Pelvic inflammatory disease

- Case scenario
- Introduction
- Pathophysiology
Introduction
• Definition
Pelvic inflammatory disease (PID) is an infection of the upper female
genital tract including any combination of endometritis, salpingitis,
tubo-ovarian abscess, and pelvic peritonitis.
It is considered to be the most serious complication of STIs.
Risk factors
• Multiple sexual partners.
• IUD
• Recent history of bath tub / SPA visit
• Previous history of PID
• Cigarettes smoking
• Recurrent chlamydia and gonorrhea infections

OCP has shown to decrease the incidence of PID possibly by:

1- increasing cervical mucus viscosity
2- decreasing menstual flow
3- modifying local immune response
Pathophysiology
• Most of PID cases are presumed to occur in two stages
1- vaginal acquisition and cervical infection
The infection is often sexually transmitted and may be asymptomatic
2- Direct ascent of the microorganisms to the upper genital tract with
infection and inflammation of these structures
The exact mechanism of ascend is unclear
Clinical features
NG MEI YEE
BMS14091113
17/4/2019
History
• Bilateral lower abdominal tender radiate to the legs
• Abnormal vaginal discharge or bleeding (intermenstrual, post coital or
breakthrough bleeding)
• Dyspareunia
• Pyrexial (>38o)
• Sexual history(recent sexual exposures,use of
condoms/contraception,previous STD)
Examination
• Systemic examination: tachycardia and high fever (severe cases)
• Abdomen examination: lower abdominal tenderness
• Pelvic examination: Bilateral adnexal tenderness, cervical
excitation(pain on moving the cervix),mass
Differential Diagnosis
• Ectopic pregnancy
• Acute appendicitis
• Ovarian cyst
• Urinary tract infection
Investigation
• Pregnancy test
• Endocervical swabs: Chlamydia and gonococcus
• Full blood count: Wcc and C-reactive protein raised
• Pelvic ultrasound:exclude abscess or ovarian cyst
• Laprocopy with fimbrial biospy and culture:gold standard,not
commonly performed
Treatment of PID
Ng Li Ying BMS 14091448
Outpatient vs Inpatient treatment
• Admission for parenteral therapy, observation, or possible surgical
intervention should be considered in the following situations:
• A surgical emergency cannot be excluded
• Lack of response to oral therapy
• Clinically severe disease
• Presence of a tubo-ovarian abscess --> drainage
• Intolerance to oral therapy
• Pregnancy
Outpatient regimen
• Ceftriaxone 500 mg IM single injection with Doxycycline 100 mg orally
twice daily for 14 days and Metronidazole 400 mg orally twice daily
for 14 days
Inpatient regimen
• Ceftriaxone 2 g IV daily plus IV/oral Doxycycline 100 mg twice daily
plus oral Metronidazole 400 mg twice daily for a total of 14 days
Complications (Early)
• Abscess
• Pyosalpinx
Complications (Late)
• Subfertility
• Chronic PID
• Chronic pelvic pain
• Ectopic pregnancy
• Fitz-Hugh-Curtis syndrome (10%)
• perihepatic adhesions that are secondary to pelvic infection (C.trachomatis)
• presented with RUQ pain
• usually diagnosed at laparoscopy
Chronic PID
• Persisting infection
• is the result of non-treatment or inadequate treatment of acute PID
• Features:
• dense pelvic adhesions
• fallopian tubes obstructed and dilated with fluid (hydrosalpinx) or pus (pyosalpinx)
• Symptoms:
• chronic pelvic pain
• dysmenorrhea
• deep dyspareunia
• heavy and irregular menstruation
• chronic vaginal discharge
• subfertility
• Examination:
• features similar to endometriosis
• abdominal and adnexal tenderness
• a fixed retroverted uterus
• Transvaginal ultrasound
• fluid collections within fallopian tubes
• surrounding adhesions
• Laparoscopy is the best diagnostic tool for chronic PID
• culture is often negative
• Treatment:
• Active infection (analgesics and antibiotics)
• Drainage
• Adhesiolysis
• Salpingectomy
Counselling
• Screen her sexual partner(s) for infection to prevent her becoming re-
infected
• Avoid unprotected intercourse until patient and her partner(s) have
completed treatment and follow up
• Counsel for complications
• Repeat episodes of PID are a/w an exponential increase in risk of
infertility
• Earlier treatment is given to lower risk of future fertility problems
References
• Kuldip Singh Integrated Approach to O&G
• Lawrence Impey Tim Child O&G
Case scenario
• A 23-year-old G0 P0 woman complains of lower abdominal tenderness
and subjective fever. She states that her last menstrual period started
5 days previously and was heavier than usual. She also complains of
dyspareunia of recent onset. She denies vaginal discharge or prior
sexually transmitted diseases. Her appetite has been somewhat
diminished. She has urinary urgency or frequency. On examination,
her temperature is 100.8°F (38.2°C), blood pressure (BP) 90/70 mm
Hg, and heart rate (HR) is 90 beats per minute (bpm). Her heart and
lung examinations are normal. The abdomen has slight lower
abdominal tenderness. There is no rebound tenderness and no
masses. No costovertebral angle tenderness is noted. On pelvic
examination, the external genitalia are normal. The cervix is somewhat
hyperemic, and the uterus as well as adnexa are bilaterally exquisitely
tender. The pregnancy test is negative.
Case scenario
• What is the most likely diagnosis? • Pelvic
Inflammatory
Disease

• What are the feared long term complications?

• Ectopic
• Infertility