facultative bacteria, anaerobes, and streptococci (16,40). Recommended regimens for the treatment of PID are listed in Table 18.5. An outpatient regimen of cefoxitin and doxycycline is as effective as an inpatient parenteral regimen of the same antimicrobials (41). Therefore, hospitalization is recommended only when the diagnosis is uncertain, pelvic abscess is suspected, clinical disease is severe, or compliance with an outpatient regimen is in question. Hospitalized patients can be considered for discharge when their fever has lysed (<99.5◦F for more than 24 hours), the white blood cell count has become normal, rebound tenderness is absent, and repeat examination shows marked amelioration of pelvic organ tenderness (42).
Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea (Table 18.3). One of these STDs usually is found in the male sexual partners of women with PID not associated with chlamydia or gonorrhea (43,44).
Tubo-ovarian Abscess An end-stage process of acute PID, tubo-ovarian abscess is diagnosed when a patient with PID has a pelvic mass that is palpable during bimanual examination. The condition usually reﬂects an agglutination of pelvic organs (tube, ovary, bowel) forming a palpable complex. Occasionally, an ovarian abscess can result from the entrance of micro-organisms through an ovulatory site. Tuboovarian abscess is treated with an antibiotic regimen administered in a hospital (Table 18.5). About 75% of women with tubo-ovarian abscess respond to antimicrobial therapy alone. Failure of medical therapy suggests the need for drainage of the abscess (45). Although drainage may require surgical exploration, percutaneous drainage guided by imaging studies (ultrasound or computed tomography) should be used as an initial option if possible. Trocar drainage, with or without placement of a drain, is successful in up to 90% of cases in which the patient failed to respond to antimicrobial therapy after 72 hours (46).
Figure 18.2 Showing the appearance of the ulcers of chancroid (A), herpes (B), and syphilis (C). The ulcer of chancroid has irregular margins and is deep with undermined edges. The syphilis ulcer has a smooth, indurated border and a smooth base. The genital herpes ulcer is superficial and inﬂamed. (Modified from Schmid GP, Shcalla WO, DeWitt WE. Chancroid. In: Morse SA, Moreland AA, Thompson SE, eds. Atlas of sexually transmitted diseases. Philadelphia, PA: Lippincott, 1990.)
Genital Ulcer Disease In the United States, most patients with genital ulcers have genital HSV or syphilis (47–50). Chancroid is the next most common cause of sexually transmitted genital ulcers, followed by the rare occurrence of lymphogranuloma venereum (LGV) and granuloma inguinale (donovanosis). These diseases are associated with an increased risk for HIV infection. Other infrequent and noninfectious causes of genital ulcers include abrasions, fixed drug eruptions, carcinoma, and Behcet’s disease.