QuestionSBA
QuestionChoice
Gram-negative rods
49921
e
Gram-positive cocci on a vaginal specimen may indicate bacterial vaginosis.
QuestionChoice
Gram-positive budding yeast cells
49920
d
these are likely to be lactobacilli.
QuestionChoice
Gram-positive cocci on a vaginal specimen may indicate bacterial vaginosis.
49918
b
Gram-positive cocci
QuestionChoice
Gram-positive bacilli are a normal finding on a vaginal sample
49919
c
Gram positive bacilli
QuestionChoice
This patient has signs and symptoms of pelvic inflammatory disease. Gram-negative diplococci inside cells on a vaginal specimen indicate gonorrhoea infection, one of the most common causes of pelvic inflammatory disease.
49917
a
Intracellular gram-negative diplococci
Concept
Chapter
# Summary


Pelvic Inflammatory Disease (PID) is a sexually transmitted infection that spreads from the vagina into the cervix and upper genital tract. The primary pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae, though often, no pathogen can be isolated. Patients typically present with generalised abdominal pain, discharge, postcoital bleeding, adnexal tenderness, cervical motion tenderness, and sometimes right upper quadrant pain due to Fitz-Hugh-Curtis syndrome. The diagnostic approach includes pelvic examination, pregnancy test, swabs for gonorrhoea and chlamydia, blood tests, and transvaginal ultrasound. Management typically consists of a combination of antibiotics, usually administered in an outpatient setting, and analgesia as required.


# Definition


Pelvic inflammatory disease (PID) is a condition that arises when an infection spreads from the vagina to the cervix, and subsequently to the upper genital tract.


# Aetiology


While Gonorrhoea and Chlamydia contribute to approximately 20% of PID cases, various anaerobic bacteria are also implicated. In certain instances, no pathogen can be isolated. PID is predominantly spread via sexual contact.


# Signs and Symptoms


PID is typically diagnosed based on clinical symptoms and signs. These include:


- Bilateral abdominal pain
- Vaginal discharge
- Post-coital bleeding
- Adnexal tenderness
- Cervical motion tenderness upon bi-manual examination
- Fever


Approximately 10% of patients present with right upper quadrant pain, secondary to inflammation of the liver capsule. This condition is referred to as Fitz-Hugh-Curtis syndrome (see below).


# Differential Diagnosis


Several conditions may present similarly to PID and should be considered in the differential diagnosis:


- **Appendicitis:** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting.
- **Ectopic Pregnancy:** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor.
- **Endometriosis:** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation.
- **Ovarian Cyst:** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination.
- **Urinary Tract Infection:** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.


# Investigations


The following investigations are usually carried out to diagnose PID:


**Bedside:**


- Bimanual examination, which may show cervical motion tenderness
- Pregnancy test
- Swabs for gonorrhoea and chlamydia, or urinary NAAT testing 


**Bloods:**


- FBC, including WCC 
- CRP 


**Imaging:**  

- Transvaginal ultrasound


# Management


Treatment of PID is **medical** involves a combination of antibiotics, the first-line being:

- Ceftriaxone (given intramuscularly) + doxycycline + metronidazole


If the infection is mild/moderate, these antibiotics are given orally (except ceftriaxone which is intramuscularly) and in an outpatient setting. 
If the infection is severe, all three antibiotics are given intravenously (and may later be converted to oral) in an inpatient setting.




In addition, it is important to avoid unprotected intercourse whilst PID is untreated to prevent spread of infection to sexual partners.


# Complications


The potential complications associated with PID are:


- Chronic pelvic pain: This is likely a result of tubal damage, secondary to inflammation. 
- Infertility: Occurs as a result of tubal damage, impairing passage of an ovum and/or sperm for fertilisation to occur. 
- Ectopic pregnancy: Occurs as a result of tubal damage and scarring causing impaired passage of a fertilised ovum through to the endometrium. 
- Fitz-Hugh-Curtis Syndrome (see below). 

# Fitz-Hugh-Curtis Syndrome


Fitz-Hugh-Curtis syndrome occurs when adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm in the context of PID. Despite this, liver function tests are usually normal. An abdominal ultrasound should be performed to rule out the presence of stones. A definitive diagnosis and treatment typically require laparoscopy and administration of antibiotics.


# NICE Guidelines

[Click here to see information on NICE about PID](https://cks.nice.org.uk/topics/pelvic-inflammatory-disease/)

# References


[Patient Info](https://patient.info/womens-health/pelvic-pain-in-women/pelvic-inflammatory-disease)
15
2185
Pelvic inflammatory disease
Topic
26
Gynaecology
Intracellular gram-negative diplococci
10020
A 22-year-old female presents to her local sexual health clinic with a 4 day history of abdominal cramps, similar to menstrual cramps.She has also noticed new thick thick, yellow vaginal discharge. She denies any vulval itching

She has had unprotected intercourse with multiple casual male partners in the last three months.

She has a Mirena coil in situ for contraception.

A bimanual examination reveals cervical tenderness, and on speculum examination, the cervix appears inflamed. Her coil threads are visible. There is a thick yellow-green discharge present in the vaginal vault. A sample is obtained from the upper vagina and cervix for near-patient microscopy.


What is the most likely finding on microscopy which would account for her symptoms?
a