What is the appropriate evaluation and treatment for a patient with pelvic pain during intercourse and exercise, cervical motion tenderness, left lower quadrant pain, and rectal pain?

Pelvic Inflammatory Disease (PID): Evaluation and Treatment

This patient meets minimum diagnostic criteria for PID and requires immediate empiric antibiotic therapy without waiting for test results. The presence of cervical motion tenderness alone is sufficient to initiate treatment in a sexually active woman when no other cause is identified 1.

Diagnostic Approach

Maintain a low threshold for PID diagnosis because delayed treatment can cause permanent reproductive damage including tubal infertility, chronic pelvic pain, and ectopic pregnancy, even with mild or atypical presentations 1, 2.

Minimum Criteria (Treatment Required if Present)

• Cervical motion tenderness (present in this patient) 1
• OR uterine/adnexal tenderness 1

The patient's left-sided pain with cervical motion tenderness satisfies these minimum criteria 1.

Additional Supportive Criteria to Obtain

• Wet mount microscopy: Look for white blood cells on saline preparation of vaginal secretions 1
• Cervical discharge assessment: Check for mucopurulent discharge 1
• Temperature: Fever >101°F (>38.3°C) increases diagnostic specificity 1
• Laboratory tests: Elevated ESR or C-reactive protein 1
• STI testing: NAAT for N. gonorrhoeae and C. trachomatis on cervical or urine specimens 2, 3

Critical diagnostic pearl: If cervical discharge appears normal AND no white blood cells are found on wet prep, PID is unlikely and alternative diagnoses should be investigated 1.

Immediate Treatment Protocol

Begin empiric broad-spectrum antibiotics immediately—do not delay for culture results 2, 4.

Outpatient Regimen (Appropriate for This Patient)

• Ceftriaxone 500 mg IM single dose (or 1g if weight >150 kg) 2, 4
• PLUS Doxycycline 100 mg orally twice daily for 14 days 2, 4
• PLUS Metronidazole 500 mg orally twice daily for 14 days (given rectal pain suggesting possible anaerobic involvement) 2, 4

Required Antimicrobial Coverage

Treatment must cover N. gonorrhoeae, C. trachomatis, anaerobes, gram-negative facultative bacteria, and streptococci 1, 2.

Follow-Up and Monitoring

Reassess within 48-72 hours 2, 4:

• If no clinical improvement, consider hospitalization for parenteral antibiotics 2, 4
• Consider alternative diagnoses if symptoms worsen 2

Indications for Hospitalization

• Pregnancy 2, 4
• Clinically severe illness 2, 4
• Tubo-ovarian abscess 2, 4
• No response to oral therapy 2, 4
• HIV infection 2, 4
• Inability to tolerate oral medications 4

Partner Management

Treat sexual partner(s) empirically with regimens effective against C. trachomatis and N. gonorrhoeae 2, 3:

• Azithromycin 1g orally single dose OR Doxycycline 100mg orally twice daily for 7 days 3
• Patient must avoid sexual intercourse until both partners complete treatment 2, 3

Alternative Diagnoses to Consider

Given the rectal pain and left-sided location, also evaluate for:

Appendicitis

• Although typically right-sided, can present atypically 1
• CT abdomen/pelvis with IV contrast has 95% sensitivity if PID treatment fails 1

Ovarian Pathology

• Transvaginal ultrasound is the initial imaging of choice if diagnosis remains uncertain after 48-72 hours 1, 5
• Can identify tubo-ovarian abscess, ovarian torsion, or hemorrhagic cysts 1, 5

Ectopic Pregnancy

• Must be excluded with serum β-hCG in all reproductive-age women before finalizing PID diagnosis 1, 5

Critical Pitfalls to Avoid

• Do not delay treatment waiting for culture results—untreated PID causes irreversible reproductive damage 1, 2
• Do not require multiple criteria before treating—this reduces sensitivity and misses cases 1
• Do not forget partner treatment—reinfection is common without concurrent partner therapy 2, 3
• Do not miss ectopic pregnancy—always obtain pregnancy test first 1, 5
• Do not stop antibiotics early—complete the full 14-day course even if symptoms improve 2, 4