CASE: VAGINITIS, CERVICITIS, PID (BACTERIAL VAGINOSIS AND TOA)
Maria is a 35yo Latino female walking into the ED alone. She presents to triage complaining of vaginal discharge for 1 week
and lower abdominal pain for past 2 days. It is a weekend evening, and you are at a moderate-sized ED facility where there is
GYN on-call consultation, limited after-hours radiology, and 24-hour onsite laboratory services.
TRIAGE QUESTIONS
What are the first steps in triaging Maria? What is necessary to assign an ESI? (N)
 Airway, Breathing, Circulation; objective assessment and targeted subjective questioning focusing on signs/symptoms of
acuity/hemodynamic instability
o GEN – bleeding from any source? Fever?
o CV – lightheadedness, dizziness, palpitations?
o GI – N/V?
o GYN – LMP? Possibility could be pregnant?
 Vital signs
 Pain assessment – (O)PQRST model as an example
o Onset, provoke/palliate, quality, radiation, severity, timing
 Pregnancy assessment **Starting the process to determine pregnancy at triage is very important
o LMP & collect urine at triage anticipating need for urine hCG
o POC pregnancy test if available
o If no standing protocol for RN to place urine hCG, ask provider to place order now
 Screening for violence, trauma
ABCs are intact. Maria reports heavy yellow “fishy smelling” vaginal discharge for the past week with worsening lower
abdominal pain for 2 days. She denies any bleeding or lightheadedness. She’s felt feverish, a little nauseous and overall
“crummy”. Her LMP was 3 weeks ago and was normal. She is sexually active, and when asked if she could be pregnant, she
says “No.” Maria screens negative for violence or trauma, but reports military sexual trauma (MST) when she was active duty.
VS: T 99, HR 101, BP 124/72, RR 16, 96% on room air
Pain: 6/10, generalized lower abdomen, constant ache with intermittent shooting pains, non-radiating
What ESI (Emergency Severity Index) level would you assign Maria and why? (N)
 ESI =3, based on stable vital signs and need for 2 or more resources (labs, IV medication, imaging)
What would you communicate to the primary nurse? How would you orient Maria to the next steps of care? (N)
 Communication to primary nurse – verbal is ideal, but may only use EDIS (electronic patient tracking system)
o Example: “Female, CC: vaginal discharge, abdominal pain x 2 days, stable, require private room for pelvic exam”
 Communication to Maria
o Need for urine sample; need to assess for pregnancy
o Taking to private ED treatment room; need to change into gown
o Plans for blood work and pelvic exam
o Inform staff if feeling worse
o All in compassionate, non-judgmental manner
PRIMARY NURSE ASSESSMENT
Once triaged, what nursing steps should occur before initial provider assessment (i.e. care, nursing assessment? (N)
 Nursing care
o Immediate actions – peripheral IV
o Anticipate next steps/Nursing protocoled orders
 Urine, for hCG and UA (if not obtained in triage)
 Blood work, obtain appropriate color-top tubes (CBC, CMP, coags)
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IVF ready
Prepare for pelvic exam (supplies, equipment, chaperone, etc.)
Given Maria’s +MST, offer comfort measures for pelvic exam such as choice in provider gender, choice
of patient position during pelvic exam, choice of verbal guidance through pelvic exam, etc.
Nursing assessment
o Additional HPI, focused ROS
o Targeted OB/GYN history
 Gravida/Para
 Sexual activity – when was last encounter?
 Method of contraception?
 Recent exposure to STI? hx previous STI?
 Prior treatments?
 GU symptoms – dysuria, hematuria, frequency?
o Medication reconciliation, allergy assessment
o Reassessment from triage findings
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Maria was brought back alone to a private treatment room and gets changed into a gown. On your initial nurse assessment,
you note a middle-aged woman, sitting on the exam table in mild-to-moderate discomfort.
On your questioning you find she is G1P0 (miscarriage 7yrs ago). She’s sexually active and doesn’t use any method of
contraception. She denies any recent exposure to STI, but says she had trichomonas in her teens. She denies dysuria,
hematuria or increased urinary frequency. Maria used an other-the-counter treatment for yeast 5 days ago because she
thought that’s what the discharge was from, but it didn't help. She also took a few doses of acetaminophen and ibuprofen for
the pain with little relief. Medication reconciliation confirms she is on fluoxetine; she is allergic to sulfa.
Maria appreciated being given choices is it relates the pelvic exam and her history of MST. She prefers a female provider,
and one is available. She also finds it helpful to sit more upright to be able to see the provider during the exam and prefers
being talked through the steps of the exam.
VS reassessment reveals
T 99.1, HR 108, BP 135/82, RR 16
Pain 9/10
What would you communicate with the provider? (N)
 Notify provider of immediate needs
 Update provider on changes in condition since triage
 Summarize pertinent findings (SBAR approach is one example of systematic way to provide report)
o Situation: CC - vaginal discharge for 1 week, worsening bilateral lower abdominal pain for 2 days
o Background: prior treatment with OTC antifungal and analgesics with no relief; +MST, prefers female provider
o Assessment: VS stable, +nausea, no vomiting, subjective fever, increasing pain
o Recommendation: pain control, maybe IVF, pelvic exam set-up
 Example “Maria is a 35yo female with 1 week of vaginal discharge and worsening bilateral lower abdominal pain for 2
days. She took OTC medications with no relief of discharge or pain. She does have a history of MST and prefers a
female provider. She’s stable now, has nausea without vomiting, ongoing pain and subjective fever. Do you want me to
get some pain medication, start IVF and set-up for pelvic exam?”
PROVIDER ASSESSMENT
The provider walks into the treatment room and finds a woman sitting, hunched over, holding her abdomen and tearful. VS
are T 99.1, HR 108, BP 135/82, RR 16; Pain 9/10
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What is your first step in her management? (P)
 Pain control
 Consider antiemetics and IVF
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What historical questions would you ask Maria during your assessment? (P) See question list below
Targeted HPI & ROS (to complement/confirm what has already been asked/obtained)
o Vaginal discharge & abdominal pain focused
OB/GYN history, including menstrual & sexual histories
Medical and surgical histories
Social history – tobacco, illicit drugs, alcohol
Appropriate questions to ask for vaginal discharge and abdominal/pelvic pain history:
1. LMP? Was it normal? Are periods regular?
2. Quantity & characteristics of discharge – amount, odor, consistency, color, itching?
3. Use of douching, sex toys, creams/lotions/sprays/lubricants, foreign bodies (pessary, female condom, contraceptive ring,
tampon)?
4. Are you sexually active? With men, women or both? When were you last sexually active? Number of sexual partners?
5. Method of contraception? Consistent use? Consistent barrier method use?
6. History of sexually transmitted infections?
7. Recent GYN procedures?
8. N/V? Urinary symptoms?
9. Vaginal, rectal or urinary tract bleeding?
10. Last bowel movement?
11. Last meal?
12. Allergies?
13. Medications? (specifically OTC medications or self-remedies)
What elements of the physical exam would you perform? What key findings are you looking for? (P)
 Physical exam with pelvic exam; using pelvic exam to specifically look for
o Signs of trauma
o Vaginal discharge
o Vaginal/cervical lesions
o Pelvic organ tenderness or mass
How do you prepare for the pelvic exam? How do you prepare Maria for the pelvic exam? (N&P)
 (N) Gather and set-up supplies and equipment
o Appropriate room and exam table
o Proper positioning of patient
o Light source, speculums, lubrication, swabs, specimen collections (options include pH paper, wet mount supplies
and transfer medium, vaginitis DNA probe, GC/Ch probe)
 (N&P) Ensure female provider, per patient request
 (N&P) Attend to privacy
o Private room, exam table with foot of bed away from door, pull curtain, sign on door/locked door
o Appropriate gowning and draping
 (P) Explanation of pelvic exam process, verbal consent
 (N&P) Verbal guidance through pelvic exam, per patient request
 (N&P) Allow Maria to empty bladder
The nurse provides Maria with 4mg morphine IV push and 1L NS IVF per provider orders. While the provider is assessing
Maria, the nurse is gathering supplies for the pelvic exam (detailed above).
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Maria tells the provider she’s been having large amounts of yellow frothy “fishy” smelling vaginal discharge. She denies
douching, but admits to using sex toys with lubrication; no other topicals apart from the recent antifungal cream. She is
sexually active with 1 female partner only for the past 10 years. No known exposure to STIs, but confirms the remote history
of trichomonas. Past medical history is significant for PTSD, MST. She has no surgical history, nor recent GYN
procedures. She’s allergic to sulfa. She takes only fluoxetine. She last ate 10 hours ago. She is a smoker, but denies alcohol
or drug use.
The nurse relays negative pregnancy test results.
The female nurse serves as the chaperone, supplies are ready, exam steps have been described and Maria has given verbal
consent for pelvic exam. Her privacy has been attended to. Maria sits as upright as possible during the pelvic exam and is
talked through each step of the exam, per her stated preference.
Physical exam (provide elements requested)
GEN: mild distress, A&O
HEENT: normal
PULM: CTAB
CV: mild tachycardia, regular rhythm
ABD: soft, non-distended, left lower abdominal tenderness with voluntary guarding, no rebound, no CVAT
PELVIC:
External inspection: normal external genitalia, no lesions, no signs of trauma
Speculum: moderate yellow watery discharge at introitus and pooled in vaginal vault, no discharge from closed cervical os
Bimanual: moderate-severe CMT, normal uterus, left adnexal tenderness with questionable fullness
SKIN: normal
NEURO: non-focal, GCS-15
How would you summarize your findings and plan to Maria? (P)
 Key exam findings
 Concerns
 Next steps in care
 Example “After completing your exam, Maria, I noticed the vaginal discharge and a fair amount of tenderness around your
left ovary and tube which makes me concerned. I’d like to send some labs and get a transvaginal ultrasound. This
means a vaginal probe will be inserted in the vagina to get a better look at the female organs. We’ll be looking for any
abnormalities that could explain your symptoms like infection.”
WORKING DIFFERENTIAL DIAGNOSIS AND EVALUATION
What is your differential diagnosis? What is your lead/working diagnosis and why? (P)
 Prioritize life, limb or fertility threats
o Ovarian torsion
o Tubo-ovarian abscess (TOA)
o Pelvic inflammatory disease (PID)
o Ruptured ovarian cyst
 Others: pyelonephritis, nephrolithiasis, diverticulitis, colitis, vaginitis, cervicitis, cystitis
What is your approach to narrowing your differential diagnosis? What key exam findings help you; what labs, and/or
imaging would you obtain? (P)
 Key exam findings
o Yellow, watery vaginal discharge
o CMT and unilateral/left adnexal tenderness with voluntary guarding
 Labs – CBC, coags, CMP, UA, wet mount or vaginitis DNA probe, GC/Ch probe
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Imaging (recall your facility has limited after-hours radiology, including US)
o TVUS – Does anybody feel an emergent TVUS is indicated which may mean calling in the radiology tech?
 Indications include:
 Hospitalization requiring inpatient treatment
 Clinical suspicion of pelvic abscess/TOA, ovarian torsion, ectopic pregnancy
 Identification of pelvic mass on exam or inability to adequately assess the adnexa
o CT or MRI – could these be used instead of TVUS?
 TVUS preferred
What are your key elements of Maria’s reassessment and how can you facilitate care? (N)
 Reassessment (VS, pain)
 Arrange transport to radiology, provide for privacy needs
Maria is ready to be transported to radiology. The initial morphine improved her pain a bit, but after the pelvic exam, she is
still in moderate pain.
VS reassessment reveals
HR 92, BP 122/72
Pain 5/10
The nurse provides Maria with an additional 4mg morphine IV push as ordered before she goes to radiology. Labs show:
WBC 15,000
Hgb 14.1
Hct 42.2
Platelets 350,000
INR 1
Na 136
Cl 97
HCO3 24
K 3.8
BUN/Cr 10/0.5
Glucose 97
LFTs normal
Clean catch UA: 15-20 squamous epithelial cells, 6-10 WBCs, negative LE/nitrites, RBCs, and bacteria
Wet mount:
pH 5.5, WBCs 20/hpf, >20% clue cells, no trichomonads, no hyphae/budding yeast
GC/Ch probe: pending
MANAGEMENT
How do you interpret the labs? (P)
 Wet mount, pH suggestive of BV and consistent with vaginal discharge appearance
 Leukocytosis suggests infection
 Contaminated urine
How do these lab results change your differential diagnosis? (P)
 BV is diagnosed
 Differential diagnoses revised as below
o Ovarian torsion
o TOA
o PID
o Ruptured ovarian cyst
 Others: pyelonephritis, nephrolithiasis, diverticulitis, colitis, vaginitis (BV), cervicitis (wouldn’t alone explain left adnexal
tenderness), cystitis
Does BV alone explain Maria’s presentation and exam and findings? (P)
 No, because lower genital tract infection such as BV does not cause pelvic pain nor pelvic organ tenderness
The radiologist calls with the TVUS results: ill-defined heterogenous, complex left adnexal mass associated with fluid-filled
tubular structure and peri-tubular stranding consistent with inflammation; small amount of free fluid is seen in the cul-de-sac.
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How do you interpret the TVUS results? (P)
 Left tubo-ovarian abscess
What are your next steps in the ongoing management of Maria? (N)
 Reassessment
 Support hemodynamics
 Update provider to status and response to treatment
Maria has received a total of 8mg morphine IV and 1L NS has infused.
VS reassessment reveals
T 100.9, HR 101, BP 130/82, RR 16
Pain 2/10
Given your findings on Maria’s reassessment, what do you anticipate? (N)
 Anticipate the need for blood cultures, possible antipyretic and initiation of antibiotics
 Update provider to change in status
What are your next steps in the ongoing management of Maria? (P)
 Order blood cultures, antipyretic
 Start antibiotics; discuss choice
o For TOA: clindamycin & gentamycin OR 2nd generation cephalosporin & doxycycline +/- metronidazole
o For BV: metronidazole – although not of paramount concern currently; treatment could be deferred for later
 GYN consultation
What information do you communicate to the consultant? (P)
 35 yo female with vaginal discharge & pelvic pain, now febrile
 Exam shows vaginal discharge, left adnexal tenderness and fullness
 Leukocytosis, wet mount consistent with BV
 TVUS consistent with left TOA
 Has received 8mg morphine with good pain control, 1L NS, blood cultures obtained, started on antibiotics
How would you orient/summarize Maria to the plan of care? (P)
 Explain TOA and BV diagnoses
 Ongoing explanation of next steps in care including treatment plan, need for admission
Maria continues to report feeling better. Blood cultures were drawn prior to antibiotic initiation of cefoxitin, doxycycline (IV
because of desire to keep NPO), metronidazole.
VS reassessment reveals
T 99.2, HR 90, BP 128/72, RR 16
Pain 2/10
GYN consult – agree with IV antibiotic choice, keep NPO in the event of surgical indication (i.e. TOA rupture or failure to
improve), GYN will be in to evaluate and repeat pelvic exam. Plan for admission.
Private, female inpatient accommodations are made for Maria and bed availability is confirmed.
HANDOFF/DISPOSITION
What are the proper handoff procedures in this scenario? (P&N)
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(P) Admission criteria based on hemodynamic instability, need for continuous monitoring, potential intervention, further
work-up
(P&N) Admission process followed
(N) Reassessment, update provider to changes
(P&N) Verbal report to accepting service
(P&N) Communicate plan to Maria
Maria defervesced the next day and remained afebrile for 48 hours. She was converted to oral doxycycline and oral
metronidazole to complete a 14-day course of both and discharged to home. She was followed-up as an outpatient with GYN
where a repeat TVUS showed complete resolution in her TOA.
KEY LEARNING POINTS – VAGINITIS, CERVICITIS, PID
 All female patients with abdominal pain, pelvic pain and/or vaginal complaints who are <52 years of age should have
pregnancy assessed at triage
 Life and fertility threatening conditions must be recognized
 All female patients with abdominal pain, pelvic pain or vaginal discharge require pelvic exam with adequate pelvic exam
set-up prior to specialty consultation
 When performing a pelvic exam, adhering to patient dignity, privacy and appropriate female chaperone requirements are
crucial
 Emergency providers should be able to differentiate upper from lower genital tract infections based on the presence of
pelvic organ tenderness
 Females in same-sex relationships can be at risk for polymicrobial infection of PID and develop TOA
 Indications for emergent TVUS when PID is suspected include: hospitalization requiring inpatient treatment, clinical
suspicion of pelvic abscess/TOA, and identification of pelvic mass on exam or inability to adequately assess the adnexa
 Emergency providers should be familiar with appropriate CDC-recommended antibiotic regimens for TOA and start IV
antibiotics in the ED
 Frequent communication between nurses and providers, noting changes in assessment and plan of care, is crucial
 The plan of care should be effectively communicated to patients throughout the encounter
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