This power point is about syndromic approach - management of lower abdominal pain in females and genital ulcers. This is an easier approach to treat such conditions as it covers for numerous causative microorganisms at the same time. Moreover treatment can be started earlier and one might not wait for Culture and Sensitivity test to start treatment.

1. MANAGEMENT OF
LOWER ABDOMINAL PAIN IN FEMALES
AND
GENITAL ULCERS
CHOYTOO Shiksha
Community Medcine
29.02.16
SSR Medical college, Mauritius

2. Management of lower abdominal
pain in females

3. Causative Organisms
 Neisseria gonorrhea
 Chlamydia trachomatis
 Mycoplasma
 Gardnerella
 Anaerobic bacteria
 bacteroids specifically gram positive cocci

4. MANAGEMENT
OF PREGNANT
WOMEN
HISTORY EXAMINATION
LABORATORY
INVESTIGATIONS
TREATMENT
OUT PATIENT
TREATMENT
SYNDROME SPECIFIC
GUIDELINES FOR
PARTNER
MANAGEMENT
HOSPITALISATION

5. History
 Site of pain- lower abdomen
 Associated features
 Fever
 Vaginal discharge
 Menstrual irregularities
 Dysmenorrhea
 Dyspareunia
 Dysuria, tenesmus
 Contraceptive use eg. IUD

6. Examination
 General examination + vitals
 Per speculum examination
 Vaginal/ cervical discharge, congestion, ulcers
 Per abdomen examination
 Lower abdominal tenderness
 Pelvic examination
 Uterine tenderness, cervical movement tenderness
Note:
urine pregnancy test should be done in all women
suspected of having PID to rule out ectopic pregnancy

7. Laboratory Investigations
 Wet smear examination
 Gram stain for gonorrhea
 Complete blood count and ESR
 Urine microscopy for pus cells

8. Treatment – Out Patients
 Mild – moderate PLD cases
 Cover Neisseria gonorrheae, chlamydia
trachomatis and anaerobes
 Treatment
 Tab. Cefixime 400mg orally twice daily for 7 days +
Tab. Metronidazole 400 mg orally twice daily for 14
days + Doxycycline 100mg orally twice daily for 2
weeks
 Tab. Ibruprofen 400 mg orally 3 times a day for 3-5
days
 Tab. Ranitidine 150 mg orally twice daily

9.  Remove IUD, if present, under antibiotic cover of
24-48 hrs
 Advice abstinence during the course of treatment
and educate on correct and consistent use of
condoms
 Observe for 3 days. If there is no improvement or
symptoms worsen refer to in patient treatment
 Caution:
 PID can be serious condition. Refer patient to hospital if
she does not respond to treatment within 3 day or even
earlier if condition worsen

10. Hospitalisation of Patient
 Hospitalisation of patient with acute PID should
be seriously considered when
 Diagnosis – uncertain
 Surgical emergencies eg: appendicitis or ectopic
pregnancy cannot be excluded
 Severe illness precludes management on an out
patient basis
 Woman- pregnant
 Patient is unable to follow or tolerate an out patient
regimen

11. Management in Pregnant Women
 PID is rare in pregnancy
 Refer to district hospital for hospitalisation
 Parenteral regimen- safe in pregnancy
 Doxycycline contraindicated
 Metronidazol usually not recommended during
the first 3 months of pregnancy but should not be
withheld in case of severe acute PID (emergency)

12. Syndrome Specific Guidelines For
Partner Management
• Treat all partners in past 2 month
• Treat all male partners for urethral discharge (gonorrhea
and chlamydia)
• Provide condom and educate on correct and consistent use
• Refer for voluntary counseling and testing for HIV, Syphilis
and Hepatitis B
• Inform about the complication if left untreated
• Follow up visits- 3,7,14 days - compliance

13. Differential Diagnosis
 Ectopic pregnancy
 Twisted ovarian cyst
 Ovarian tumor
 Appendicitis
 Abdominal TB

14. Management of Genital Ulcers

15. Causative Organism
 Treponema pallidum ( syphilis)
 Hemophilus Ducreyi ( cancroid)
 Klebsiella granulomatis ( granuloma inguinale)
 Chlamydia trachomatis ( LGV)
 Herpes Simplex ( genital herpes)

16. HISTORY
EXAMINATION
LABORATORY
INVESTIGATION
TREATMENT
SYNDROME
SPECIFIC FOR
GUIDELINES
PARTNER
MANAGEMENT
MANAGEMENT
OF PREGNANT
WOMEN
PATIENT

17. History
 Genital ulcer/ vesicles
 Burning sensation in the genital region
 Sexual exposure of either partner to high risk
practices including orogenital sex

18. Examination
 Presence of vesicles
 Presence of genital ulcers
 Single or multiple
 Associated inguinal lymph node swelling

19.  Ulcer characteristics
 Painful vesicles/ ulcers, single or multiple – herpes
simplex
 Painless ulcers with shotty lymph node – syphilis
 Painless ulcer with inguinal lymph node –
granuloma inguinale and LGV
 Painful ulcer usually single, sometimes –
chancroid associated with painful bubos

20. Laboratory Investigations
 RPR test for syphilis
 for further investigations refer for higher
centers

21. Treatment
 Vesicle or multiple painful ulcers present
 Treat for herpes :
 Tab Acyclovir 400 mg orally, 3 times a day for 7 days
 Only ulcers seen ( no vesicles)
 Treat for syphilis and chancroid
 Counsel on herpes genitalis

22.  To cover syphilis:
 Inj Benzathine penicillin 2.4 million IU IM after test
dose in two divided doses
[Allergic individual : Doxycycline 100 mg daily orally,
twice daily for 14 days]
 + Azithromycin 1g orally single dose OR
Tab. Ciprofloxacin 500mg orally, twice a day for 3 days
to cover chancroid
 Treatment should be continued beyond 7 days if
ulcers have not epitheliased

23.  Refer to higher centers
 Not responding to treatment
 Genital ulcers co-exist with HIV
 Recurrent lesion

24. Management of Pregnant Women
 Quinolones - contraindicated
 Women who test positive for RPR – considered
infected unless
 Adequate treatment is documented
 Sequential serologic antibody titres have declined
 Inj Benzathine penicillin 2.4 million IU IM after test
dose
 A second dose of benzathine penicillin should be
administered IM 1 week after initial dose for women
who have primary , secondary and early latent syphilis

25. • Allergic women- erythromycin
– Tab erythromycin 500 mg oraly QID for 15 days
– Erythromycin base or ethyl succinate should be used
(estolate- hepatotoxicity)
• Neonates should be treated for syphilis
• Should be asked for h/o of genital herpes and carefully
examined for herpetic lesions
• Asymptomatic women can deliver vaginally
• Women with genital herpes at onset of labor- CS
• Acyclovir can be administered orally – first episode or
recurrent genital herpes

26. Syndrome Specific Guidelines For Partner
Management
 Treat all partners who are in contact with patient in last 3
month
 Partners should be treated for syphilis and chancroid
 Advise sexual abstinence during the course of treatment
 Provide condoms, educate about correct and consistent use
 Refer for voluntary counseling and testing for HIV, syphilis
and hepatitis B
 Schedule return visit after 7 days.