PID and tubo-ovarian abscess — structured oral station (12 minutes)

Opening prompt — "She has cervical motion and bilateral adnexal tenderness. Pregnancy test is negative. What is your management and why?"

Model response — treat empirically now: [1]

• "This is pelvic inflammatory disease. CDC 2021 says treat empirically when a sexually active at-risk woman has pelvic pain, no other cause is identified, and one or more of cervical motion, uterine or adnexal tenderness is present. She meets that on two of three."
• "I would start treatment this visit — the ceftriaxone-doxycycline-metronidazole triple — because delay scars tubes, and most tubal-factor infertility has no history of an acute episode."[1][2]

Probe 1 — "State the outpatient regimen with doses."

• "Ceftriaxone 500 mg IM once — 1 g if she is over 150 kg — plus doxycycline 100 mg orally twice daily for 14 days, with metronidazole 500 mg orally twice daily for 14 days."
• "Metronidazole is now routine in the 2021 update because anaerobes contribute to tubal destruction and BV frequently coexists."[1]

Probe 2 — "Her ultrasound shows a 6 cm tubo-ovarian abscess. Does that change your plan?"

• "Yes — a TOA is an admission criterion. I would admit for IV antibiotics — ceftriaxone 1 g IV daily plus doxycycline and metronidazole — with over 24 hours inpatient observation."
• "I would have a low threshold for image-guided or surgical drainage if she fails to improve at 48 to 72 hours, or if fever and CRP rise — the TOAST and Fouks data show abscess diameter is the dominant predictor of failed medical management, and about a third of medically-managed TOAs need intervention."[3]

Probe 3 — "She mentions a male partner she has not told. What do you do?"

This is a scored communication domain — demonstrate it out loud: [1]

• Move to her eye level, acknowledge the difficulty: "Partner treatment is part of curing you and protecting your fertility. I will help you arrange it confidentially — partner notification, or expedited partner therapy where it is available — and I would like us to talk about how you want to approach him."
• Offer an HIV and syphilis test at this visit, treat partners for the preceding 60 days, and retest gonorrhoea and chlamydia at 3 months.[1]

Probe 4 — "She asks whether this will affect her fertility. What do you say, honestly?"

• "I would be honest and precise: a single PID episode carries about a 12% chance of tubal-factor infertility — much higher than women who never have PID — and the risk rises with each further episode and with delayed treatment. That is exactly why we are treating aggressively and now, and why partner treatment and retesting matter."[2]

Probe 5 — "Two days later she develops right upper quadrant pleuritic pain with normal liver enzymes. What is this?"

• "Fitz-Hugh-Curtis syndrome — perihepatitis complicating PID. The RUQ pleuritic pain with normal liver enzymes is the clue; chronic cases show violin-string adhesions on the liver capsule at laparoscopy."
• "I would manage the PID as planned; it is classically gonococcal but now more often chlamydial."[4]