Tubal factor infertility is increased 12-50% in women

with a past diagnosis of PID. Prevention of complications is

dependent on early recognition and effective treatment.

CLINICAL PRESENTATION

..... History

Any complaint of vaginal discharge or pelvic pain requires

a detailed gynecologic history. Inquire about history of

sexually transmitted infections (STis), intrauterine device

use, pregnancies, last menstrual period, and any previous

gynecologic procedure. History should include details of

vaginal discharge, odor, irritation, itching, burning, bleeding, dysuria, and dyspareunia. In addition, determine the

presence of abdominal pain, nausea, vomiting, fevers, rash,

or joint aches.

Patients with vaginitis lack significant abdominal pain

or fevers and do not appear systemically ill. BV typically

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CHAPTER 44

presents with thin, whitish gray discharge that has a fishy

smell. In candidiasis, pruritus is the most common and

specific symptom; discharge tends to be white and occasionally thick and "cottage-cheese" like. It is important to

ask about risk factors for candida! colonization: uncontrolled diabetes mellitus, recent antibiotic use, immuno ­

suppression, and pregnancy. Patients with trichomonas

vaginitis (a sexually transmitted protozoan parasite) are

asymptomatic in 50% of cases, but the classic discharge is

described as yellow, frothy and malodorous.

Vaginal atrophy is present in 60% of women 4 years

after menopause. Symptoms of atrophic vaginitis include

vaginal dryness, soreness, itching and occasional thin,

scant, yellowish discharge.

Acute PID can be difficult to diagnose because of the

wide variation in symptoms and signs. The most common

presenting symptom is lower abdominal pain that tends to

be bilateral, dull or crampy. Approximately 75% of patients

with PID have abnormal vaginal discharge. Unilateral pain

should raise suspicion for a tuba-ovarian abscess or an

alternate diagnosis like appendicitis. Dyspareunia may be

present as well as urinary tract symptoms. Only one third

of patients with PID will have fever >100.4° F.

� Physical Examination

Obtain the patient's vital signs, particularly noting blood

pressure, pulse, and temperature. Before performing a pelvic exam, perform a focused general exam, including the

abdomen and flank. During the pelvic exam, inspect the

external genitalia. Make note of vulvar edema or erythema,

which can be a sign of vaginitis. On the speculum exam,

determine the presence of blood or discharge in the vaginal

vault. Visualize the cervix, looking for inflammation, foreign body, and discharge originating from the os.

Mucopurulent cervicitis is a common finding in both cer ­

vicitis and PID (Figure 44-l). On bimanual exam it is

important to note cervical motion tenderness (CMT) as

well as adnexal fullness or tenderness. CMT, also referred

to as the chandelier sign, is elicited by moving the cervix up

and down or laterally with the index and middle finger.

This causes movement of the uterus and tubes, which will

significantly reproduce pain in patients with PID. CMT is

sensitive but lacks specificity, as it can be positive in

patients with other sources of inflammation (appendicitis,

ruptured cysts, or ectopic pregnancy). Adnexal tenderness

appears to be the most sensitive finding (95%) for PID.

DIAGNOSTIC STUDIES

� Laboratory

Any evaluation of a woman of childbearing age in the ED

should including a pregnancy test, as the possibility of

ectopic pregnancy or septic abortion must be considered.

During the pelvic exam, vaginal secretions may be collected and tested. Microscopic examination of vaginal

secretions and evaluation of pH are useful diagnostic tools;

.A Figure 44-1. Discharge coming from the cervical os.

Reprinted with permission from Buckley RG, Knoop KJ.

Chapter 1 0. Gynecologic and Obstetric Conditions. In:

Knoop KJ, Stack LB, Storrow AB, Thurman RJ, eds. The

A tlas of Emergency Medicine. 3rd ed. New York:

McGraw-Hill, 201 0. Photo contributor: Sue Rist, FNP.

however, microscopes and reagents are not available in all

EDs.