Introduction

• Pelvic inflammatory disease (PID)

• Including the endometritis (endometrium)
the salpingitis (oviducts)
the oophoritis(ovaries)
the myometritis (uterine wall)
the peritonitis (portions of the parietal peritoneum)
the perihepatitis
 Introduction
• Causes ：
• Majority (85%) ： sexually transmitted infection (STI)
• Other (15%) ： enteric pathogens
respiratory pathogens
iatrogenic pathogens

N Engl J Med. 2015 May;372(21):2039-48. Pelvic Inflammatory Disease Robert C. Brunham, M.D., Sami L. Gottlieb,
M.D., M.S.P.H., and Jorma Paavonen, M.D.
 Introduction
• Infection pathway ：

Picture from :https://urbanareas.net/info/health/sexually-transmitted-diseases-stds/pelvic-inflammatory-disease-

sexually-transmitted-disease/
Definitions 4

• Acute PID ： acute symptoms accompanying

ascending infection from the cervix to the
endometrium, tubes, ovaries, and pelvic peritoneum.
• Chronic PID ： chronic pelvic pain, often periodic in
exacerbation. Chronic pelvic infection can also be
caused by the more rare pelvic infection with
tuberculosis (TB) and actinomycosis.
• Silent PID ： asymptomatic or mildly symptomatic
pelvic infection
Acute symptomatic PID—Symptoms 5

Lower abdominal peritonitis or Abnormal uterine

pain pelvic abscess bleeding 
Acute symptomatic PID—Examinations 6

Lower abdominal Bimanual pelvic

tenderness examination
Acute symptomatic PID—Lab data 7

Peripheral blood
Elevated ESR, CRP
leukocytosis
Acute symptomatic PID—TOA 8

Tubo-ovarian abscess
Etiology
C1 陳家源
Incidence
• Usually a disease of young women. ( late teens and early 20s )
majority diagnosed younger than 25.
• The number of cases of PID in the United States has been declining.
(2003: 168,837 cases)
• US hospitalizations for the diagnosis of PID has also been declining
since the 1980s.
• Aggressive screening for and treatment of asymptomatic gonorrhea
and chlamydia : major contributing factor to the decline in diagnosis
of and hospitalizations for PID.
Costs
• Direct and indirect costs of PID and its sequelae are estimated at $2
billion annually with 70% of these dollars spent on the caring for
acute PID.
Medical sequelae
• Medical sequelae develop in one in four women with acute PID.
• 1. Tubal obstruction : leads to infertility.
• Infertility occurs after acute PID in 6% to 60% of cases. Risk: depends on the
severity and the number of episodes of infection.
• a. After one episode: 11.4%
• b. After two episodes: 23.1%
• c. After three episodes: 54.3%
Medical sequelae cont.
• 2. Ectopic pregnancy rate increases six-to tenfold in women with PID.
• (PID -> tubal damage->Approximately 50% of all ectopic pregnancies)
• 3. Chronic pelvic pain : 20% with acute PID.
• Both chronic pelvic pain and dyspareunia can be sequelae of PID.
• 4. Mortality: particularly in neglected cases in which ruptured tubo-
ovarian abscess can lead to septic shock and death.
• (>150 deaths annually in USA)
Sexual activity
• Women who are not sexually active do not contract PID.
• Women who are sexually active but use no contraception contract
3.42 cases of PID per 100 woman-years.
• Frequent sexual activity, early onset of sexual activity, multiple sex
partners, and a recent new sex partner are associated with risk for
developing PID.
Sexual activity
• Male condoms : very effective in preventing PID, STIs.
• (Latex and polyurethane > natural membrane)
• Female condoms (polyurethane): little data exists, should reduce chance of STDs
and therefore PID.
• Oral contraceptives (OCs): appear to protect users against PID:
• Only 0.91 case per 100 woman-years among women using the pill.
• But, more likely to screen positive for chlamydia.
• Relationship between the pill and PID may be the result of sexual factors,
including:
• Decreased menstrual flow
• Decreased ability of pathogenic bacteria to attach to endometrial cells
• Progestin-induced changes in the cervical mucus that retard the entrance of bacteria.
Sexual activity cont.
• Other barrier methods of contraception (e.g., the diaphragm, sponge,
and contraceptive foam) : protect against PID.
• Spermicides may also be bactericidal.
• may increase HIV transmission during vaginal intercourse.
• Intrauterine devices (IUDs) have been linked to an increased risk of
PID (5.21 cases per 100 woman-years).
• May be related to insertion rather than a sexually transmitted infection.
• The risk is confounded by epidemiologic factors:
• lower in monogamous, healthy women
• increases with a history of STI and sexual promiscuity.
• Currently utilized IUDs are associated with a lower risk than seen with older-model IUDs.
Prevention
• Majority are sexually transmitted and are theoretically preventable.
• Prevention efforts involve:
• Education of both the public and providers about healthy sexual
behaviors: help avoid transmission of infection
• Screening of individuals at risk for STDs and provision of timely treatment
and education to individuals who screen positive to prevent ascending
infection.
• Involving male partners in screening, treatment, and prevention
programs to prevent further transmission.
• Prompt treatment of PID to prevent tubal sequelae.
BACTERIOLOGY
C1 謝和成
BACTERIOLOGY
Bacteria for cases of PID Group
Neisseria gonorrhoeae(commom) sexually active pre-menopausal females
Chlamydia trachomatis(commom)
Mycoplasma genitalium

E. coli and colonic anaerobes post-menopausal women

Mycobacterium tuberculosis Very rare pathogens
Haemophilus influenza
Streptococcus pneumonia
Actinomycosis
BACTERIOLOGY
• PID is usually a polymicrobial infection.
• 25% - 40% of cases of PID:
N. gonorrhoeae and C. trachomatis coexist in the same individual.
• 70% of women diagnosed with PID:
(Isolated from the upper genital tract)
• Endogenous aerobic bacteria:
Escherichia coli, Gardnerella vaginalis, Streptococcus species, Proteus,
Klebsiella, and Haemophilus influenzae
• Endogenous anaerobic bacteria:
Bacteroides, Peptostreptococcus, and Peptococcus
Neisseria gonorrhoeae
• Gram-negative diplococcus.
• In women diagnosed with PID:
• 27% to 80% recovered from the cervix
• 13% to 18% recovered from the fallopian tubes
• 15 % women with an endocervical N. gonorrhoeae infection go on to
develop PID
• Gonococcal PID tends to be clinically more severe than chlamydia PID
Chlamydia trachomatis
• Obligate intracellular organism.
• The most common bacterial sexually transmissible disease.
• In women diagnosed with PID:
• 5% to 39% recovered from the cervix
• 0% to 10% recovered from the fallopian tubes
• Antibodies in 20% to 40% of women with a history of PID.
• 10-15 % endocervical C. trachomatis infections produce PID
• C. trachomatis accounts for 1/3 cases of PID
• Asymptomatic subclinical infections are also common, and these may
present years later as chronic pelvic pain or infertility.
Actinomyces israelii
• In 15% of IUD-associated cases of PID
• Unilateral abscesses.
• Rarely found in women who do not use an IUD.
Pathophysiology
• When PID occurs, salpingo-oophoritis is usually preceded by cervical
infection with gonorrhea and/or chlamydia
• Infection ascends when an inciting event occurs that allows bacteria
to ascend into the uterus and then into the tubal lumen, usually
bilaterally.
• Symptomatic ascending infection follows 10% to 40% of cervical
infections with gonorrhea and chlamydia.
Inciting events
• Menstrual periods.
• Two-thirds of acute PID cases begin just after menses.
• Sexual intercourse.
• Bacterial vaginosis (BV)
• Present in up to two-thirds of women diagnosed with PID.
• Alteration of the bacterial balance in the vagina with an overgrowth of
Gardnerella vaginalis and Mycoplasma organisms. These organisms can
break down naturally protective cervical mucus
• Iatrogenic events
Iatrogenic events
• Elective abortion
• Dilation and curettage or endometrial biopsy
• IUD insertion or use
• Hysterosalpingography
• Chromopertubation at laparoscopy
 Chronology of salpingo-oophoritis
Endosalpingitis Initially edema, proceeds to destruction of luminal cells,
cilia, mucosa.
Spreads to the tubal muscularis and serosa.
Direct extension through the fimbriated end of the tube.
Oophoritis Micro abscess may develop within the ovaries.
Peritonitis Resulted from either direct extension or lymphatic spread.
Perihepatitis Occurred with adhesion, RUQ pain, known as Fitz-
Hugh-Curtis syndrome.
Sequalea of PID
• Hydrosalpinges
• Tubal obstruction
• Tubo-ovarian abscesses
• Adhesions
• Ruptured abscesses, resulting in sepsis and shock
• Chronic pelvic pain and dyspareunia
Diagnosis
蕭文宣

29
 Diagnosis of pelvic inflammatory
disease
• The wide variation in symptoms and signs associated with PID can make
diagnosis challenging.
• The presumptive clinical diagnosis of PID is made in sexually active young
women, especially women at high risk for sexually transmitted infections
(STIs)

• Minimum criteria for diagnosis

1. Lower abdominal tenderness
2. Uterine or adnexal tenderness
3. Cervical motion tenderness
30
Additional criteria
• These additional criteria are used to increase the specificity of the diagnosis

1. Oral temperature higher than 100.9°F (38.3°C) present in less than one-third of women
diagnosed with PID
2. Abnormal cervical or vaginal discharge. Mucopurulent cervical discharge with white
blood cells (WBCs) seen on wet mount is almost always seen in women with PID
3. Elevated erythrocyte sedimentation rate (ESR)
4. Elevated C-reactive protein
5. Positive test for gonorrhea or chlamydia
6. Tubo-ovarian abscess seen on ultrasound
7. Evidence of endometritis on endometrial biopsy
8. Laparoscopic evidence of PID 31
Differential diagnosis for PID
1. Ectopic pregnancy
2. Ruptured ovarian cyst
3. Endometriosis
4. Cystitis
5. Appendicitis
6. Diverticulitis
7. Irritable bowel syndrome

32
Pelvic inflammatory disease: Clinical manifestations and diagnosis, UpToDate
Diagnostic techniques
• Cervical Gram stain
1. If Gram-negative intracellular diplococci are present, gonorrhea is the presumed
diagnosis.
2. Chlamydia is not diagnosed on Gram stain.
• Serum human chorionic gonadotropin (hCG)
1. A sensitive pregnancy test is important in the differential diagnosis of pelvic pain
to rule out the possibility of ectopic pregnancy
• Blood studies
1. Leukocytosis : not a reliable indicator of acute PID. Less than 50% of women
with acute PID have a WBC count greater than 10,000 cells/mL
2. Increased ESR : a nonspecific finding, but the ESR is elevated in approximately
75% of women with laparoscopically confirmed PID 33
Diagnostic techniques
• CT scan of the abdomen and pelvis
1. helpful in ruling out appendicitis
• Endometrial biopsy with histopathologic evidence of endometritis
• Transvaginal sonography or MRI
1. showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-
ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal
hyperemia)
• Laparoscopy
1. If the disease process is unclear, this technique is the ultimate way to establish
the diagnosis

34
Diagnostic techniques
• Follow-up
1. After initiation of appropriate treatment, clinical improvement should be
observed in 48 to 72 hours.
2. If no improvement occurs, alternative diagnoses should be considered.
• Testing
1. Test for HIV and assurance of current Pap smear screening should be offered to
all women diagnosed with PID.
2. Additionally, testing for syphilis and hepatitis B should be considered.

35
Management

Speaker: C1 許赫哲
 Outpatient therapy

Ceftriaxone 250 mg IM single dose

or
Doxycycline 100 mg orally twice daily
Cefoxitin 2 g IM single dose with
for 14 days
Probenecid 1 g orally
or
other Third-generation cephalosporinitin 2 g
intramuscular single dose with
probenecid 1 g orally

with or
without Metronidazole 500 mg twice daily for 14 daysys
Hospitalization

• Severe clinical illness

• Complicated PID with pelvic abscess

• Possible need for invasive diagnostic evaluation or surgical intervention

• Inability to take oral medications due to nausea and vomiting

• Pregnancy

• Lack of response or tolerance to oral medications

• Concern for nonadherence to therapy

Initial parenteral therapy

Regimen A

Cefoxitin 2g IV every 6 hours

Doxycycline 100 mg orally or IV
or 
every 12 hours
Cefotetan 2g IV every 12 hours 
Initial parenteral therapy

Regimen B

Gentamicin 3 to 5 mg/kg IV daily

or
Clindamycin 900 mg IV every 8 hours
2 mg/kg IV once followed by 1.5 mg/kg
every 8 hours
 Transition to oral therapy

with or Metronidazole 500 mg orally twice daily

Doxycycline 100 mg twice daily for 14 days without
for 14 days
Surgical intervention

• Patient’s condition worsens or fails to improve after 72 hours of

treatment

• Severe PID, especially when TOA is present

Tubo-ovarian
abscess

• TOA is an inflammatory mass involving the fallopian tube, ovary,

and, occasionally, other adjacent pelvic organs

• The diagnosis of TOA may be suspected on examination and then

generally confirmed on ultrasound.
 Tubo-ovarian
abscess

without Minimally invasive

If meets the following criteria: improvement
• hemodynamically stable abscess drainage procedure
• abscess <7 cm
• adequate response to antibiotic
therapy
• Premenopausal

worsening
Surgical treatment
antibiotic therapy alone
other causes of pelvic
infection
other causes of pelvic infection
• Granulomatous salpingitis
• Tuberculous salpingitis
• Leprous salpingitis
• Actinomycosis
• Schistosomiasis
• Sarcoidosis
• Foreign body salpingitis
• Nongranulomatous salpingitis
Tuberculous salpingitis
• almost always represents systemic TB. The incidence is high in underdeveloped
countries and low in developed countries. It usually affects women in their
reproductive years, but an increased incidence has been reported among
postmenopausal women. Primary genital TB is extremely rare in the United
States. Induration may be noted in the paracervical, paravaginal, and parametrial tissues.
Physical The typical patient is 20 to 40 years of age with known TB and a pelvic mass.
findings Symptoms are related to a family history of TB, low-level pelvic pain, infertility, and
amenorrhea.

Grossly, the uterine tube has a classic “tobacco pouch” appearance—enlarged and distended.
The proximal end is closed, and the fimbriae are edematous and enlarged.
Pathology
Microscopically, tubercles show an epithelioid reaction and giant cell formation. Inflammation
and scarring are intense and irreversible.

standard regimens for disseminated TB, including isoniazid, rifampin,

Treatment
and ethambutol. Prognosis for cure is excellent, but the outlook for fertility is dismal.
Leprous salpingitis
• The histologic picture is similar to the one for TB, and the two are
often difficult to distinguish on a histologic basis. Langerhans giant
cells and epithelioid cells are present. Positive cultures are necessary
for a diagnosis of TB.
Actinomycosis
• Actinomycosis israelii, the causative agent, is pathogenic for humans but not for
other mammals. Most gynecologic involvement is infection secondary to
appendiceal infection, gastrointestinal tract disorders, or IUD use. A total of 100
cases are reported annually, and the age range of prevalence is about 20 to 40
years.
Physical Half the lesions are bilateral and are characterized by adnexal enlargement and
findings tenderness. Presenting symptoms may be confused with those of appendicitis.

Grossly, there is tubo-ovarian inflammation, as well as copious necrotic material on sections of

the tube. The tubal lumen may have an adenomatous appearance. Microscopically,
Pathology
actinomycotic “sulfur” granules are present. Club-like( 棒狀 ?) filaments radiate out from the
center. A monocytic infiltrate is apparent, and giant cells may be present.

Treatment prolonged course of penicillin

Schistosomiasis
• occurs most commonly in the Far East and Africa
Physical pelvic pain, menstrual irregularity, and primary infertility. The diagnosis is usually
findings made by histopathologic findings.

Grossly, lesions appear as a nonspecific tubo-ovarian process. Microscopically, the ova or

Pathology schistosome is seen surrounded by a granulomatous reaction with giant and epidermoid cells.
An egg within an inflammatory milieu is a dramatic sight.
• Sarcoidosis
• Although rare, sarcoidosis can lead to a granulomatous salpingitis.
• Foreign body salpingitis
• occurs after the use of non-water-soluble dye material for
hysterosalpingography. It may also be secondary to medications placed
within the vagina, such as starch, talc, and mineral oil.
Nongranulomatous salpingitis
• refers to any other bacterial infection, usually of the peritoneal cavity,
that can secondarily cause tubal infection, including:
1. Appendicitis
2. Diverticulitis
3. Crohn disease
4. Cholecystitis
題目
•Q ： 19 歲小姐上一次月經 (last menstrual period) 在 32 天前，
並
•有性生活史，今向 ER 求助，主述下腹痛已持續 5 天。生
命體徵：體溫 38.3 °C ， BP ： 110/75 ， HR ： 80 ，呼
吸： 16 。鏡檢發現子宮頸口有膿性滲出物、 cervical
motion tenderness ， bimanual examination 未發現明顯腫
塊但有明顯疼痛她的定量血清 hCG = 150 mIU / mL 。 尿液
分析正常、 WBC ： 14,000 。 超聲波檢查顯示子宮大小正
常，紋路正常且無 adnex 腫塊。
題目 _1
• 該患者的下一個最佳處置步驟是？
• A. Repeat serum hCG in 48 hours
• B. Penicillin G intravenously
• C. Ampicillin and gentamicin intravenously
• D. Clindamycin and gentamicin intravenously
• E. Cefazolin and doxycycline intravenously
題目 _2
• 下列對細菌學的敘述何者正確？
• A. Chlamydia trachomatis is found in 20% to 40% of cervical
specimens with PID
• B. N. gonorrhea is recovered from the cervix in up to 20% of cases
of PID
• C. H. infl uenzae is found in 15% of IUD-associated PID
• D. E. coli is the most common anaerobic bacteria identifi ed in PID
• E. N. gonorrhea and C. trachomatis coexist in 25% to 40% of cases
of PID
題目 _3
• 17 歲小姐有骨盆腔炎的症狀，但病人堅稱自己沒有性經驗。
如果子宮、輸卵管、卵巢有發炎的症狀，最可能的診斷是 ?
• A. Tuberculosis
• B. Endomyometritis
• C. Schistosomiasis
• D. Appendicitis
• E. Ectopic pregnancy
QUESTIONS 4–5 58

A 22-year-old woman, gravida 1, para 0, total abortions 1, presents

to the emergency department reporting a 6-day history of lower
abdominal pain and purulent vaginal discharge.
She denies past medical history or surgery. Her vitals are as follows:
T 38.9°C, BP 118/78, P 96, R 14.
Abdomen is without scars, bowel sounds are present, and there is
tenderness in the lower pelvic region of the abdomen. However,
there is no rebound tenderness or guarding.
Her speculum examination reveals white exudate at the external os
of the cervix.
Bimanual examination reveals severe cervical motion tenderness
and uterine tenderness. There is also a fullness in the left adnexa.
Her urine hCG is negative, and WBC count 15,000.
 59

4. The next best step in management is:

A Pelvic ultrasound
B Computed tomography scan
C Quantitative serum b-hCG
D Immediate hospitalization
E Ceftriaxone intramuscularly plus doxycycline orally
60
Clinical criteria for diagnosis of PID 61

Minimum criteria for diagnosis ：

a. Lower abdominal tenderness
b. Uterine or adnexal tenderness
c. Cervical motion tenderness

Additional criteria ：
d. Oral temperature higher than 100.9 ° F (38.3 ° C)
e. Abnormal cervical or vaginal discharge.
f. Elevated ESR, CRP
g. Positive test for gonorrhea or chlamydia
h. Tubo-ovarian abscess seen on ultrasound
i. Evidence of endometritis on endometrial biopsy
j. Laparoscopic evidence of PID
 62

4. The next best step in management is:

A Pelvic ultrasound =>evaluate for a tubo-ovarian abscess
B Computed tomography scan =>is not as useful as an
ultrasound
C Quantitative serum b-hCG =>urine hCG is negative
D Immediate hospitalization =>if tubo-ovarian abscess
E Ceftriaxone intramuscularly plus doxycycline orally =>if
rule out tubo-ovarian abscess
 63

4. The next best step in management is:

A Pelvic ultrasound =>evaluate for a tubo-ovarian abscess
B Computed tomography scan =>is not as useful as an
ultrasound
C Quantitative serum b-hCG =>urine hCG is negative
D Immediate hospitalization =>if tubo-ovarian abscess
E Ceftriaxone intramuscularly plus doxycycline orally =>if
rule out tubo-ovarian abscess
 64

5. The most important reason to admit this patient to the

hospital is:
A WBC count
B Temperature
C Pelvic examination
D Age of patient
E Patient is unreliable
Hospitalization of PID’s indications 65

1. Until other serious diagnoses are excluded, including

appendicitis and ectopic pregnancy
2. If the patient is an adolescent
3. If a pelvic abscess is suspected on examination or
ultrasound
4. Severe systemic/peritoneal symptoms including high
fever, or signs of peritonitis
5. Inability to tolerate oral outpatient treatment
because of vomiting
6. If the patient is pregnant
7. If HIV infection is present
8. If the patient has not responded to outpatient
management at 48- to 72-hour follow-up
 66

5. The most important reason to admit this patient to the

hospital is:
A WBC count
B Temperature =>Severe systemic/peritoneal symptoms
including high fever, or signs of peritonitis
C Pelvic examination =>If a pelvic abscess is suspected on
examination or ultrasound
D Age of patient =>22 years-old, not adolescent
E Patient is unreliable
 67

5. The most important reason to admit this patient to the

hospital is:
A WBC count
B Temperature =>Severe systemic/peritoneal symptoms
including high fever, or signs of peritonitis
C Pelvic examination =>If a pelvic abscess is suspected on
examination or ultrasound
D Age of patient =>22 years-old, not adolescent
E Patient is unreliable