Lower abdominal pain

All sexually active women presenting with lower abdominal pain should be carefully evaluated for the presence of salpingitis and/or endometritis-pelvic inflammatory disease (PID). In addition, routine bimanual and abdominal examinations should be carried out on all women with a presumptive STI, since some women with PID or endometritis will not complain of lower abdominal pain. Women with endometritis may present with complaints of vaginal discharge and/or bleeding and/or uterine tenderness on pelvic examination. Symptoms suggestive of PID include abdominal pain, dyspareunia, vaginal discharge, menometrorrhagia, dysuria, pain associated with menses, fever, and sometimes nausea and vomiting.

PID is generally caused by N. gonorrhoeae, C. trachomatis and anaerobic bacteria (Bacteroides spp. and Gram-positive cocci). It is difficult to diagnose because clinical manifestations are varied. PID becomes highly probable when one or more of the above symptoms are seen in a woman with adnexal tenderness, evidence of lower genital tract infection and cervical motion tenderness. Enlargement or induration of one or both fallopian tubes, tender pelvic mass, and direct or rebound tenderness may also be present. The patient's temperature may be elevated but is normal in many cases. In general, clinicians should err on the side of over-diagnosing and treating milder cases. Patients with acute PID should be admitted to hospital if:

• the diagnosis is uncertain,

• surgical emergencies such as appendicitis and ectopic pregnancy need to be excluded,

• a pelvic abscess is suspected,

• severe illness precludes management on an outpatient basis,

• the patient is pregnant,

• the patient is unable to follow or tolerate an outpatient regimen,

• the patient has failed to respond to outpatient therapy,

• clinical follow-up 72 hours after the start of antimicrobial treatment cannot be guaranteed.

See recommended regimens for lower abdominal pain related to sexually transmitted diseases below.

Further reading

Guidelines for the management of sexually transmitted infections. Geneva, World Health Organization, 2001 (document WH0/HIV_AIDS/2001.01).

Dallabetta GA, Laga M, Lamptey PR. Control of sexually transmitted diseases: a handbook for the design and management of programs. Arlington, VA, AIDSCAP Project, Family Health International, 1997.

Lower abdominal pain

INPATIENT THERAPY: recommended syndromic treatment (3 alternative regimens)

1. ceftriaxone, 250 mg intramuscularly, once daily plus doxycycline, 100 mg orally or intravenously, twice daily or tetracycline, 500 mg orally, 4 times daily

2. clindamycin, 900 mg intravenously, every 8 hours plus gentamicin, 1.5 mg/kg intravenously every 8 hours

3. ciprofloxacin, 500 mg orally, twice daily, or spectinomycin 1 g intramuscularly, 4 times daily plus metronidazole, 400-500 mg orally or intravenously, twice daily or chloramphenicol, 500 mg orally or intravenously, 4 times daily

Note: For all three regimens, continue treatment for at least 2 days after the patient has improved and follow with: • doxycycline, 100 mg orally, twice daily for 14 days or tetracycline, 500 mg orally, four times daily for 14 days

Note: Patients taking metronidazole should be cautioned to avoid alcohol. Tetracyclines are contraindicated in pregnancy.

OUTPATIENT THERAPY: recommended syndromic treatment

• single-dose therapy for uncomplicated gonorrhoea plus

• doxycycline, 100 mg orally, twice daily for 14 days or tetracycline, 500 mg orally, four times daily for 14 days plus

• metronidazole, 400-500 mg orally, twice daily for 14 days

Note: Patients taking metronidazole should be cautioned to avoid alcohol. Tetracyclines are contraindicated in pregnancy.

Outpatients with PID should be followed up at 72 hours and admitted if their condition has not improved.

OUTPATIENT THERAPY: alternative syndromic treatment where single-dose therapy for gonorrhoea is not available:

• trimethoprim (80 mg) + sulfamethoxazole (400 mg), 10 tablets orally once daily for 3 days and then 2 tablets orally twice daily for 10 days plus

• doxycycline 100 mg orally, twice daily or tetracycline 500 mg orally, 4 times daily for 14 days plus

• metronidazole 400-500 mg orally, twice daily for 14 days

Note: This regimen should be used only in areas where trimethoprim-sulfamethoxazole has been shown to be effective in the treatment of uncomplicated gonorrhoea. Patients taking metronidazole should be cautioned to avoid alcohol. Tetracyclines are contraindicated in pregnancy.

Outpatients with PID should be followed up at 72 hours and admitted if their condition has not improved.

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