Master the board step 3

Gynecology
Cervicitis
This is the diagnosis when cervical discharge is found on routine exam, usually
without other symptoms. Get cervical cultures (for chlamydia and gonorrhea).
Manage positive results by giving a single dose of oral azithromycin and IM
ceftriaxone.
Acute Salpingo-oophoritis
This is suspected when there is cervical motion tenderness on exam and the
patient complains of lower pelvic pain after menstruation.
Always treat cervicitis to
cover both chlamydia and
gonorrhea.
• Antibiotics that treat
gonorrhea:
– Ceftriaxone IM
– Cefixime PO
• Antibiotics that treat
chlamydia:
– Azithromycin PO
– Doxycycline PO
Diagnostic Testing
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Cervical cultures will be positive.
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WBC and ESR are elevated.
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Rule out pelvic abscess with sonogram.
Treatment
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Outpatient: One dose of IM ceftriaxone plus doxycycline
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Inpatient: IV cefotetan or cefoxitin plus doxycycline
Chronic Pelvic Inflammatory Disease
This classically presents with infertility or dyspareunia. The patient may also
have a history of ectopic pregnancy or abnormal vaginal bleeding.
Diagnostic Testing
Cervical cultures and laboratory tests will be negative. Sonogram will show
bilateral cystic pelvic masses (hydrosalpinges).
Treatment
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Lysis of tubal adhesions, which may be helpful for infertility
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Severe, unremitting pelvic pain may require a pelvic clean-out (TAH, BSO)
Tuboovarian Abscess
This advanced form of pelvic inflammatory disease is diagnosed when the
case describes an ill-appearing woman with severe, lower abdominal/pelvic
pain, back pain, and rectal pain, with systemic signs and symptoms (nausea,
vomiting, fever, tachycardia).
Diagnostic Testing
WBC and ESR are markedly elevated, there is pus on culdocentesis, and
sonogram shows a unilateral pelvic mass that appears as a multilocular, cystic,
complex adnexal mass. Blood cultures will grow anaerobic organisms.
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