Abnormal Vaginal Discharge may be due to Acute Pelvic Inflammatory Disease (PID)

Many ladies suffer from abnormal vaginal discharge, pain in lower abdomen with or without fever. It may be due to infection in tubes responsible for carrying the eggs from ovary to womb. Chronic infection may lead to tubal block and infertility, apart from the discomfort of suffering.

It may be due to what is termed as pelvic inflammatory disease (PID; not Prolapsed Inter-vertebral Disc).

Though the diseases cannot always be confirmed due to lack of diagnostic facilities available in the centres; but can come under most probable diagnosis clinically. Lack of definitive clinical diagnostic criteria and because of the potential consequences of not treating PID, an empirical treatment can be started.

Image via Wikipedia; Chlamydial Cervicitis

The clinical features suggestive of a diagnosis of PID are:

• Bilateral lower abdominal pain on pressure (tenderness); sometimes radiating to the thighs and back (Backache).
• Abnormal vaginal or cervical discharge of varying colour, thickness and quantity.
• Fever (greater than 38°C).
• Abnormal vaginal bleeding (inter-menstrual, post-coital or 'breakthrough').
• Deep pain during sexual act (dyspareunia). 
• Cervical motion tenderness on bi-manual vaginal examination by healthcare professional.
• Adnexal (tubes and ovaries) tenderness on bi-manual vaginal examination (with or without a palpable mass).
• Women with suspected PID should be tested for gonorrhoea and chlamydia.

1. Testing for gonorrhoea should be with an endocervical specimen and tested;

• Culture (direct inoculation on to a culture plate or transport of swab to laboratory within 24 hours).
• Using a nucleic acid amplification test (NAAT). If gonorrhoea is detected using a NAAT, an additional endocervical swab should be taken for gonococcal culture to allow the reporting of antibiotic sensitivities and revision of therapy.
• If women is at high risk of gonorrhoea should have an endocervical swab for gonococcal culture taken at their first examination; for example, where the woman's partner has gonorrhoea, clinically severe disease, sexual contact abroad.
• Additionally, sexual partner should be examined for sexually transmitted diseases.

2. Testing for chlamydia should also be from the endocervix, preferably using a NAAT (such as polymerase chain reaction, strand displacement amplification). Taking an additional sample from the urethra can increase the diagnostic yield for gonorrhoea and chlamydia; but may be performed, if the more sensitive NAAT is not available. A first catch urine or self-taken vulvovaginal swab sample provides an alternative sample for some NAATs.
Treatment:
Outpatient antibiotic treatment should be commenced as soon as the diagnosis is suspected:

1. Oral ofloxacin 400 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days.
2. Intramuscular ceftriaxone 250 mg/Cefoxitin single dose, followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days.
3. Broad-spectrum antibiotic therapy is generally required to cover Neisseria gonorrhoeae, Chlamydia trachomatis and anaerobic infection.
4. Ofloxacin should be avoided in women who are at high risk of gonococcal PID because of increasing quinolone resistance.

Those women at high risk of acquiring gonorrhoea include those whose partner has gonorrhoea, in clinically severe disease or if there is a history of sexual contact abroad.

Metronidazole may be discontinued in those women with mild or moderate PID who are unable to tolerate it.
Provisional diagnosis and early start of treatment may be helpful in many patients not having access to the centres having the facilities for tests, particularly in India.