical treatment on minimum criteria matters.^[2][3]