What is the evaluation protocol for testing and treating Sexually Transmitted Diseases (STD) and Pelvic Inflammatory Disease (PID)?

Evaluation Protocol for STDs and PID

The evaluation protocol for STDs and PID requires a low threshold for diagnosis, with testing for N. gonorrhoeae and C. trachomatis in all suspected cases, followed by empiric treatment based on minimum clinical criteria to prevent long-term reproductive complications. 1

Diagnostic Criteria for PID

Minimum Clinical Criteria (Sufficient to Initiate Treatment)

• Lower abdominal tenderness 1
• Bilateral adnexal tenderness 1
• Cervical motion tenderness 1

Additional Criteria to Increase Diagnostic Specificity

• Oral temperature >38.3°C (>101°F) 1
• Abnormal cervical or vaginal discharge 1
• Elevated erythrocyte sedimentation rate and/or C-reactive protein 1
• Laboratory evidence of cervical infection with N. gonorrhoeae or C. trachomatis 1

Definitive Diagnostic Criteria (For Selected Cases)

• Histopathologic evidence of endometritis on endometrial biopsy 1
• Transvaginal sonography showing thickened fluid-filled tubes or tubo-ovarian complex 1
• Laparoscopic abnormalities consistent with PID 1

Required Laboratory Testing

For All Suspected PID Cases

• Cervical cultures for N. gonorrhoeae 1
• Cervical culture or non-culture test for C. trachomatis 1

For Suspected Vaginal Infections

• Vaginal pH testing (BV and trichomoniasis: pH >4.5; candidiasis: pH ≤4.5) 2
• Wet mount microscopy with saline and 10% KOH to identify trichomonads, yeast, or pseudohyphae 2

For Suspected Epididymitis

• Gram-stained smear of urethral exudate for diagnosis of urethritis 1
• Culture or nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1
• Examination of first-void urine for leukocytes 1
• Syphilis serology and HIV counseling/testing 1

Treatment Approach

Hospitalization Criteria for PID

• Uncertain diagnosis 1
• Surgical emergencies cannot be excluded 1
• Pelvic abscess is suspected 1
• Pregnancy 1
• Adolescent patient (compliance concerns) 1
• Severe illness precludes outpatient management 1
• Patient unable to tolerate outpatient regimen 1
• Failed outpatient therapy 1
• Clinical follow-up within 72 hours cannot be arranged 1

Follow-Up Requirements

• Patients should demonstrate substantial clinical improvement within 3 days after initiating therapy 1
• If no improvement occurs within 48-72 hours, reconsider alternative diagnoses or treatment 1
• Some experts recommend rescreening for C. trachomatis and N. gonorrhoeae 4-6 weeks after therapy 1

Management of Sex Partners

• Treatment of sex partners is imperative for patients with PID or STDs 1
• Sex partners should be examined and treated if they had sexual contact with the patient during the 60 days preceding symptom onset 1
• Empiric treatment for both C. trachomatis and N. gonorrhoeae is recommended for partners, regardless of PID etiology 1
• Special arrangements should be made to provide care for male partners in settings where only women are treated 1

Patient Education

• Explain the nature of the disease and encourage compliance with therapy 1
• Emphasize the need to take all medication regardless of symptom resolution 1
• Review contraindications and potential side effects 1
• Identify and address potential compliance problems 1
• Explain the purpose of follow-up evaluation 1
• Emphasize the need to avoid sex until treatment is completed 1
• Stress the importance of partner evaluation and treatment 1

Special Considerations

Pregnancy

• Pregnant women with suspected PID should be hospitalized and treated with parenteral antibiotics due to high risk for maternal morbidity, fetal wastage, and preterm delivery 1

HIV Infection

• Immunosuppressed HIV-infected women with PID should be managed aggressively using parenteral antimicrobial regimens 1

Common Pitfalls to Avoid

• Failure to recognize mild or atypical presentations of PID, leading to delayed treatment and increased risk of complications 1, 3
• Inadequate adherence to CDC treatment recommendations in clinical practice 4
• Treating empirically without proper diagnosis for vaginal infections 2
• Failing to treat sexual partners, particularly in cases of trichomoniasis 2
• Not maintaining a low threshold for diagnosis, as PID can cause significant reproductive damage even with mild symptoms 1
• Neglecting to screen asymptomatic patients for STIs according to guidelines, which may increase risk of both acute and subclinical PID 3