A 32-year-old Chinese presents with foul-smelling vaginal discharge and severe lower abdominal pain. Discuss how you would manage this patient.

The patient’s presenting symptoms are suggestive of an infective cause, e.g. pelvic inflammatory disease. However, it may also be due to an acute abdomen causing the pain, e.g. appendicitis and it is important to exclude these possible causes in the history and physical examination as they are life-threatening conditions. As in all cases of females presenting with a severe lower abdominal pain, ectopic pregnancy should be a diagnosis at the back of the mind till proven otherwise. Therefore I would admit the patient and keep monitor her condition. 

History

1.	Pain:
-	Site: gives an idea of the organ giving rise to the pain – whether the pathology lies in the ovaries, uterus or elsewhere.
-	Duration of pain and past history of similar pains: to determine whether it is an acute or chronic problem.
-	Nature of pain: sharp stabbing pain or dull crampy-like aches; constant or intermittent pain.
-	Dyspareunia, dysmenorrhoea. 
-	Any aggravating or relieving factors.

2.	Discharge:
-	Color: causative organism. 
-	Nature: curdy or thin.
-	Any bleeding or clots. 
-	Any associated vulval itchiness or soreness.

3.	Fever, chills or rigors,

4.	Sexual history:
-	When sexual intercourse last takes place.
-	Number of partners.
-	Type of contraception used, e.g. IUCD increases the risk of pelvic inflammatory disease. 

5.	Menstrual and obstetric history:
-	Intermenstrual or post-coital bleeding.
-	Irregular bleedings, menorrhagia.
-	Subfertility and ectopic pregnancies.
-	Last menstrual period and duration of amenorrhoea.

6.	Urinary symptoms like dysuria, frequency, nocturia to exclude a urinary tract infection.

7.	Abdominal symptoms like nausea and vomiting, diarrhoea, constipation, recent change of bowel habits, tenesmus. 

Physical examination

1.	General: fever, tachycardia.

2.	Abdomen:
-	Distension.
-	Palpable mass.
-	Signs of peritonism: guarding, rigidity and rebound tenderness.

3.	Pelvic examination:
-	Cervical excitation.
-	Adnexal mass and tenderness.
-	Mobility of uterus will indicate presence of adhesions.

Investigations

1.	FBC:
-	Hb: anaemia.
-	WBC: leucocytosis.

2.	Urine pregnancy test: to exclude ectopic pregnancy.

3.	High vaginal swab for bacterial vaginosis, candidiasis, trichomonas vaginalis and escherichia coli.

4.	Endocervical swab for neisseria gonorrhoea and chlamydia trachomatis.

5.	Rectal and urethral swab.

6.	Urine FEME and culture to exclude urinary tract infection.

7.	Blood cultures.

8.	CRP and ESR to monitor effectiveness of treatment. 

Management

After safely excluding potential life-threatening conditions such as acute appendicitis and ectopic pregnancies, the patient can be started on empirical antibiotic treatment consisting of doxycycline, ceftriazone and metronidazole become the culture results return. 

The patient’s vital signs and parameters such as temperature, pulse rate, blood pressure and respiratory rate should be monitored constantly. She should be given adequate analgesia for her abdominal pain and hydration. 

If the patient remains afebrile for 2 days, she can be given oral antibiotic therapy consisting of a quinolone and metronidazole and discharge. She should be reviewed in two weeks’ time and swabs are repeated to ensure infection is fully treated. Contact tracing should also be done to detect possible similar infections in her sexual partners and to screen patients for other STDs such as herpes and syphilis. 

Counseling should be given for:

1.	Appropriate sexual behavior and use of contraception to reduce risk of future infections.
2.	Increased risk of ectopic pregnancy in the future. 

If the patient does not respond to empirical antibiotic treatment within 48 hours, a laparoscopy should be done. It is both diagnostic and therapeutic:

1.	Diagnostic:
-	Better visualization of any abscesses, adhesions, fibrosis.
-	Culture fluid from fallopian tube and pouch of Douglas.

2.	Therapeutic:
-	Drainage.
-	Adhesiolysis.
-	Abscess rupture and removal.

If the PID is of an acute nature, it is unlikely the patient has much adhesions or abscess formation and laparoscopy should be able to clear her of any remaining infection. However, if she suffers from chronic PID, laparoscopy alone may not be able to remove all the adhesions and abscesses completely and she may consequently continue to have chronic pelvic pain in the future. The patient should be follow-up regularly half-yearly and assess the severity of her condition. In protracted cases where the pain has become unbearable, a total hysterectomy is the only definitive form of treatment. The patient can be offered this option if she no longer wants to have any more children.