Complex pelvic infection with equivocal ultrasound
Suspected fistula or deep pelvic inflammatory process
Contraindications and limitations
Non MRI compatible implants
Limited availability in time sensitive deterioration
Interpretation pearls
Abscess characterization
Alternative diagnoses identification
CT
CT abdomen pelvis
Indications
Suspected complicated pelvic inflammatory disease
Concern for alternate intra abdominal pathology
Contrast considerations
Renal dysfunction risk
Prior anaphylactoid contrast reaction
Limitations
Limited sensitivity for early pelvic inflammatory disease
Radiation exposure consideration in pregnancy
Ultrasound
Pelvic ultrasound
Indications
Positive pregnancy test with pain or bleeding
Suspected tubo ovarian abscess
Technique
Transvaginal ultrasound preferred when feasible
Transabdominal ultrasound adjunct
Key findings
Adnexal mass with complex fluid
Free fluid in pelvis
Limitations and pitfalls
Early ectopic may be indeterminate
Normal ultrasound does not exclude early pelvic inflammatory disease
Special Tests
Vaginal testing and microscopy details
Vaginal testing
Whiff test
Fishy odor after KOH supports bacterial vaginosis
Negative does not exclude bacterial vaginosis
Saline wet mount
Clue cells
Motile trichomonads
KOH microscopy
Hyphae
Budding yeast
Gram stain
Nugent scoring where available
Useful in recurrent or unclear cases
Pelvic exam based bedside tests
Pelvic exam maneuvers
Cervical motion tenderness
Supports pelvic inflammatory disease in appropriate context
Not specific for pelvic inflammatory disease
Adnexal tenderness
Supports pelvic inflammatory disease or adnexal pathology
Consider ultrasound if significant tenderness
Uterine tenderness
Supports pelvic inflammatory disease
Consider endometritis postpartum
Specimen collection considerations
Specimen collection
Self collected vaginal swabs
Acceptable for NAAT in many settings
Useful when pelvic exam declined
Cervical swabs
Consider with cervicitis concern
Consider with pelvic inflammatory disease concern
Extragenital testing
Rectal if receptive anal intercourse
Pharyngeal if receptive oral sex
ECG
When ECG is relevant
ECG indications in this presentation
Syncope or presyncope
Concern for hemorrhage in pregnancy related emergency
Evaluate alternate causes of syncope
Severe sepsis physiology
Evaluate ischemia from demand
Baseline rhythm assessment
Medication related electrical risk
QT prolongation considerations
Azole antifungals
Fluconazole associated QT risk
Higher risk with other QT prolonging drugs
Antiemetics
Ondansetron
Droperidol
High risk patterns
QTc prolongation
Ventricular ectopy
Assessment
Syndromic classification
Syndrome framing
Vaginitis pattern
Predominant vulvovaginal irritation
Discharge predominant without cervicitis signs
Cervicitis pattern
Mucopurulent endocervical discharge
Cervical friability
Pelvic inflammatory disease pattern
Pelvic pain with cervical motion tenderness
Uterine or adnexal tenderness
Risk stratification
Severity and risk stratification
Pregnancy status
Positive pregnancy test escalates ectopic evaluation
Negative pregnancy test supports outpatient pathways when stable
Systemic illness
Fever with tachycardia increases invasive infection concern
Normal vitals supports uncomplicated vaginitis
Follow up reliability
Reliable follow up supports delayed treatment for pending tests
Unreliable follow up favors empiric therapy when risk high
Working diagnoses and uncertainty
Working diagnosis and uncertainty
Likely bacterial vaginosis
Elevated pH pattern
Clue cells or positive criteria
Likely vulvovaginal candidiasis
Pruritus predominant
Yeast on microscopy or classic exam
Likely trichomoniasis
High risk exposure
Positive NAAT or wet mount
Cannot exclude pelvic inflammatory disease
Pelvic pain with tenderness
Low threshold for treatment
Plan
Approach to the critical patient
First 5 minutes
Monitoring and access
Cardiac monitor for instability
Two large bore IV lines for shock physiology
Immediate tests
Urine pregnancy test
Point of care glucose in altered mental status
Resuscitation
IV crystalloid bolus for hypotension
Early broad spectrum antibiotics for sepsis physiology
Time critical imaging triggers
Immediate pelvic ultrasound for positive pregnancy test with pain
Immediate surgical consultation for peritonitis
Diagnostic sequencing
Diagnostic plan
Pregnancy assessment first
Urine pregnancy test
Serum beta hCG if high suspicion with negative urine test
Pelvic evaluation
Speculum exam when feasible
Bimanual exam for tenderness and masses
Vaginitis testing
pH testing
Wet mount and KOH microscopy
STI testing
Gonorrhea NAAT
Chlamydia NAAT
Therapeutics
Empiric and directed therapy
Bacterial vaginosis treatment options
Metronidazole 500 mg PO twice daily for 7 days
Metronidazole gel 0.75 percent intravaginal once daily for 5 days
Clindamycin cream 2 percent intravaginal at bedtime for 7 days
Vulvovaginal candidiasis treatment options
Fluconazole 150 mg PO once
Fluconazole 150 mg PO once with repeat dose in 72 hours for severe symptoms
Topical azole intravaginal for 7 days
Trichomoniasis treatment
Metronidazole 500 mg PO twice daily for 7 days
Tinidazole 2 g PO once as alternative when appropriate
Partner treatment required to prevent reinfection
Uncomplicated gonorrhea treatment
Ceftriaxone 500 mg IM once if under 150 kg
Ceftriaxone 1 g IM once if 150 kg or higher
Doxycycline 100 mg PO twice daily for 7 days if chlamydia not excluded
Chlamydia treatment when gonorrhea excluded
Doxycycline 100 mg PO twice daily for 7 days
Azithromycin 1 g PO once in pregnancy
Pelvic inflammatory disease outpatient regimen
Ceftriaxone 500 mg IM once
Doxycycline 100 mg PO twice daily for 14 days
Metronidazole 500 mg PO twice daily for 14 days
Pregnancy considerations
Prefer topical azole therapy for candidiasis in pregnancy
Avoid delaying ectopic evaluation when pregnancy test positive
Reassessment loop
Reassessment
Clinical response checkpoints
Vital signs reassessment within 60 minutes if initially abnormal
Pain reassessment after analgesia
Result driven adjustments
Modify antibiotics based on NAAT results
Escalate to pelvic ultrasound if tenderness worsens
Safety net triggers
New fever after discharge
Increasing pelvic pain
Disposition
Admission and higher level care
Inpatient admission criteria
Tubo ovarian abscess concern
Adnexal mass on exam or imaging
Systemic toxicity
Sepsis physiology
Hypotension after fluids
Lactate elevation with clinical deterioration
Pregnancy related emergency concern
Positive pregnancy test with pain
Peritoneal signs
Unable to tolerate oral therapy
Persistent vomiting
Intractable pain
Observation pathway
Observation criteria
Indeterminate pelvic ultrasound in pregnancy
Repeat beta hCG trend
Repeat ultrasound timing per protocol dependent
Moderate pelvic inflammatory disease without sepsis
IV antibiotics initiation
Symptom trajectory monitoring
Discharge criteria and follow up
Safe discharge criteria
Stability
Afebrile or improving
Hemodynamically stable
Low risk abdominal exam
No peritoneal signs
Pain controlled with oral medications
Plan reliability
Able to fill medications
Reliable follow up arranged
Follow up timing
48 to 72 hours for pelvic inflammatory disease reassessment
1 to 2 weeks for persistent symptoms or recurrent discharge
Discharge Instructions
Copy discharge instructions
Copy discharge instructions
Summary
You were seen for vaginal discharge
Common causes include bacterial vaginosis, yeast infection, and sexually transmitted infections
Medications
Take your medications exactly as prescribed until finished
Do not share antibiotics or antifungals with others
Sexual activity and partners
Avoid sex until treatment is completed and symptoms are improving
Partners may need testing and treatment if an STI is suspected or confirmed
Testing results
Some test results may return after you leave
Follow the plan given for how you will receive results and any changes to treatment
Return to the emergency department now for
Fever or shaking chills
New or worsening pelvic or abdominal pain
Fainting or severe dizziness
Heavy vaginal bleeding
Vomiting that prevents taking medications
Follow up
Arrange follow up with primary care or a sexual health clinic within the recommended time window
Return sooner if symptoms do not improve within 48 to 72 hours
References
Guidelines and key sources
Key references
US Centers for Disease Control and Prevention STI Treatment Guidelines 2021
Trichomoniasis section updated online
Gonorrhea and pelvic inflammatory disease regimens
American College of Obstetricians and Gynecologists Practice Bulletin 215 Vaginitis in Nonpregnant Patients 2019
Amsel criteria and Nugent scoring
Diagnostic and treatment overview
Public Health Agency of Canada Canadian Guidelines on Sexually Transmitted Infections Vaginitis syndromic guidance 2023
Pregnancy considerations
Canadian context regimens
American Academy of Family Physicians Vaginitis diagnosis and treatment review 2018
Comparative testing performance discussion
Primary care and ED applicable algorithms
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.