PLAB 2 Gynae: Mastering Pelvic Inflammatory Disease Management Guidelines

PLAB 2 Gynae: Mastering Pelvic Inflammatory Disease Management Guidelines

Pelvic Inflammatory Disease (PID) is a high-yield topic for the PLAB 2 OSCE, combining critical diagnosis, sensitive communication, and crucial management planning, often including safe prescribing. As an examiner and medical expert, I can confirm that candidates frequently struggle with the comprehensive management pathway required by UK guidelines.

This guide breaks down the essential steps to ace a PID station in your PLAB 2 exam, aligning with BASHH (British Association for Sexual Health and HIV) and UK clinical standards.

1. The Diagnostic Approach: Keeping the Threshold Low

In PLAB 2, if a patient presents with symptoms suggestive of PID, you must assume PID until proven otherwise. The diagnosis is primarily clinical, meaning you do not need laboratory confirmation before starting treatment.

Key History Components (The PLAB 2 Checklist):

• Symptoms: Bilateral lower abdominal pain (dull or aching), deep dyspareunia, abnormal vaginal or cervical discharge, intermenstrual/post-coital bleeding, and systemic symptoms (fever, nausea).

• Risk Factors: Young age, multiple sexual partners, unprotected sex, history of STIs (especially Chlamydia or Gonorrhoea), recent IUD insertion (rarely).

• Exclusion: Ensure you ask about red flags (ectopic pregnancy, appendicitis) and menstrual history.

Examination Findings (If Required):

While a full examination might not be possible in the time limit, candidates must propose the necessary examinations:

1. Abdominal: Tenderness (often bilateral lower quadrants).

2. Bimanual Pelvic Exam: Cervical motion tenderness (the classic 'cervical excitation' sign), adnexal tenderness.

2. Communication: Sensitive and Clear Explanation

PID requires a clear, empathetic explanation. Remember, this is often a difficult conversation involving sexual health.

3. Management and Prescribing Guidelines (The BASHH Regimen)

The treatment for PID is empirical and must cover the most common causative organisms, Neisseria gonorrhoeae and Chlamydia trachomatis.

First-line Outpatient Regimen (Crucial for PLAB 2):

Candidates must be prepared to prescribe this combination, usually for 14 days:

1. Ceftriaxone 1g intramuscular (IM) single dose (to cover Gonorrhoea), followed by:

2. Doxycycline 100mg twice daily (BD) for 14 days (to cover Chlamydia and other organisms), plus:

3. Metronidazole 400mg twice daily (BD) for 14 days (to cover anaerobic bacteria).

Examiner Tip: Always confirm drug allergies (especially penicillin/cephalosporins) and pregnancy status before prescribing. If the patient is pregnant, Doxycycline is contraindicated, and alternatives (like Erythromycin) must be considered.

When to Refer/Admit (Red Flags):

PID can be severe, and candidates must know when to escalate care (i.e., criteria for inpatient/IV antibiotics):

• PID in a pregnant patient.

• Systemic signs of severe infection (high fever, sepsis).

• Tubo-ovarian abscess suspected.

• Inability to tolerate oral antibiotics (vomiting).

• Lack of clinical improvement after 72 hours of oral treatment.

4. Safety Netting and Follow-up

Effective safety-netting is non-negotiable in PLAB 2, especially when sending a patient home on antibiotics.

1. Review Appointment: Arrange a follow-up with the Sexual Health or Gynaecology clinic within 72 hours to ensure symptoms are improving and to receive test results.

2. Urgent Advice: Instruct the patient to return immediately if the pain worsens, if they develop high fever, or if they are unable to keep down the medication.

3. Sexual Abstinence: Advise sexual intercourse should be avoided until treatment is complete and follow-up swabs are negative.

4. Partner Notification: This is a vital step. You must explain the need to contact and screen all sexual partners from the last 6 months (even if asymptomatic) to prevent reinfection.

By following this structured approach—from confident diagnosis and sensitive communication to guideline-compliant prescribing and thorough safety netting—you will demonstrate the comprehensive competence required to pass the PID station in your PLAB 2 exam.