Emergency Medicine Hub / Infectious Diseases • 3 min read • 3 sections

Sexually Transmitted Infections, Pelvic Inflammatory Disease & DGI

Comprehensive emergency protocol for sexually transmitted infections (STIs), acute pelvic inflammatory disease (PID), disseminated gonococcal infection (DGI), and ulcerative genital lesions. Features CDC guideline-directed antimicrobial regimens, hospitalization criteria for tubo-ovarian abscesses (TOA), violin-string adhesions of Fitz-Hugh-Curtis syndrome, and clinical differentiation of painful vs. painless genital ulcers.

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

PID Outpatient Regimen

Ceftriaxone 500 mg IM (1g if >= 150 kg) + Doxycycline 100 mg PO BID x 14d + Metronidazole 500 mg PO BID x 14d

Inpatient TOA Regimen

Cefotetan 2g IV q12h (or Cefoxitin 2g IV q6h) PLUS Doxycycline 100 mg IV/PO q12h; add Metronidazole for TOA

DGI Classic Triad

Tenosynovitis + Dermatitis (sparse necrotic pustules on distal extremities) + Polyarthralgias (migratory)

Painful vs Painless Ulcers

Painful: HSV (multiple vesicles on red base) and Chancroid (deep ragged ulcer with bubo). Painless: Syphilis (clean chancre)

Fitz-Hugh-Curtis Syndrome

RUQ pain with 'violin-string' perihepatic adhesions; normal AST/ALT with prominent peritoneal enhancement on CT

Bottom-Line Clinical Pearl

In Pelvic Inflammatory Disease (PID), maintain a low threshold for empiric treatment: any sexually active female with pelvic or lower abdominal pain accompanied by cervical motion tenderness, uterine tenderness, or adnexal tenderness must be treated immediately to prevent tubal scarring, ectopic pregnancy, and chronic infertility. Hospitalize patients with tubo-ovarian abscess (TOA), pregnancy, or intolerance to oral medications for parenteral IV antimicrobial regimens.

1. Pelvic Inflammatory Disease (PID): Diagnostic Criteria & Resuscitation

Pelvic Inflammatory Disease is an ascending polymicrobial infection originating in the cervix and spreading to the endometrium, fallopian tubes, ovaries, and pelvic peritoneum. The primary pathogens are Neisseria gonorrhoeae and Chlamydia trachomatis, alongside Mycoplasma genitalium and endogenous vaginal anaerobes. The CDC sexually transmitted infection guidelines mandate immediate empiric therapy based on clinical criteria:

Diagnostic Criteria	Clinical Findings	Threshold for Treatment
Minimum Clinical Criteria (Presumptive Diagnosis)	In a sexually active female with lower abdominal or pelvic pain, the presence of >= 1 of the following on bimanual pelvic examination: 1. Cervical Motion Tenderness ('Chandelier Sign') 2. Uterine Tenderness 3. Adnexal Tenderness.	IMMEDIATE EMPIRIC ANTIMICROBIAL THERAPY: Do not delay treatment for culture, NAAT, or ultrasound results. Delaying treatment by even 48 hours dramatically increases the risk of tubal factor infertility and ectopic pregnancy.
Additional Supportive Criteria	- Oral temperature > 38.3°C (101°F) - Abnormal cervical or vaginal mucopurulent discharge - Abundant white blood cells on wet mount - Elevated ESR or C-reactive protein (CRP) - Positive laboratory test for N. gonorrhoeae or C. trachomatis.	Enhances diagnostic specificity. Absence does not exclude PID.
Definitive Imaging Criteria	Transvaginal Ultrasound (TVUS) demonstrating Tubo-Ovarian Abscess (TOA), thickened fluid-filled fallopian tubes with incomplete septations (hydrosalpinx/pyosalpinx), or 'cogwheel' sign on cross-section.	Confirms complex upper genital tract disease. A normal ultrasound NEVER excludes uncomplicated endometritis or salpingitis.

2. CDC Guideline-Directed Antimicrobial Regimens: Outpatient vs. Inpatient

Clinical Cohort	Recommended First-Line Antimicrobial Regimen	Hospitalization Triggers & Clinical Pearls
Outpatient Regimen (Mild to Moderate PID)	Triple Combined Regimen: 1. Ceftriaxone 500 mg IM in a single dose (1.0 gram IM if body weight >= 150 kg) PLUS 2. Doxycycline 100 mg PO BID for 14 days PLUS 3. Metronidazole 500 mg PO BID for 14 days.	Adding Metronidazole is now mandatory in all CDC guidelines to cover anaerobes (Bacteroides fragilis) and treat concurrent Trichomonas vaginalis and bacterial vaginosis. Re-evaluate within 48-72 hours; lack of clinical improvement mandates hospital admission.
Inpatient Parenteral Regimen (Severe PID or Tubo-Ovarian Abscess)	1. Cefotetan 2.0g IV every 12 hours (OR Cefoxitin 2.0g IV every 6 hours) PLUS Doxycycline 100 mg PO/IV every 12 hours OR 2. Ampicillin-Sulbactam (Unasyn) 3.0g IV every 6 hours PLUS Doxycycline 100 mg PO/IV every 12 hours. (If TOA present: add Metronidazole 500 mg IV q8h or Clindamycin for enhanced anaerobic activity).	MANDATORY HOSPITALIZATION CRITERIA: 1. Tubo-Ovarian Abscess (TOA) on ultrasound 2. Pregnancy (high risk of maternal/fetal morbidity) 3. Severe illness, high fever, intractable nausea/vomiting 4. Inability to tolerate or comply with outpatient oral therapy 5. Clinical failure of outpatient therapy after 72 hours 6. Surgical emergencies cannot be excluded (e.g., acute appendicitis).

3. Disseminated Gonococcal Infection (DGI) & Genital Ulcer Differential

Disseminated Gonococcal Infection (DGI) occurs in 0.5-3% of patients with mucosal gonorrhea due to bacteremic dissemination of serum-resistant strains of Neisseria gonorrhoeae:

Infection/Ulcer	Classic Clinical Manifestations	Physical Exam & Diagnostic Signatures	Targeted Pharmacotherapy
Disseminated Gonococcal Infection (DGI)	Young, sexually active patient presenting with either: 1. Arthritis-Dermatitis-Tenosynovitis Syndrome: Migratory polyarthralgias, tenosynovitis (swelling of multiple tendon sheaths: wrists, fingers, ankles), and painless cutaneous lesions. 2. Purulent Monoarthritis: Acute septic arthritis of knee, wrist, or ankle with large purulent synovial effusion.	Cutaneous lesions are sparse (typically 2 to 10 lesions): petechial or necrotic pustules on an erythematous base located on distal extremities and palms/soles. Blood and synovial fluid cultures are frequently negative (< 30-50%); perform mucosal NAAT testing of urogenital, pharyngeal, and rectal sites for confirmation.	Ceftriaxone 1.0 gram IV every 24 hours (continue for 24-48 hours after improvement, then transition to oral therapy for 7 days total) PLUS Doxycycline 100 mg PO BID x 7 days for presumptive chlamydia co-infection.
Herpes Simplex Virus (HSV-1/HSV-2)	Acute onset of multiple exquisitely painful vesicles that rupture to form shallow, tender ulcers with erythematous borders. Dysuria, tender bilateral inguinal adenopathy.	Multiple grouped vesicles on an erythematous base ('dew drops on a rose petal').	Valacyclovir 1,000 mg PO BID for 7 to 10 days (or Acyclovir 400 mg PO TID).
Primary Syphilis (Treponema pallidum)	Painless solitary ulcer (Chancre) at site of inoculation. Appears 2-3 weeks post-exposure.	Indurated, clean base, sharply demarcated, painless, rubbery borders; accompanied by painless bilateral inguinal lymphadenopathy.	Benzathine Penicillin G 2.4 million units IM single dose. (If penicillin-allergic: Doxycycline 100 mg BID x 14 days).
Chancroid (Haemophilus ducreyi)	Exquisitely painful genital ulcer accompanied by painful, fluctuant, suppurative inguinal adenopathy (Bubo).	Deep, ragged, undermined borders with a friable, purulent necrotic base; bleeds easily upon scraping.	Azithromycin 1.0 gram PO single dose OR Ceftriaxone 250 mg IM single dose.

Tubo-Ovarian Abscess Rupture & Fitz-Hugh-Curtis Syndrome

A ruptured Tubo-Ovarian Abscess (TOA) is a catastrophic surgical emergency that rapidly produces diffuse polymicrobial peritonitis, septic shock, and death. Any patient with known or suspected TOA who develops sudden severe generalized peritonitis, hypotension, or acute lactic acidosis mandates immediate resuscitation and emergent exploratory laparotomy with gynecologic surgery. Furthermore, suspect Fitz-Hugh-Curtis Syndrome (perihepatitis) in young females presenting with severe right upper quadrant pain that mimics acute cholecystitis; laparoscopy demonstrates pathognomonic 'violin-string' fibrinous adhesions between the liver capsule and anterior abdominal wall.

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