Management of lower abdominal
pain / pelvic inflammatory disease
Woman complains of lower abdominal pain
Education and counselling
Promote / provide condoms
Arrange full check-up and
treatment for gonorrhoea,
chlamydia and trichomonas
for sex partner/s
If no VE and no history of discharge,
consider treatment if age < 35 and
other risk indicators present : deep
dyspareunia, intermenstrual
bleeding, STI or PID in past
12 months
Take history, examine patient
Take 2 endocervical swabs: MC&S, NAAT Gono/Chlamydia/Trichomonas
Take 1 high vaginal swab: MC&S
Take blood for HIV, syphilis serology, +/-Hep B (if not immune and can do follow up see p 14)
If dysuria or urinary frequency present take a mid-stream urine for MC&S
YES
YES
NO
NO
Manage for other conditions
Are any of the following present?
Missed, overdue or delayed period
Recent delivery, miscarriage or abortion
Abdominal guarding, rigidity or rebound tenderness
Abdominal mass or swelling
Active vaginal bleeding
Patient is pregnant
Patient is very unwell or Temp >38°C
Day 1: ceftriaxone 250mg IV/IM and azithromycin 1g oral
Day 2: start doxycycline 100mg bd and metronidazole 400mg bd for 14 days
(daily roxithromycin 300mg if breastfeeding instead of doxycycline; see p 27 re doxycycline)
Immediate transfer to hospital
Review on day 3: if no improvement, send to hospital
Review on day 8: if no improvement send to hospital
Repeat azithromycin 1g
Continue medications to day 14
Review on day 14 with full examination. Consult
local SHU or gynaecologist if not fully improved
*
*
30
Management of male urethral discharge or
dysuria
Causes
Usually caused by gonorrhoea or chlamydia but is sometimes caused by trichomonas or
other organisms.
It is not possible to tell by clinical examination which organism is the cause
.
History, examination and tests
•
sore throat, see p 5).
Ask the man about other possible STI symptoms (eg. sores, warts or lumps, rash,
•
outside the Top End or Central Australia (see p 14).
Ask about his sexual partners in the past 3 months and whether any of them are from
Examination
(see Male examination, p10)
Investigations
(see Investigations-males, p 15)
Do a full STI check
If discharge is present
Take 2 swabs (no need to swab inside the penis):
•
swab in transport media);
First swab for MC&S for gonorrhoea (roll onto glass slide and let dry in air and put
•
pathology company instructions (dry tube for PCR, transport media tube for TMA, see
p 13);
Second swab for NAAT for gonorrhoea, chlamydia and trichomonas according to
•
for gonorrhoea, chlamydia and trichomonas.
If discharge is not present, send a first void urine for gonorrhoea culture and NAAT
If history of receptive oral or anal sex
Take 2 swabs of throat or anus:
•
First swab for MC&S for gonorrhoea,
•
Second swab for NAAT for chlamydia.
For men over 40 years of age who have dysuria and no discharge
•
Collect midstream urine MC&S to check for a urine infection (UTI);
•
Blood test for syphilis serology, HIV +/- hepatitis B (HBsAg, HBsAb, and HbcAb)
See hepatitis B, p 14.
SHBBVU Guidelines May 2008
31
Treatment
Treat immediately for gonorrhoea and chlamydia even if no discharge is present.
•
Give oral amoxycillin 3g and probenecid 1g and azithromycin 1g once only.
•
If allergic to penicillin contact the local Sexual Health Unit.
•
Australia (see p 14) - then give
instead.
If he has had a recent sexual partner who is from outside the Top End or Centralceftriaxone 250mg IMI and azithromycin 1g orally
•
given the same treatment.
Make sure that sexual partner/s from the last 3 months are checked for STIs and
•
Explain that all partner/s need to be treated as well so he doesn’t get re-infected.
•
treatment.
Advise him not to have sex until 1 week after both his treatment and his partner/s
•
Discuss safe sex and condom use.
Follow up
•
test results for other infections and discuss safe sex and condom use again.
If resources permit, ask him to come back in 1 week to be sure he is better, check the
•
If no improvement, discuss with the local SHU.
If he has symptoms 1 week after treatment
It may be re-infection, resistant infection, trichomonas or another organism.
•
- if trichomonas is present then treat him and his partner/s with 1 dose of
Check the results of the tests taken initially:
metronidazole 2g
- if culture for gonorrhoea was positive, check the antibiotic sensitivity.
or tinidazole 2g orally (don’t give tinidazole to pregnant women),
•
back or never got better in the first place.
If he did not have trichomonas, ask whether his symptoms got better and then came
•
Check the original treatment was taken properly. Repeat if it was not.
•
Make sure all sexual partners were tested and treated.
•
If re-infection is likely, repeat the STI check-up and treatment.
•
(see p 14).
Ask if he had sex with someone from outside the Top End or Central Australia
•
necessary to do an intra-urethral swab to confirm a diagnosis of urethritis and
maximise the chance of culturing gonorrhoea (see technique below).
Talk with the local SHU about what further tests or treatment are needed. It may be
Doing a urethral swab (ie. from inside the penis)
If an antibiotic resistant gonorrhoea is suspected then another specimen for MC&S is
needed.
•
If discharge is present take a swab of it for MC&S for gonorrhoea.
•
- moisten the tip of a thin urethral swab with sterile saline (ie. the wire stem swab not
the wooden stem swab);
- gently insert the tip of the swab 1-2cm into the urethra, leave it in place for a few
seconds and then withdraw it.
If there is no discharge then:
•
Gently roll the swab on a glass slide and let dry in the air.
•
Put the swab in transport medium (charcoal is best but Stuarts medium can be used).
•
Keep the swab at room temperature: do not refrigerate or let it get too hot.
•
Write ‘MC&S for gonorrhoea’ on the form and get it to the lab as soon as possible.
32
Take blood for HIV, syphilis serology, +/-Hep B
(if not immune and can do follow up see p 14)
Take 2 swabs of discharge for:
MC&S, NAAT Gono/Chlamydia/Trichomonas
Take first void urine for:
MC&S, NAAT Gono/Chlamydia/Trichomonas
Management of male urethral discharge
Patient complains of urethral discharge or dysuria
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