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.