SUEZ CANAL UNIVERSITY

FAMILY MEDICINE DEPARTMENT

PROGRAM OF MSC-FAMILY AND COMMUNITY HEALTH
COURSE TITLE: WOMEN HEALTH CARE
Course no. 112
Task no. 4
Problem (1)
A 21-year-old woman, married one month ago, presents to your clinic
complaining of lower abdominal pain for three days duration. It is associated
with foul-smelling vaginal discharge . Also she has nausea, vomiting and
dizziness. There are no urinary or bowel symptoms. Last menstrual period
was just before marriage. On examining the patient, the temperature is 37c,
Speculum examination: shows an erythematous cervix and mucopurulant
discharge comes from the cervical OS.
Q1. Discuss the possible differential diagnoses of this patient complaints
Q2. Describe the most probable diagnosis of the above mentioned patient
and rationalize your diagnosis.
Q3. Explain the further assessment needed for this patient
Q4.sDetermine the proper management plan of this patient according to the
recent evidence
Q5. Discuss the recent evidence regarding screening of this/ theses infections
Q6. Explain the possible complications if treatment is ignored.

Q1Approach to diagnosis of this patient needs differential diagnosis of:

1. Causes of lower abdominal pain in young female
2. Causes of vaginal discharge (mucopurulant discharge)
3. causes of sexually transmitted disease as patient is newly married and sexually
active.
 differential diagnosis of lower abdominal pain -1

:a-Gynecologic causes
 endometriosis
o The primary symptom of endometriosis is pelvic pain, often associated with
menstrual period.menstrual pain is worse than usual and increase over time.

 ovarian torsion
o Sudden onset of unilateral lower abdominal pain which is initially visceral in character
(vague and poorly localized) and may be accompanied by nausea and vomiting

 Ovarian cyst
o Most cysts don't cause any symptoms.

o A large ovarian cyst can cause abdominal discomfort.

o If a large cyst presses on the bladder, patient may feel the need to urinate more
frequently because bladder capacity is reduced.

 tubo-ovarian abscess
.b-Gastrointestinal causes
 Appendicitis
 bowel obstruction
 diverticulitis; gastritis
 inguinal hernia
 irritable bowel syndrome
 mesenteric venous thrombosis

.c-Urinary (excluded by urinary symptoms)

Cystitis; pyelonephritis; ureterolithiasis

:d-Obstetric causes (Pregnant women)

 ectopic pregnancy (Pregnancy test must be done to be excluded)
 endometritis (postpartum)
 ovarian torsion
  ovarian vein thrombosis (postpartum)
 placental abruption; uterine impaction

differential diagnosis of vaginal discharge -2

History Examination investigation

Bacterial vaginosis to 75% 50% discharge Amsel's criteria: at least 3

asymptomatic;fishy typically out of 4 of: thin,
odour especially after homogeneous, homogeneous discharge;
intercourse; off-white, thin, grayish- vaginal pH >4.5; a
thin, homogeneous white and odorous positive whiff test or
discharge; rarely dysuria release of amine odour
and dyspareunia; risk with the addition of base;
factors including new clue cells on microscopic
sexual partner or >3 in evaluation of saline wet
past year, douching, preparation
cigarette smoking
KOH test of vaginal
discharge: presence of
fishy odour when KOH is
added to vaginal discharge
More

wet mount microscopy of

vaginal discharge: clue
cells

trichomoniasis purulent, malodorous, typically, wet mount microscopy of

thin discharge; can also erythema of the vaginal discharge: positive
present with burning, vulva and vaginal for Trichomonas vaginalis
pruritus, dysuria, mucosa; vaginal
frequency, and discharge (green- culture from vaginal
dyspareunia; symptoms yellow, frothy) sample on Diamond
may be worse during and strawberry medium: positive
menstruation cervix are not rapid antigen and nucleic
reliable clinical acid amplification tests of
signs but may be vaginal sample: positive
present

Vulvovaginal vulvar pruritus, dysuria, erythema of the vaginal discharge pH: pH

candidiasis pain, burning, swelling, vulva, vaginal 4 to 4.5
redness, soreness, mucosa, and vulva
irritation, dyspareunia; oedema; with wet mount microscopy of
 usually little or no
discharge but if present,
appears white and
clumpy, curd-like; more
frequent in patients with
diabetes
Candida albicans vaginal discharge:
discharge usually budding yeast and hyphae
thick, adherent,
cottage cheese- vaginal discharge culture:
like, but may be Candida
thin and loose;
with Candida
glabrata usually
little discharge

Chlamydia often asymptomatic; or cervix friable, nucleic acid amplification

trachomatis infection purulent or erythematous and tests using cervical,
mucopurulent discharge oedematous, with vaginal, or urine sample:
from endocervix, purulent or positive
intermenstrual or mucopurulent
postcoital bleeding, discharge; Chlamydia trachomatis
dysuria, urinary possible cervical culture: positive
frequency, dyspareunia, motion Chlamydia trachomatis
vulvovaginal irritation; tenderness; with antigen detection: positive
pain and fever rare Chlamydia
trachomatis:
yellow opaque
endocervical
discharge, easily
induced cervical
bleeding

Neisseria gonorrhea asymptomatic; or cervix normal or culture cervical sample on

infection vaginal pruritus and/or a with friable modified Thayer-Martin
mucopurulent discharge; mucosa and medium: positive
abdominal pain or purulent discharge
dyspareunia suggests DNA cervical or urethral
extension to upper tract; probe: positive
may lead to PID, ectopic nucleic acid amplification
pregnancy, infertility if tests of endocervical
untreated swabs, liquid
Papanicolaou smear,
vaginal swabs, or urine:
positive

Irritant and allergic vaginal itching and vulvar erythema, none: diagnosis is clinical
vaginitis discharge in association non-specific
with use of topical vaginal discharge
medications, spermicidal
products, douching
 solutions, condoms, or
diaphragms; can be
reaction to sperm, latex,
dyes, soap, tampons,
pads

Non-specific irritation from bubble scant to copious none: diagnosis is clinical

vaginitis baths, perfumed soaps, foul-smelling
tight-fitting clothes, discharge
back-to-front wiping can
lead to non-specific
vaginitis; vulvar skin
easily traumatised

Differential diagnosis of sexually transmitted disease -3

DISEASE SYMPTOMS

Chlamydia Asymptomatic, or dysuria, discharge (penile or vaginal),

pain with sex, abdominal or testicular pain, breakthrough
bleeding

Gonorrhea Asymptomatic, or dysuria, discharge (penile or vaginal),

pain with sex, abdominal or testicular pain, breakthrough
bleeding

Trichomoniasis Asymptomatic, or vaginal discharge with odor or itching

Genital herpes simplex virus Asymptomatic, or recurrent, painful vesicular or

ulcerative lesions in the genital area

Syphilis Asymptomatic, or painless ulcer (chancre), systemic rash

including palms and soles, cardiovascular and neurologic
involvement

Lymphogranuloma venereum Inguinal adenopathy, self-limited papule or ulcer,

proctocolitis
 .Q2

From

:History
history of complaint:complaining of lower abdominal pain for three days duration associated with -1
.foul-smelling vaginal discharge with nausea, vomiting and dizziness

:ask her about-

 Dyspareunia
 Vaginal discharge
 Genital skin lesions
 Abnormal vaginal bleeding
 Dysuria
 Genital burning
 Genital itching
 Genital malodor
 Lower abdominal or pelvic pain
 Ask about increased vaginal discharge, dysuria, urinary frequency, and intermenstrual or -
, postcoitalbleeding

Cervicitis is often asymptomatic in gonorrhea, chlamydia, and T vaginalis infections. When present,
symptoms are often nonspecific and may include increased vaginal discharge, dysuria, urinary
frequency, and intermenstrual or postcoital bleeding.If the infection has been long-standing,
.symptoms can include low abdominal or low back pain

Most patients with herpes simplex virus (HSV) infection are asymptomatic. However, the first -
episode of genital herpes is frequently highly symptomatic and is marked by painful ulcerations
associated with fever, myalgia, headache, and general malaise. Dysuria, vaginal discharge, and
urethral discharge are also common symptoms. Recurrent outbreaks of HSV tend to be milder, but
most patients have prodromal symptoms of itching or tingling, followed by the appearance of
.vesicles

Because many causes of cervicitis are initially asymptomatic, ask all sexually active women for -2
.their complete gynecologic and sexual history at the initial evaluation and yearly thereafter

gynaecologic history:(age of menarche, date of last menstrual period, gravida, para, pregnancy or -3
.delivery complications, date of last Papanicolaou test [Pap smear])

.Our patient`s Last menstrual period was just before marriage-

:sexual history-4

Number of recent and current partners (in the last 3 mo) -

Condom use -

Non-barrier contraception use -

Exchanging of sex for money or drugs -

Previous diagnoses of sexually transmitted infections (STIs) -

.our patient is married one month ago -

Ask about symptoms related to other systems: in our patient there are no urinary or bowel -5
.symptoms

:Physical Examination
 The physical examination should include a general survey, an external inspection, and pelvic
speculum and bimanual examinations. In certain patients, a rectal examination should be
performed.
 On examining our patient, her temperature is 37c,
 The physical examination is crucial to the evaluation and diagnosis of cervicitis, but it should
not be limited to the pelvic region. An assessment for lymphadenopathy, skin lesions, oral
lesions, joint redness or swelling, abdominal pain, and costovertebral angle tenderness can
point to disseminated infection.
 The pelvic examination must be performed in a competent and sensitive manner. The
presence of a nursing assistant is advised to help with the examination and to act as a
chaperone. Always explain to the patient what is going to be done before proceeding. Begin
with a neutral touch on the patient's thigh and visually investigate the external genitalia in
good lighting. Note any skin lesions (eg, warts, ulcers, vesicles, excoriations, erythema),
inflammation of the Bartholin or Skene glands, or inguinal lymphadenopathy.
 Speculum examination
 Perform the speculum examination with water or gel lubrication (eg, Surgilube or K-Y jelly),
and include direct visualization of the vaginal walls and cervix. Remember that normal
vaginal secretions are nonadherent to the vaginal walls, clear to white in color, and
nonodorous. Normal vaginal secretions have an acidic pH of less than 4.5. Vaginitis is
present if the vaginal discharge is copious, colored, and malodorous, or if the pH is greater
than 4.5.
 Cervicitis is suspected if the cervix is erythematous, edematous, or easily friable. Classic
mucopurulent cervicitis is present if thick, yellow-green pus is visible in the endocervical
canal (the cervical os) or on an endocervical swab specimen. Laboratory specimens are
collected for study at this point. Note cervical warts or ulcerations.
 Our patient`s Speculum examination: shows an erythematous cervix and mucopurulant
discharge comes fromthe cervical os.
 Bimanual examination
 After the speculum is removed, a bimanual examination is performed to assess tenderness or
enlargement of the cervix, uterus, and adnexa. Cervicitis or pelvic inflammatory disease
(PID) is suspected if the patient has cervical motion tenderness (ie, if she experiences pain or
tenderness while the examiner gently moves the cervix from side to side).
 The following images depict a normal cervix, followed by images of cervicitis caused by
various organisms

So
From history and examination patient most probably has
.infectious cervicitis ,(Mostly chlamidiatrachomitas)
Second probably niesseria gonorrhea
Q3
Diagnosis
To make provisional diagnosis, we need =
Complete history(mentioned in answer of Q.2)
Physical examination(mentioned in answer of Q.2)
Investigation

:To confirm diagnosis, we need to =

:Identify the infectious Agents-1
Because the causes of vulvovaginitis and cervicitis overlap, the initial diagnostic approaches to the 2 -
.conditions are identical

:Assess the following-

,appearance of vaginal secretions -1

,measure the pH of the secretions -2

and perform microscopy with isotonic sodium chloride solution and 10% potassium -3
.hydroxide (KOH) along with a whiff test

:other Investigations -2
Pregnancy test to exclude pregnancy*
 The Centers for Disease Control and Prevention (CDC) recommends testing on self- or clinician- *
.collected endocervical and vaginal swab specimens, as well as on urine specimens

Gonococcal cervical infection can be diagnosed from the presence of gram-negative intracellular *
.diplococci (GNID) in endocervical fluid. However, only 50% of affected women have this finding

In cases of suspected or documented treatment failure, perform culture and antimicrobial *

.susceptibility testing

:culture of the vaginal discharge -3

 If cervicitis is suspected or mucopurulent cervicitis is observed, then cervical discharge is
collected for culture and, optionally, for Gram stain.
 The microscopic finding of gram-negative intracellular diplococci has a sensitivity of 60%
and a specificity of more than 90% for gonorrhea. The observation of more than 30
leukocytes per oil immersion field is highly suggestive of chlamydia and gonorrhea.
 Although culture is still regarded as the criterion standard, many alternative techniques for
the diagnosis of gonorrhea and chlamydia are available. They include enzyme immunoassay
(EIA), direct fluorescent antibody [DFA] staining, DNA probe, and PCR assay.

Nucleic acid amplification tests (NAATs) -4

are preferred over the other tests, because they are highly sensitive and specific for diagnosing
.gonococcal and chlamydial infections

NAATs can be performed on vaginal, cervical, and urine samples; the presence of 10 or more WBCs
in vaginal fluid in the absence of trichomoniasis suggests endocervical inflammation from gonococcal
.or chlamydial infection

 The advantages of alternative techniques over conventional cultures include reduced

turnaround time and lack of dependence on the complex and expensive systems needed to
culture chlamydia and gonorrhea.
 Alternative techniques also possess the ability to detect both C trachomatis and N
gonorrhoeae with the same sample.
Cervicitis may be a sign of upper genital tract infection; therefore, women who present with a new
episode of cervicitis should be assessed for signs of pelvic inflammatory disease and tested for
Chlamydia trachomatis and Neisseria gonorrhoeae infections using nucleic acid amplification
testing.(CDC 2015)
 :Diagnostic clues
:Two major diagnostic signs characterize cervicitis

a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an )1

endocervical swab specimen (commonly referred to as mucopurulent cervicitis)

sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the )2
.cervical os

Screening in high-risk populations

 Women at risk for sexually transmitted infections (eg, women with multiple partners, sexually
active women aged 25 years or younger [including adolescents], women with a history of
previous sexually transmitted infections [STIs], and pregnant women) should be annually
screened for gonorrhea and chlamydia. Such screening in this population has been proven to be
cost effective.

.Q4
Management plan
:For proper management, family physician should make the following

 Diagnosis (using history, examination, needed

investigation as mentioned in Q1 Q2)
 Differential diagnosis of the case to reach to the most
probable diagnosis as mentioned in Q1, Q2.
  Identification of risk factors
 Pharmacological treatment
 Treatment of male partner
 Health education
 Follow up

Goals of treatment(for non-pregnant)

.Treat patient -1

Prevent complication (sequelae of disease such as pelvic inflammatory disease (PID), tubo-ovarian -2
abscess, ectopic pregnancy, and infertility

.Prevent spread of infection -3

.During pregnancy, prevention of peripartum complications and neonatal infection -4

:PHARMACOLOGIC TREATMENT*
KEY RECOMMENDATIONS FOR PRACTICE

CLINICAL RECOMMENDATION EVIDENCE COMMENTS

RATING

Azithromycin (Zithromax) is recommended as a first- A Based on randomized

line treatment for Chlamydia trachomatis infection controlled trials
.during pregnancy

Quinolones should not be used in the treatment C Based on expert opinion

.of Neisseria gonorrhoeae infection

Provision of expedited partner treatment lessens the risk B Based on limited

of reinfection for patients treated for N. randomized controlled
 .gonorrhoeae or C. trachomatisinfection trial evidence

Antimicrobial Management ( medication)

Chlamydial cervicitis -1
: The CDC recommends the following regimens for presumptive treatment of chlamydial cervicitis

 Azithromycin 1 g oral (PO) in a single dose, OR

 Doxycycline 100 mg PO twice daily (bid) for 7 days
These patients should also be treated concurrently for gonococcal infection in areas with high
gonorrhea prevalence or if the individual’s personal risk is high. Effective alternative agents to
: azithromycin and doxycycline include erythromycin, levofloxacin, and ofloxacin, as follows

 Erythromycin base 500 mg PO four times daily (qid) for 7 days, OR

 Erythromycin ethylsuccinate 800 mg PO qid for 7 days, OR
 Levofloxacin 500 mg PO daily (qd) for 7 days, OR
 Ofloxacin 300 mg PO bid for 7 days

:Gonococcal cervicitis -2
For uncomplicated gonococcal infections of the cervix, the CDC updated their recommendations, as
: follows

 Ceftriaxone 250 mg administered intramuscularly (IM) in a single dose, PLUS

 Azithromycin 1 g PO in a single dose (preferred, owing to tetracycline resistance) or

doxycycline 100 mg PO bid for 7 days
: Alternatively, if ceftriaxone is not an option, the following regimens are recommended

 Single-dose injectable cephalosporin regimens, PLUS

 Azithromycin 1 g PO in a single dose (preferred) or doxycycline 100 mg PO bid for 7
days, PLUS

 Test-of-cure in 1 week (with culture, including phenotypic antimicrobial susceptibility; if culture

is unavailable, obtain NAAT)

 If the patient has a severe cephalosporin allergy, azithromycin 2 g PO in a single dose plus test-
of-cure in 1 week are recommended.
Prognosis

 Gonorrhea and chlamydia infections can be cured with antibiotic therapy.

 Complications from untreated infectious cervicitis depend on the pathogen. Untreated
gonorrhea and chlamydia infections can lead pelvic inflammatory disease(PID), which can
then result in infertility, chronic pelvic pain, and ectopic pregnancy. Other morbidity may
include spontaneous abortion, premature rupture of membranes, and preterm delivery if
infection is present during pregnancy.
 Patients who have persistent symptoms after treatment should be re-tested by culture,
and if these cultures are positive for gonococcus, isolates should be submitted for
resistance testing.
 Recurrent or resistant gonorrhoea infections should be treated with intramuscular
ceftriaxone plus high-dose azithromycin and infectious disease consultation. A test of
cure should be repeated 1 week after re-treatment.
 Treatment failures should be reported to the CDC through the local or state health
department within 24 hours of diagnosis

Partner Treatment*
It is standard practice to recommend that sex partners of patients diagnosed with an STD be treated *
to decrease the risk of reinfection and to decrease the incidence and prevalence of STDs among social
.networks

The primary goal is for the patient's sex partners to be seen by a physician for testing, treatment, and *
.education

For all patients with gonorrhea, every effort should be made to ensure that the patients' sex partners *
from the preceding 60 days are evaluated and treated for N gonorrhoeae with a recommended
.regimen

If a heterosexual partner of a patient cannot be linked to evaluation and treatment in a timely *

fashion, then expedited partner therapy should be considered, using oral combination antimicrobial
therapy for gonorrhoea, which can be delivered to the partner by the patient or a disease investigation
.specialist, or through a collaborating pharmacy
 :NON-PHARMACOLOGIC TREATMENT*
Reassurance
Reassure patient that Gonorrhea and chlamydia infections can be cured without complication if she
.follow treatment plan

Patient Education
 Patients must understand that cervicitis is a preventable, sexually transmitted infection (STI) and
that the most effective way to prevent the transmission of the infective agents that cause the
disease is to avoid sexual intercourse with infected partners.
 Ideally, both partners should be tested for common STIs, including human immunodeficiency
virus, before initiating a sexual relationship. If the risk of infection is unknown by testing, then a
condom should be used for all sexual acts. Condoms are available for men and women and have
been proven to decrease the transmission of many STIs, including HIV, when used appropriately
and consistently.
 To avoid reinfection following cure, infected women must ensure that all of their sexual partners
are treated for STIs.

Goals of treatment (for pregnant)

 avoiding maternal, postnatal, and neonatal infection and preventing peripartum
complications.
 Antibiotic recommendations are adjusted in favour of drugs with better safety profiles in
pregnancy.
 Sexual partners must be evaluated and treated, intercourse should be avoided for 7 days, and
a test of cure should be performed 1 week after treatment to document eradication of
infection.

:Chlamydial infection -1
 Several medications commonly used to treat Chlamydia are contraindicated in pregnancy
(such as doxycycline, ofloxacin, and levofloxacin).
 Azithromycin and amoxicillin are recommended first-line agents. [B Evidence]
 Erythromycin can be used as an alternative agent, but may be associated with decreased
compliance given the frequency of gastrointestinal adverse effects. [B Evidence]
 :Gonorrhea -2
 Ceftriaxone is the recommended first-line agent. [C Evidence]
 Alternative agents are cefixime, ceftizoxime, cefoxitin with probenecid, cefotaxime, and
cefuroxime
 Azithromycin should also be given orally to cover other co-pathogens and to provide another
antimicrobial with activity against N gonorrhoeae at a different molecular target.
 Pregnant women should be re-tested at 1 week for cure.

Approach Considerations
 Admit women to the hospital if pelvic inflammatory disease [PID] is suspected or pregnant.
 If the patient is unable to take oral medication because of intractable nausea, vomiting, or
abdominal pain, then hospitalization for intravenous medication is warranted.
In most cases, test-of-cure is not necessary, because of the high efficacy of the medications used. In
the case of persistent symptoms or pregnancy, follow-up testing is recommended

:Prevention*
 Have your partner always use condoms during sex.
 Limit the number of people you have sex with.
 Don't have sex with a partner who has genital sores or penile discharge.
 If you get treatment for a sexually transmitted disease, ask your doctor if your partner should
also be treated.
 Don't use feminine hygiene products. These may cause irritation of your vagina and cervix.
 If you have diabetes, try to maintain good control of your blood sugar.
 Avoid using tampons.
 Don't douche.
 Know the name of your partner, and the dates you had sexual relations.
  Make a list of all medications or supplements you're taking.
 Know your allergies.

Q5. Screening of sexually transmitted diseases

 Sexually transmitted disease are:

 Chlamydia

 genital herpes infections.

 Gonorrhea

 hepatitis B and C

 human immunodeficiency virus (HIV)

 human papillomavirus (HPV)

 syphilis.

Key Recommendations for Practice

Evidence
Clinical recommendations
rating

Screen sexually active, nonpregnant women at increased risk of

A
.chlamydia, gonorrhea, HIV, and syphilis infection

Screen all pregnant women for hepatitis B, HIV, and syphilis;

additionally, screen all pregnant women at increased risk of A
.chlamydia and gonorrhea infection
 Screen sexually active men at increased risk of HIV and syphilis
A
.infection

Do not routinely screen women and men who are not at increased risk
A
.of sexually transmitted infections

Comparison of STI Screening Recommendations for Sexually Active Nonpregnant Women

STI USPSTF CDC AAFP ACOG

Chlamydia Screen women Screen women 25 Screen women 25 Screen women 25

younger than 25 years and younger years and younger years and younger
years and others at and others at and others at and others at
increased risk increased risk increased risk increased risk

Gonorrhea Screen women Screen women at Screen women Screen adolescents

younger than 25 increased risk younger than 25 and others at
years and others at years and others at increased risk
increased risk increased risk

Syphilis Screen women at Screen women Screen women at Screen women at

increased risk exposed to increased risk increased risk
syphilis

HIV Screen women at Screen all Screen women at Screen women at

increased risk increased risk increased risk

Hepatitis Do not screen Provide Do not screen No specific

B general population prevaccination general population recommendation
screening for
women at
increased risk

Hepatitis Do not screen Screen women at Do not screen Screen women at

C general population; increased risk general population; increased risk
insufficient insufficient
evidence to evidence to
 recommend for or recommend for or
against screening against screening
women at increased women at increased
risk risk

HSV Do not screen Do not screen Do not screen Screen if sexual

general partner has HSV
population

HPV Insufficient Do not screen for Insufficient Testing with a Pap

evidence to use as subclinical evidence to use as smear is an option
primary screening infection primary screening for women older
test for cervical test for cervical than 30 years
cancer cancer

Comparison of STI Screening Recommendations for Pregnant Women

STI USPSTF CDC AAFP ACOG

Chlamydia Screen women Screen all Screen women 25 Screen women at

younger than 25 years and younger increased risk
years and others at and others at
increased risk increased risk

Gonorrhea Screen women Screen women at Screen women at Screen women at

younger than 25 increased risk increased risk increased risk
years and others at
increased risk

Syphilis Screen all Screen all Screen all Screen all

HIV Screen all Screen all Screen all Screen all

Hepatitis Screen all Screen all Screen all Screen all

B
Hepatitis No specific Screen women at No specific Screen women at
C recommendation increased risk recommendation increased risk

HSV Do not screen No specific Do not screen No specific

recommendation recommendation

Q6
:Complications
Genital complications of chlamydia-1
:Complications in women*
 pelvic inflammatory disease (PID)
o Can occur with untreated Neisseria gonorrhoeae or Chlamydia trachomatis infections
(40% risk).

 Tubo-ovarian abscess (TOA) : Can occur with untreated PID.

 ectopic pregnancy
o Ectopic pregnancies can occur with tubal damage following PID. Risk increases with
each subsequent infection.

 Infertility
 o Infertility can be caused by tubal obstruction or impaired motility following PID.

 chronic pelvic pain

o Whether it is due to chronic inflammation or adhesive processes, the risk increases
with each subsequent episode.

 chronic persistent cervicitis

- If left untreated, the infection may seriously affect the uterus and Fallopian tubes (pelvic
inflammatory disease (PID)).
- About 2-5 women in 100 with chlamydia develop PID.
- This may develop suddenly and cause a high temperature (fever) and pain.
- It can also develop slowly over months or years without causing symptoms (also known as
silent PID). However, over time, scarring or damage to the Fallopian tubes may occur and
can cause:

 Chronic (persistent) pelvic pain.

 Difficulty becoming pregnant (infertility).

- Inflammation of the cervix (cervicitis)

- Inflammation of the urethra (urethritis)
- Inflammation of the lining of the uterus (endometritis)
- Inflammation of fallopian tubes (salpingitis)
- Inflammation of Bartholin's glands (Bartholinitis).
- Pelvic infection (abscess)
-

:Complications in pregnant women*

 If patient become pregnant, an increased risk of ectopic pregnancy. In this condition, the
pregnancy develops in a Fallopian tube and can cause serious life-threatening problems.
 Miscarriage
 Preterm labor and stillbirth
 Premature rupture of the membranes (PROM)
 Chronic pelvic pain due to scarring of the pelvic organs

:Complications in male partner*

 Urethritis
 Inflammation of the tubes that hold sperm (epididymitis)
 Inflammation of the prostate, the gland that makes most of the fluid in semen (prostatitis)
 Infertility

Extragenital complications of chlamydia-2

:complications in women or men*
 Conjunctivitis, spread by touching the infected area and then touching the hand to the eye
 Inflammation of the mucous membrane of the rectum (proctitis), if the chlamydia is from anal
sex
 Reiter's syndrome is a rare complication which can occur in both men and women. This causes
arthritis and eye inflammation. It may be due to the immune system 'over-reacting' to
chlamydial infection in some cases.
 Reactive arthritis
 Lymphogranuloma venereum, or LGV. This is caused by a type of chlamydia that is usually
rare in the United States, but it is becoming more common in men who have sex with men. It
causes open sores in the genital area, headache, fever, fatigue, and swelling of the lymph
nodes in the groin. It also causes proctitis in people who get chlamydia through anal sex

:Complications in newborns*
 Premature delivery. A premature infant has an increased risk of health problems.
 Inflammation of the surface of the eyes and the lining of the eyelids (conjunctivitis). About
one-half of newborns who have chlamydia get conjunctivitis.
 Infection of the nose and throat, Ear infection (otitis media)
 Lung infections, such as pneumonia
 Urethritis, though this is very rare in infants
Problem (2)
A 35 – years – old obese female presents to your primary care clinic
complaining that her menses become longer than usual and she has heavy
,irregular menses over the past five months .she described an increased lower
abdominal cramps over 8 days of her last menstrual period . This was unlike
her usual menses that was regular with average amount . she has two
children and she is divorced. On examination , she had some palmer and
mucosal membrane pallor ,BP 110/70mmhg .bimanual examination was
normal .
Q1 : Discuss the further assessment you need for this patient
Q2: explain the suggested causes of her conditions.
Q3 : mention the most possible diagnosis that explain the patient condition
and give your rational
Q4 : in the light of the shared management concept , demonstrate the
different lines of managements with discussion of proper management plan
of this patient using the recent evidence .