Upper

Genital
Tract
Infections
CC BURIAS, Dan Matthew E.
WVSU-COM/MC
 OUTLINE

Pelvic
Non-puerperal
01 Inflammatory 02 Endometritis
Disease (PID)

Pelvic Pelvic
03 Actinomycosis
04 Tuberculosis
 01
Pelvic
Inflammatory
Disease
 An infection in the upper genital tract not
associated with pregnancy or intraperitoneal
pelvic operations

The infection and inflammation may be

present at any point along a continuum that
includes endometritis, salpingitis, and peritonitis
 Anatomic Locations of PID
Ovary
(Oophoritis)
Broad
Ligaments Uterine Serosa
(Parametritis)

Endometrium Uterine Wall

(Endometritis) (Myometritis)

Oviducts
(Salpingitis)
 4.4%
Estimated prevalence of
self-reported lifetime PID in
sexually experienced women of
reproductive age (18-44 years
old)

2.5M
Estimated prevalence of
self-reported lifetime PID
 Of the total cases, ¾ occur in women younger
than 25 years of age.; identifying this age
group as high-risk

75% The incidence decreases after the age of 25

years old
CDC Fact Sheet on Pelvic Inflammatory Disease (2017)

Annually, PID occurs in 1-2% of young, sexually active

women

Most common serious infections occur in women ages

16-25 years old.

PID is rare among women without menstrual periods,

which include the following:
● Premenarchal
● Pregnant
● Post-menopausal
 Risk Factors (1/3)

Early age of Single

coitarche Social Factors
status

Multiple Low
Sexual Socioeconomic Use of IUD
Partners Status
 Risk Factors (2/3)

Young Age Other Sexual Partner w/

(<25 years STIs urethritis or
old) gonorrhea

Previous Endocervical testing

diagnosis of Not using mechanical
positive for N.
PID and/or chemical
gonorrhoeae or C.
contraceptive barriers
trachomatis
 Risk Factors (3/3)

Iatrogenic Genetic
 Classification

Pelvic Inflammatory Disease

Symptomatic Atypical/”Silent”
PID PID

Acute PID Chronic PID

 Classification

Pelvic Inflammatory Disease

Symptomatic Atypical/”Silent”
PID PID

Acute PID Chronic PID

 Etiologies of Acute PID
Usually polymicrobial
Ascending infection from the vagina and cervix
● Enhanced during menstruation
Classic etiologic agents:
● N. gonorrhoeae
● C. trachomatis
Other agents:
● T. trachomatis
● BV-associated microorganisms (predominantly anaerobic species)
● Mycoplasma genitalium (associated with milder symptoms)
● Respiratory Pathogens
● Enteric Pathogens
 N. gonorrhoeae
● A fastidious, obligate aerobe, motile,
gram-negative diplococci; also facultatively
intracellular
● Selectively adheres to non-ciliated
mucus-secreting cells
● Induces a robust, acute complement-mediated
inflammatory response, damaging the ciliated
cells
● Remains in the oviducts for at most a few days
● Produces less scarring and adhesions
C. trachomatis
● A non-motile, coccoid, obligate intracellular
bacteria
● Has become more prevalent than gonorrhea
(chlamydial-to-gonococcal diagnostic ratio of 4:1)
● Does not cause an acute inflammatory response
● Primary infection is self-limited, with mild
symptoms and little permanent damage
● May remain in the oviducts for months/years after
initial colonization
● Cell-mediated, Delayed hypersensitivity (Type IV)
reaction is responsible for subsequent tissue
injury, which are cause by hypersensitivity to
persistent chlamydial antigens produce continued
scarring and destruction; more likely to have
severe tubal scarring and Fitz-Hugh-Curtis
syndrome
● The most common etiology for atypical/silent PID
Burnham RC, Gottlieb SL, Paavonen J. Pelvic Inflammatory Disease [Review Article]. N Engl J Med 2015; 372:2039-2048
 Pathogenesis of Acute PID

Initiating Event: Inoculation and spread of Colonization of tissue

Ascending Infection infection along the mucosal Tissue inflammation
Lymphovascular spread surface, sometimes extending Cell/Complement-mediated
Transperitoneal spread to the ovaries and nearby immune destruction of tissues
peritoneum Scarring and adhesions
 Clinical Features

Wide range of non-specific clinical signs and symptoms

Develop during or soon following menstruation
The most frequent symptom is new-onset lower abdominal and pelvic
pain;
● Pain is diffuse, bilateral, and usually described as constant and dull
● Pain exacerbated by motion or sexual activity and, on occasions, the
pain may become cramping
● Usually lasts <7 days
 Clinical Features

Other symptoms:
● Purulent vaginal discharge
● Spotting/Heavy Menstrual Bleeding (Menorrhagia)
● Fever and Chills
● Dysmenorrhea
● Dyspareunia
● Anorexia, Nausea and Vomiting (late)
5-10% develop perihepatic inflammation or Fitz-Hugh-Curtis Syndrome
 Clinical Features

N. gonorrhoeae C. trachomatis
Rapid onset Indolent course
Pelvic pain usually begins a few days Slow onset
after the start of menstrual period Less Pain
Less Fever
 Clinical Features

On physical examination:
● Lower abdominal and pelvic tenderness on palpation (HALLMARK)
○ Direct tenderness and occasional rebound tenderness
● Pelvic examination
○ Cervical Motion Tenderness (CMT)
○ Bilateral tenderness of the parametria and adnexa, with
exacerbation on uterine or cervical movement
○ Palpation of ill-defined adnexal fullness, which represents edema,
inflammatory adhesions to small and large intestines, or an
adnexal complex or abscess
 Diagnosis

Key Points
PID is a clinical diagnosis
Laboratory tests are requested to increase the diagnostic specificity of
history and physical examination
Laparoscopic visualization - most accurate method for diagnosis
The CDC guidelines is followed for the diagnosis of PID
 Laboratory Tests

● Serum or urine Beta-hCG - to rule out ectopic pregnancy (TRIAD of

pain, amenorrhea and vaginal bleeding)
● Complete blood count (CBC) - baseline test; exclude
hemoperitoneum and identify WBC elevation
● Liver transaminase levels - for those with suspected Fitz-Hugh-Curtis
Syndrome
● Saline preparation of cervical or vaginal discharge
● Endocervical testing for N. gonorrhoeae and C. trachomatis
● Endometrial Biopsy - to diagnose endometritis
Histologic section of acute salpingitis
Histologic section of acute salpingitis, higher magnification
 Imaging Tests

Ultrasonography
● Limited value for patients with mild/moderate presentation
● Transvaginal UTZ - helpful adjunct for documenting adnexal mass
○ Characteristic findings of acute salpingitis:
■ Distended, ovoid-shaped tube filled with anechoic or echogenic fluid
■ Fallopian tube wall thickening
■ Incomplete internal septa
■ “Cogwheel” appearance when inflamed tubes are imaged in cross section
■ Marked vascularity with low-impedance blood flow in color Doppler
● MRI - sensitive but expensive and not readily available in some
hospitals
Transvaginal sonographic image of acute salpingitis
Sonographic image of a cross section of a dilated
and fluid-filled fallopian tube
 Laparoscopy

Done in some countries and institutions

Characteristic findings:
● Tubal serosal hyperemia
● Tubal wall edema
● Purulent exudates coming from the fimbriated ends (pyosalpinx)
● Pooling of purulent material in the cul-de-sac
Helpful in excluding other pathologies (e.g. appendicitis and adnexal
torsion)
Pooling of purulent material in the pouch of Douglas/Posterior
cul-de-sac
 Diagnosis

Minimum Criteria
Empirical treatment of PID should be initiated in sexually active
young women and others at risk for STIs if one or more of
the following are present and no other causes(s) for the
illness can be identified:
● Lower abdominal tenderness or
● Adnexal tenderness or
● Cervical motion tenderness
 Diagnosis

Additional Criteria
One or more of the following additional criteria can be used to enhance the
specificity of the minimum clinical criteria and support a diagnosis of PID:
● Oral temperature >38° C
● Abnormal cervical or vaginal discharge (mucopurulent)
● Presence of abundant WBCs on microscopy of vaginal secretions
● Elevated erythrocyte sedimentation rate (>15mm/hr)
● Elevated C-reactive protein
● Laboratory documentation of cervical infection with N. gonorrhoeae or
C. trachomatis
 Diagnosis

Definitive Criteria
● Histopathologic evidence of endometritis on endometrial
biopsy
● Transvaginal sonography or MRI showing thickened
fluid-filled tubes, with or without free pelvic fluid or
tubo-ovarian complex
● Laparoscopic abnormalities consistent with PID
● Note: Although initial treatment can be made before
bacteriologic diagnosis of C. trachomatis or N. gonorrhoeae
infection, such a diagnosis emphasizes the need to treat sex
partners
 Differential Diagnosis

Ectopic pregnancy
Ovarian torsion
Rupture of an adnexal mass
Acute appendicitis
Gastroenteritis
Endometriosis
 Treatment

Medical Surgical
 Treatment

Medical Surgical
 Medical Treatment

Key Points
Early administration of empirical, broad-spectrum antibiotics should be
given/administered
Goals of treatment:
● Resolution of symptoms
● Preservation of tubal function
Sexual partners should be evaluated and treated for chlamydia/gonorrhea
CDC has recommended antibiotic regimens for the out-patient and
in-patient management
 Medical Treatment

Outpatient/Ambulatory Management
Ceftriaxone, 250 mg IM, single dose
or
Cefoxitin, 2 g IM, single dose, and Probenecid, 1 g PO administered concurrently in a
single dose
or
Other parenteral third-generation cephalosporin (e.g., ceftizoxime, cefotaxime)
plus
Doxycycline, 100 mg PO bid for 14 days
with or without
Metronidazole, 500 mg PO bid for 14 days
 Follow-up for Outpatients

Initial assessment: 2-3 days after therapy initiation to assess response

Subsequent assessment: 4-6 weeks after therapy completion to assess

resolution and establish post-treatment baseline
 Treatment Failure in Outpatient
Therapy

Non-compliance
Reinfection
Inadequate antibiotic coverage for penicillinase-producing gonorrhea
Chromosomally mediated resistant N. gonorrhoeae
Resistant facultative or anaerobic organisms
 Indications for Hospitalization

Surgical emergencies (e.g., appendicitis) cannot be excluded

The patient is pregnant
The patient does not respond clinically to oral antimicrobial therapy
The patient is unable to follow or tolerate an outpatient oral regimen
The patient has severe illness, nausea and vomiting, or high fever (>38.3oC)
The patient has a tubo-ovarian abscess (TOA)
 Medical Treatment

Inpatient Management
Parenteral Regimen A
Cefotetan, 2 g IV every 12 hr
or
Cefoxitin, 2 g IV every 6 hr
plus
Doxycycline, 100 mg PO or IV every 12 hr, continued for 14 days
Note: Because of pain associated with infusion and development of marked
superficial phlebitis, doxycycline should be administered orally when possible, even
when the patient is hospitalized. PO and IV administration of doxycycline provide
similar bioavailability.
 Medical Treatment

Inpatient Management
Parenteral Regimen B
Clindamycin, 900 mg IV every 8 hr
plus
Gentamicin, loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5
mg/kg) every 8 hr. Single daily dosing may be substituted.

If with renal disease:, replace aminoglycoside with Aztreonam 2g IV every 8 hours or a third
-generation cephalosporin (e.g. ceftizoxime, cefotaxime)

Transition to 14-day agent: Clindamycin 450mg QID or Doxycycline 100mg BID; If with TOA: (1)
Clindamycin 450mg QID + Doxycycline 100mg BID or (2) Metronidazole 500mg BID + Doxycycline
100mg BID
 Medical Treatment

Parenteral Regimen A Parenteral Regimen B

Excellent coverage for community Excellent coverage for anaerobic

acquired infections infections and facultative gram-negative
rods; preferred in patients with an
Less ideal for a pelvic abscess or abscess, IUD-related infection, and pelvic
anaerobic infections infections after a diagnostic/operative
procedures
 Medical Treatment

Inpatient Management
Alternative Parenteral Regimens
Ampicillin-sulbactam, 3 g IV every 6 hr
plus
Doxycycline, 100 mg PO or IV every 12 hr combination
 Medical Treatment

Inpatient Management

General Recommendations:
● IV antibiotics should be continued for at least 24 hour after substantial
improvement
● If a mass is detected (e.g. TOA), add Ampicillin to the regimen B
(clindamycin + gentamicin)
● If there is no mass detected, shift to oral therapy after 24 when patient is
already afebrile
 Criteria for Discharge

Lysis of fever for >24 hrs

Normal WBC count
Absent rebound tenderness
Marked amelioration of pelvic organ tenderness
 Treatment

Medical Surgical
 Operative Treatment

Indications:
● Ruptured tubo-ovarian abscess
● Laparoscopic drainage of a pelvic abscess
● Persistent mass in old women whom future child-bearing is not a
consideration
● Removal of persistent symptomatic mass
 Operative Treatment

Interventions:
● Drainage of cul-de-sac abscess via percutaneous drainage or
colpotomy incision
● CT-guided, transvaginal or transabdominal percutaneous aspiration
or drainage of pelvic abscesses
○ Contraindication: any suspicion of an infected carcinoma
● Laparoscopic aspiration of TOA
 Classification

Pelvic Inflammatory Disease

Symptomatic Atypical/”Silent”
PID PID

Acute PID Chronic PID

 Atypical/ “Silent” PID

● Subclinical/Asymptomatic/relatively asymptomatic
● Associated with Chlamydial infection
● May be more common that symptomatic PID
● Follows multiple or continuous low-grade infection in asymptomatic
women
● Repeated asymptomatic infections are associated with tubal infertility and
ectopic pregnancy
 Atypical/ “Silent” PID

● Not a clinical diagnosis; rather an ultimate diagnosis

○ Incidentally detected in patients who undergo workup for infertility
● Prompt treatment of the patient after detection
 Atypical/ “Silent” PID

● On laparoscopy/laparotomy:
○ Externally, there might be adhesions but the oviducts are grossly
normal
○ Internally, the tubes may show flattened mucosal folds, extensive
deciliation of the epithelium, and secretory epithelial cell degeneration
○ Alternatively, hydrosalpinx may be found
○ Fitz-Hugh-Curtis may also be present
 Complications and Sequelae of PID

Recurrent acute PID

Tubo-ovarian Abscess (TOA)
Tubal Factor Infertility
Ectopic pregnancy
Chronic pelvic pain (from hydrosalpinx and adhesions)
 Prevention

Behavioral Barriers

Monogamy
Reducing sexual partners
Condom
Avoiding certain sexual
Spermicide
practices
Diaphragm/Spermicide
Inspecting and questioning
Vaccines
partners
Public Health
● Primary Prevention
○ Teaching safe sex practice to adolescents
○ Promote use of condoms and chemical barrier methods
● Secondary Prevention
○ Universal screening for women at high risk for chlamydia and
gonorrhea
○ Screening for active cervicitis
○ Increase use of sensitive tests to diagnose lower genital infections
○ Treatment of sexual partners
○ Educate patients to prevent recurrent infection
 02
Non-puerperal
Endometritis
 Overview

Infection of the uterine lining

A distinct clinical syndrome
Distinct risk factors:
● Douching in the past 30 days
● Douching in days 1 to 7 of the menstrual cycle
● Use of IUD
 Etiology

Associated with lower genital tract infections with:

● C. trachomatis
● N. gonorrhoeae
● BV-associated microorganisms
● M. genitalium
● T. vaginalis
 Clinical Features

Cervical Motion Tenderness (CMT)

Rebound Tenderness
Fever
Abnormal Uterine Bleeding
Uterine Tenderness

Or

Subclinical
 Diagnosis

Endometrial Biopsy (EMB) - gold standard

● Criteria:
○ At least one (1) plasma cell/x120 magnification, FOV of the
endometrial stroma
○ >5 neutrophils/x400 magnification, FOV in the superficial
endometrial epithelium
○ Severe cases: diffuse lymphocytes and plasma cells; stromal
necrosis
 Non-specific endometritis showing dense plasma cell infiltration of the stroma with
polymorphonuclear cells in the reactive epithelium.
From Mazur, M. T., & Kurman, R. J. (2005). Endometritis. Diagnosis of Endometrial Biopsies and Curettings, 147–162. doi:10.1007/978-0-387-26321-2_7
 Treatment

Antibiotic therapy:
● Cefixime 400 mg PO
and
● Azithromycin 1000 mg
with or without
● Metronidazole 1g PO BID
 03
Pelvic
Actinomycosis
 Overview

Rare infection of the upper genital tract

Actinomyces israelii - most common species found
● Filamentous, gram (+)ve , rod-shaped, anaerobic bacterium
Other species: A. naeslundii, A. odontolyticus, A. turicensis, A. gerencseriae,
A. cardiffensis, A. urogenitalis, A. hongkongensis
 Overview

Usually associated with chronic use of IUD (ave. of 8 years)

Gynecologic procedures are other sources
Rarely isolated and is commonly part of a polymicrobial infection
Tubo-ovarian abscess is the most common presentation
 Clinical Features

Pelvic UID-associated actinomycosis usually mimics malignancies, uterine myoma

or adenomyosis or even tuberculosis; “great pretender”
Other signs and symptoms:
● Lower abdominal pain
● Constipation
● Weight loss
● Vaginal discharge
● (+/-) Fever, esp. if with peritonitis
● (+/-) Lymphadenopathies
Associated with chronic endometritis
● Adhesions
● Indurations
● Fibrosis
 Diagnosis

Actinomyces infection is diagnosed histopathologically

● Presence of filamentous bacteria
● Abscess and granuloma formation/Sulfur granules
○ Demonstrates eosinophilic club-like structures that radiate
from the periphery of the granule (Splendore-Hoeppli
phenomenon)
● Extensive reactive fibrosis
 Actinomycotic abscesses containing sulfur granules with radiating filaments
Choi et al. Clinical Features of Abdominopelvic Actinomycosis: Report of Twenty Cases and Literature Review. 2009. Yonsei medical journal 50(4):555-9.
 Differential Diagnosis

Pelvic Mass (benign and malignant)

Metastatic cancers
Lymphoproliferative disorders
Retroperitoneal fibrosis
Endometriosis
Diverticular Abscess
Crohn’s Disease
Pelvic Tuberculosis
 Tubo-ovarian abscess infected with actinomyces
Srinivas GN et al. Bilateral ovarian actinomycosis masquerading as ovarian malignancy; without any history of intrauterine contraceptive device [Case
Report]. Medical Journal of Dr. D.Y. Patil University. 2013; 6(4).
 Treatment
Removal of IUD
Surgical drainage
Antibiotic therapy
● Penicillin is the drug of choice
● Regimens:
○ 2-6 weeks high dose penicillin G IV (18-24M units/day) followed by
6mo-1yr oral penicillin 2-4g/day (Journal) or
○ Oral penicillin, doxycycline or a fluoroquinolone for 12 weeks (Compre
Gyne)
○ If allergic to penicillin, doxycycline, minocycline, clindamycin and
erythromycin can be substituted (Journal)
○ Erythromycin is safe for pregnant patients (Journal)
 04
Pelvic
Tuberculosis
 Overview
Primarily causes chronic salpingitis and chronic endometritis
Usually occurs in pre-menopausal women
A consequence of hematogenous spread from the primary infection site,
usually the lungs
Sites of infection:
● Fallopian tubes (most common)
● Endometrium
● Ovaries
 9.6M
Global new cases of TB in the
year 2014 alone; 60 % were in
South East Asia and Western

1.1%
Pacific

19%
Extrapulmonary TB
cases in the Philippines
in 2005

Pelvic/Genital TB
 Etiology

Mycobacterium tuberculosis
Mycobacterium bovis
 High-Risk Patients
History of latent TB infection
Previous contact with a person with TB
Residing in a community with high TB prevalence
Concurrent HIV infection or AIDS
 Clinical Features
May be insidious or rapidly progressive disease; “great pretender”
Clinical signs and symptoms:
● Constitutional symptoms (anorexia, weight loss)
● Infertility
● Abnormal Uterine Bleeding
● Mild to moderate chronic abdominal and pelvic pain
● Ascites
Some women may be asymptomatic
Physical findings include:
● Mild adnexal tenderness
● Bilateral adnexal masses
● Fixation of adnexa because of scarring
 Diagnosis
Suspected if the patient does not respond to conventional antibiotic
therapy
Positive tuberculin skin test/PPD
+/- pulmonary tuberculosis in CXR
Biopsy
● Classic giant multinucleated cells
● Granuloma formation
● Caseous necrosis
Culture - definitive diagnosis
 Diagnosis
Intraoperative findings: characteristic everted distal ends of the
oviducts, producing a “tobacco pouch” appearance
Other tests:
● Chest radiograph
● IV pyelography
● Serial gastric washings
● Urine Cultures
Laparoscopic findings showing caseous nodule in a case of female genital tuberculosis
Sharma et al. Effect of antitubercular treatment on ovarian function in female genital tuberculosis with infertility. 2016. Journal of Human Reproductive
Sciences. 9(3):145.
 Laparoscopy showing bilateral hydrosalpinx, tubo-ovarian
masses, adhesions and frozen pelvis (arrows) in pelvic tuberculosis
Sharma et al. Female genital tuberculosis: Revisited. Indian J Med Res 148 (Supplement), December 2018, pp 71-83 DOI: 10.4103/ijmr.IJMR_648_18
 Treatment
Medical: 2 months HRZE/4-7 months HR regimen (6-9 months total)
● Isoniazid
● Rifampicin
● Pyrazinamide
● Ethambutol
● If with multi-drug resistant (MDR) strain, add Streptomycin
Surgery is reserved for the following indications:
● Women with persistent pelvic masses
● Presence of resistant organisms
● Age of >40 years
● Women whose endometrial cultures remain positive
Complications

Simple tubal blockage

Tubo-ovarian abscess
Frozen Pelvis
 Course of PID

PID Short term Long-term complications

complications
Infection and Infertility
Immune-mediated Fitz-Hugh Curtis Ectopic Pregnancy
tissue and Syndrome Scarring
architectural Tubo-ovarian Abscess Adhesions/Frozen Pelvis
destruction Chronic Pelvic pain
 Complications of PID

Tubo-ovarian Fitz-Hugh-Curtis
Abscess (TOA) Syndrome
Tubo-ovarian
abscess
 Terminologies

Tubo-Ovarian Complex Tubo-Ovarian Abscess

Early; Both the tube and ovary are Late; The tissue planes and distinction
readily recognisable on UTZ between fallopian tube and ovary are
already lost or hard to distinguish on
UTZ
 Overview

End-stage of PIDs
Agglutination of pelvic organs (e.g. oviducts, ovary, bowel) forming a
palpable complex
Typically unilateral; bilateral in severe cases
Associated with high morbidity and mortality, especially if with severe
systemic sepsis
 Etiology
Disease extension:
● Pelvic Inflammatory Disease (PID) - most common
● Appendicitis
● Diverticulitis
● Inflammatory Bowel Disease (IBD)
● Iatrogenic/Surgery
 Risk Factors
Non-use of barrier contraception
Intrauterine contraceptive devices,
Previous episode(s) of PID
Earlier age at first intercourse
Multiple sexual partners,
Diabetes Mellitus
Immunocompromised state
Etiology
 Diagnosis

Palpable, tender adnexal mass

Raised inflammatory markers
Radiologic findings demonstrating a mass
 Imaging

Ultrasonography CT scan MRI

Complex cystic adnexal A thick-walled, cystic Complex pelvic mass

or cul-de-sac mass adnexal mass with with low signal intensity
Thick irregular walls internal septations and on T1-weighted
Areas of mixed surrounding sequences and
echogenicity inflammatory changes heterogeneously high
(+) septations signal intensity on
Internal echoes from T2-weighted sequences
debris
 Ultrasound images of a tubo-ovarian abscess in a woman with pelvic
actinomycosis
Moustafa M. Tubo-ovarian abscess secondary to actinomycosis: unexpected presentation and its treatment. Gynecol Surg (2015)
12:53–55 DOI 10.1007/s10397-014-0871-3
 Tubo-ovarian Asbcess
Monro K, Gharaibeh A, Nagabushanam S, Martin C. Diagnosis and management of tubo-ovarian abscesses [Review Article]. The
Obstetrician & Gynaecologist, Royal College of Obstetricians and Gynecologists. 2018;20:11–9. DOI: 10.1111/tog.12447
 Treatment

Initiate 1-hour bundle sepsis/”sepsis six” protocol if sepsis signs and

symptoms were noted

Administration of parenteral IV antibiotics (preferably Regimen B)

 Treatment

If no improvement within 2-3 days, consider:

● Abscess drainage
○ Imaging-guided percutaneous drainage/aspiration
● Antimicrobial regimen modification
For large abscesses (>8cm): Initial therapy is drainage plus IV antibiotics
 Treatment

Indication for surgery:

● TOA rupture - emergency!
● Refractory abscesses
Goals of Surgery:
● Abscess drainage
● Excision of necrotic tissue
● Peritoneal cavity irrigation
 Complications

Life-threatening peritonitis
Chronic Pelvic Pain
Subfertility
Hysterectomy specimen from a 23-year-old woman
with bilateral tubo-ovarian abscesses
Laparoscopic view of acute PID and a tubo-ovarian
abscess
Fitz-Hugh-
Curtis
Syndrome
 Overview of FHC Syndrome
Pathogenesis is still not well understood, but could result from
transperitoneal or hematologic dissemination of infectious organisms,
resulting to perihepatic inflammation and adhesions

Most common etiologic agents are N. gonorrhoeae and C. trachomatis

Other etiologic agents:
● Tuberculosis
● Anaerobic streptococci
● Coxsackie virus
 Clinical Features
Signs and symptoms
● Persistent signs and symptoms of PID plus RUQ pain, sharp pleuritic
pain, and tenderness on palpation of the RUQ/Liver
● Friction rub along the right anterior costal margin
● Pain may radiate to the shoulder or to the back
Laboratory Tests
● (+/-) elevated liver transaminases
 Intraoperative Findings
On Laparoscopic/Laparotomy,
● “Violin string” adhesions of the perihepatic surface and anterior
parietal peritoneum
● Inflamed liver capsule
 Treatment

Medical treatment is targeted to Laparoscopic adhesiolysis for

the causative organism relief of persistent symptoms
 Perihepatic enhance on CT in Fitz-Hugh-Curtis Syndrome
You, Je Sung et al. “Clinical features of Fitz-Hugh-Curtis Syndrome in the emergency department.” Yonsei medical journal vol. 53,4 (2012):
753-8. doi:10.3349/ymj.2012.53.4.753
Classic “Violin string” adhesions in Fitz-Hugh-Curtis Syndrome
A laparoscopic image of a 62-year old woman who had a 3-month long history of RUQ pain, diagnosed with
FHC syndrome
Guerra, F., & Coletta, D. (2019). Fitz-Hugh–Curtis Syndrome. New England Journal of Medicine, 381(22), e38. doi:10.1056/nejmicm1813625
 -FIN-

Thank you!
REFERENCES
(Main)
 REFERENCES
(Supplementary)
Centers for Disease Control and Prevention. 2015 Sexually Transmitted Disease Treatment Guidelines:
Pelvic Inflammatory Disease. 2015. Accessed from https://www.cdc.gov/std/tg2015/pid.htm

Centers for Disease Control and Prevention. Pelvic Inflammatory Disease (PID) Detailed Fact Sheet.
2017. Accessed from https://www.cdc.gov/std/pid/stdfact-pid-detailed.htm

Chua J, Mejia CID, Berba RP. Prevalence, Clinical Profile, and Treatment Outcomes of Adult Patients
Diagnosed with Disseminated Tuberculosis seen at University of the Philippines Manila-Philippine
General Hospital Tuberculosis Directly Observed Treatment Short Course (TB-DOTS) Clinic.2017. Acta
medica Philippina 51(4):300-309

Könönen E, Wade WG. 18 March 2015. Actinomyces and related organisms in human infections. Clin
Microbiol Rev doi:10.1128/CMR.00100-14.
 REFERENCES
(Supplementary)
Lely RG, van Es HW. Case 85: Pelvic Actinomycosis in Association with an Intrauterine Device.
Radiology 2005; 236:492–494.10.1148/radiol.2362031034

Valour et al. Actinomycosis: etiology, clinical features, diagnosis, treatment, and management. Infection
and Drug Resistance 2014:7 183–197. http://dx.doi.org/10.2147/IDR.S39601

Wong VK, Turmezei TD, Weston VC. Actinomycosis [Clinical Review]. BMJ 2011;343:d6099 doi:
10.1136/bmj.d6099

Theofanakis CP, Kyriakidis AV. Fitz-Hugh-Curtis Syndrome [Review Article]. Gynecol Surg (2011)
8:129–134 DOI 10.1007/s10397-010-0642-8

Monro K, Gharaibeh A, Nagabushanam S, Martin C. Diagnosis and management of tubo-ovarian

abscesses [Review Article]. The Obstetrician & Gynaecologist, Royal College of Obstetricians and
Gynecologists. 2018;20:11–9. DOI: 10.1111/tog.12447
 REFERENCES
(Supplementary)
Neonakis IK, Spandidos DA, Petinaki E. Female genital tuberculosis: A review. Scandinavian Journal of
Infectious Diseases, 2011; 43: 564–572