Expectant medical treatment consists of oral hydration or intravenous ﬂuids (if the patient is unable to tolerate oral intake), antibiotics for UTI, and pain control. Surgical management, such as lithotripsy or open surgery, is an option for renal and urethral lithiasis. Nonpregnant women (and pregnant women who are afebrile with a normal WBC count) with pyelonephritis and all women with cystitis can be treated on an outpatient basis. Nonpregnant women with pyelonephritis can be treated with a 14-day course of a ﬂuoroquinolone or trimethoprim/ sulfamethoxazole (some recommend one intravenous dose of a third-generation cephalosporin before discharging patients with oral antibiotics) (see Chapter 18) (32). Caution should be used with trimethoprim/sulfamethoxazole given rising resistance patterns. It is important to follow up urine culture sensitivities and treat accordingly. If there is no improvement, raising concerns for patient compliance, inability to tolerate oral medications and ﬂuids, or whether the patient may be immunocompromised as related to AIDS, intravenous drug use/abuse, diabetes, pregnancy, or chronic steroid use, then the patient should be hospitalized and given intravenous antibiotics.
Tuberculosis should be excluded as a cause of pyelonephritis if the characteristic sterile pyuria is present and the patient’s condition does not improve with antibiotics.
All women of reproductive age with acute pelvic pain should have a complete blood count with differential, ESR, urinalysis, and a sensitive qualitative urine or serum pregnancy test. If not diagnosed expeditiously, an acute process can often result in significant morbidity or mortality. For patients who have chronic pelvic pain and develop acute exacerbation, it is important to rule out a superimposed acute process. Symptoms of fever, chills, diaphoresis, abnormal vaginal bleeding, dizziness, syncope, emesis, significant diarrhea, obstipation, dysuria, hematuria, and hematochezia, and/or signs of elevated temperature, tachycardia, orthostasis, abdominal distention, abnormal bowel sounds, ascites, peritonitis, or abnormal pregnancy are all indicative of an acute process.
Laboratory tests for the evaluation of acute pelvic pain include a CBC with differential, erythrocyte sedimentation rate, clean catch midstream RUA, gonorrhea and chlamydia nucleic acid amplification testing (NAAT) from cervix or urine, and urine or serum pregnancy test. The sedimentation rate is nonspecific, but often is the only abnormal laboratory finding in women with subacute PID. If the pregnancy test is positive, a quantitative β-human chorionic gonadotropin (βhCG) should be ordered. Other studies that are recommended include transvaginal pelvic ultrasound, or if imaging is not available, culdocentesis. The ﬂuid from culdocentesis can be sent for hematocrit if bloody ﬂuid is obtained or Gram stain with culture if the ﬂuid is purulent. The presence of a mass in the cul-de-sac precludes culdocentesis. CT with and without contrast, abdominal x-rays, or upper or lower Gastrografin studies help rule out gastrointestinal pathology when gastrointestinal symptoms predominate. CT is useful for evaluation of retroperitoneal masses or abscesses related to the gastrointestinal tract. Pelvic MRI can be diagnostic if the pelvic ultrasound cannot determine whether a mass is uterine or adnexal.