PELVIC INFLAMMATORY DISEASE AND VAGINAL

DISCHARGE

PREPARED BY :
1) SHEHAN JAYASINGHE (SUKD1701715)
2) SABRIENA BINTI MOHAMED NAZIM (SUKD1702212)
PELVIC INFLAMMATORY DISEASE
 DEFINITION

• Defined when there is ascending infection from the

endocervix to higher reproductive tract.

• Subsequent inflammation of upper female genital tract

• Infection of the fallopian tubes involving ovaries and

peritoneum

• It is a recognised complication of chlamydia and less

frequently of gonorrhea.
 ETIOLOGY

Primary organisms (sexually transmitted)

• Neisseria gonorrhoeae
• Chlamydia trachomatis
• Mycoplasma genitalium

Secondary organism (normally found in vagina)

• Non-hemolytic streptococci
• Escherichia coli
• Staphylococci
 RISK FACTORS

• Multiple sexual partners

• Unprotected sexual intercourse
• Regular vaginal douching
• History of pelvic inflammatory disease
• Use of intra-uterine contraceptive device
• Being a sexually active woman younger
than 25 years
 CLINICAL FEATURES

• Lower bilateral abdominal pain

• Dyspareunia
• Altered vaginal discharge
• Intermenstrual bleeding
• Postcoital bleeding
• Fever
• Dysuria
 PHYSICAL EXAMINATION

• Abdominal examination - tenderness, guarding, rigidity

• Pelvic examination - cervical motion tenderness, uterine tenderness,
adnexal tenderness
• Speculum examination - purulent discharge from cervix
• Bimanual examination - tenderness while moving the cervix
 DIAGNOSTIC CRITERIA

CDC diagnostic criteria for PID - 2010

Minimum criteria :
• Cervical motion tenderness
• Uterine tenderness
• Adnexal tenderness
Additional criteria :

• Oral temperature >38.3

• Abnormal cervical or vaginal mucopurulent discharge
• Presence of abundant numbers of WBC on saline microscopy of vaginal
fluid
• Elevated erythrocyte sedimentation rate
• Elevated c-reactive protein
• Laboratory documentation of cervical infection with N.Gonorrhoeae or
C.Trachomatis
 DEFINITIVE CRITERIA

• Endometrial biopsy with histopathological evidence of endometritis

• Transvaginal sonography or MRI techniques showing thickened,
fluid-filled tubes with or without free pelvic fluid or tubo-ovarian
complex, or doppler studies suggesting pelvic infection
• Laparoscopic abnormalities consistent with PID
 DIFFERENTIAL DIAGNOSIS

• Ectopic pregnancy
• Acute appendicitis
• Pelvic endometriosis
• Adnexal tumours
• Septic miscarriage
 INVESTIGATIONS
• Endocervical swab and high vaginal swabs and presence of abundant numbers of
WBC on saline microscopy of vaginal fluid
• A. Endocervical swab - C. Trachomatis and N. Gonorrhoeae
• B. High vaginal swab - trichomonas vaginalis and bacterial vaginosis
• C. Negative swabs does not exclude PID
• FBC: TWCC elevated 
• CRP: elevated
• USS: tubo-ovarian abscess, cogwheel appearance, fallopian tube thickening and
hydrosalpinx
• Laparoscopy: 
• Oedema and erythema of the tubes
• Purulent exudates from the fimbrial ends
• Evidence of salpingo-oophoritis
• Peritubal adhesion
• Pelvic abscess

• Urine analysis to exclude urinary tract infection

• Urine pregnancy test to rule out ectopic pregnancy

 MANAGEMENT
1.Treated as outpatient settings and reviewed after 72 hours for response of
treatment :

A.Antibiotic regime - cover for both chlamydia and gonorrhoea

• I. Doxycycline 100 mg BD ✕ 2/52 and metronidazole 500 mg BD ✕ 5/7
• II. If gonorrhoea - add ciprofloxacin 500 mg as a single dose

B.Outpatient treatment: for mild disease

• I.Cefuroxime 250-500 mg PO BD
• Ii.PLUS doxycycline 100 mg PO BD
• Iii.PLUS 400 mg every 4 hours
C.IV therapy for moderate to severe disease
• I.2nd or 3rd generation cephalosporins, e.G. Cefuroxime 750 mg IV q8h OR 
ceftriaxone 2g IV q24h
• Ii.PLUS doxycycline 100 mg PO q12h
• Iii.PLUS metronidazole 400 mg PO q8h
D.Duration -  14 days

2.Contact tracing and treatment of partners

3.Avoid intercourse during course of treatment

4.Tubo-ovarian abscess: drainage required by ultrasonic guided aspiration or

laparoscopy
5. ADMISSION REQUIRED IF:

• Surgical cause has not been excluded

• Adolescent
• High grade fever
• Symptoms are severe
• Failure in outpatient management
• Tubo-ovarian abscess is suspected
 COMPLICATIONS

• Infertility: the risk of infertility following PID is related to the number of

episodes of PID and their severity.
• Ectopic pregnancy.
• Chronic pelvic pain.
• Perihepatitis (fitz-hugh curtis syndrome): causes right upper quadrant pain.
• Tubo-ovarian abscess.
• Reiter's syndrome.
• In pregnancy : PID is associated with an increase in preterm delivery,
and maternal and fetal morbidity.
• Neonatal : perinatal transmission of c. Trachomatis or N.
Gonorrhoeae can cause ophthalmia neonatorum. Chlamydial
pneumonitis may also occur.
• Delaying treatment for pelvic inflammatory disease increases risk of
infertility.
 VAGINAL
DISCHARGE
 Vaginal discharge may be physiological or pathological

Physiological
 Physiological vaginal discharge composed of bacterial flora, water, electrolytes, and
vaginal and cervical epithelium.
 The secretions increase during ovulation, pre-menstrual and during pregnancy.
 It is typically white, floccular, odorless, and seen in dependent areas of the vagina.
Pathological
 Secreted from lesions in vagina or cervix, or due to pelvic inflammatory disease (PID).
 It is often associated with:
- foul-smelling
- itchiness
- bleeding
- soreness
Normal Vaginal Discharge
Natural  in secretion at :
● A few days before ovulation
● During the first 2 weeks of life (because
maternal estrogens are transferred before
birth)
● During the few months before menarche
and during pregnancy (when estrogen
production increases)
● Hormonal drugs that contain estrogen
Factors that predispose to overgrowth of bacterial vaginal pathogens include:
● Use of antibiotics
● Alkaline vaginal pH (due to menstrual blood, semen, or a decrease in
lactobacilli)
● Poor hygiene
● Frequent douching
● Pregnancy
● Diabetes mellitus
● Intravaginal foreign body (tampon, vaginal pessary)

Types of Discharge
Bloody / Brown
Cloudy / Yellow
Frothy, yellow or greenish
Pink
Thick, white, cheesy
White, gray, or yellow with
fishy odor
Types of Discharge
Indication Associated symptoms
Irregular menstrual cycles, or • Abnormal vaginal bleeding
less often, cervical / • Pelvic pain
endometrial CA
Gonorrhea • Bleeding between periods
• Urinary incontinence
• Pelvic pain
Trichomoniasis • Pain during urination, vaginal itching
Lochia
Yeast infection • Swelling and pain around the vulva
• Pruritis (vagina)
• Dyspareunia
Bacterial vaginosis • Itching / burning of the vagina
• Redness & swelling of the vaginal /
vulva
Causes of Vaginal Discharge
ABNORMAL
VAGINAL
DISCHARGE
 ABNORMAL VAGINAL DISCHARGE

The common conditions giving rise to vaginal infections and discharge are as follows :
 Bacterial vaginosis
 Trichomonal vaginitis
 Candidal vulvovaginitis
 Atrophic vaginitis
 Bacterial Vaginosis (BV)
 BV is the most common vaginal infection, responsible for 40-50% of all cases caused by a
shift in the composition of the normal bacterial flora.

 There is an increase in anaerobic bacteria, Prevotella and Mobiluncus, Gardnerella

vaginalis and a decrease in the concentration of lactobacilli.

 Causes/Risk factors are :

 Using perfumed bubble bathsand some scented soaps
 Smoking
 Washing underwear with strong detergents

**BV cannot be caught from toilet seats, bedding, swimming pools, or touching objects
CLINICAL FEATURES
1. Vaginal discharge may:
 Be watery and thin
 Be gray or white in color
 Have a strong and unpleasant smell, often described
as fishy

2. Less commonly, there may be:

 A burning sensation during urination
 Itching around the outside of the vagina
 Diagnostic criteria
Amsel’s criteria
• Requires at least three of the following four criteria must be present for diagnosis:

Fishy odour
 TREATMENT
 Highly effective with metronidazole- 200 mg orally thrice daily for 7 days
 Clindamycin Cream (2%) and metronidazole (0.75%) gel are recommended for vaginal
application daily for 5 days to prevent obstetric complications
 The patient’s sexual partner should be treated simultaneously
 Cure rate is 80%.
 Recurrence is common but should only be treated if symptoms returns
 PREGNANCY AND BACTERIAL VAGINOSIS

Presence of bacterial vaginosis in the first trimester can lead to late second trimester
miscarriages and preterm labour with its associated complications.

Women with a previous history of second trimester loss or preterm delivery should have
a vaginal swab performed in early pregnancy and if bacterial vaginosis is detected, it
should be actively treated in the early second trimester of pregnancy.

Metronidazole is safe to use in pregnancy, however, large or prolonged doses should be

avoided.
 TRICHOMONAS VAGINITIS
● Vaginal trichomoniasis is the most common and important
cause of vaginitis in the childbearing period.

● Causative Organism : Trichomonas vaginalis, a pear-

shaped unicellular flagellate protozoa.

● Mode of Transmission
○ Sexual contact, the male harbors the infection in the
urethra and prostate.
○ The transmission may also be possible by the toilet
articles from one woman to the other or through
examining gloves.
 CLINICAL FEATURES
 Sudden profuse, offensive watery, greenish vaginal discharge often dating from the
last menstruation.
 Irritation and itching of varying degrees within and around the introitus are common.
 Presence of urinary symptoms such as dysuria and frequency of micturition.
 There may be history of previous similar attacks. Women with trichomoniasis should
be evaluated for other STDs including N. gonorrhea, C. trachomatis, and HIV.
 PHYSICAL EXAMINATION
 Thin, greenish-yellow and frothy
offensive discharge per vaginum.
 Vulva is inflamed with evidences of
pruritus.
 Vaginal walls become red and
inflamed with multiple punctate
hemorrhagic spots. Similar spots are
also found over the mucosa of the
portio vaginalis part of the cervix on
speculum examination giving the
appearance of ‘strawberry’
 DIAGNOSIS
 Identification of the trichomonas is done by hanging drop preparation. If found negative
even on repeat examination, the confirmation may be done by culture.
 Culture of the discharge collected by swabs.
 In suspected cases, gonococcal or monilial infection should be excluded.
 TREATMENT
 Metronidazole 200 mg thrice daily by mouth is to be given for 1 week. A
single dose regimen of 2 g is an alternative.
 Tinidazole single 2 gm dose PO is equally effective.
 The husband should be given the same treatment schedule for 1 week.
 Resistance to metronidazole is extremely rare.
 The husband should use condom during coitus irrespective of
contraceptive practice until the wife is cured.
 CANDIDAL VULVOVAGINITIS
 Candidal vaginitis is vaginal infection
with Candida species, usually Candida
albicans.

 Candida albicans is part of the normal

vaginal flora in 25% of the women and
causes 90% of candidal vaginitis.

 The fungi multiply & grow rapidly when

concentration of Lactobacilli decreases.
 CLINICAL FEATURES

 Vaginal discharge (thick & white). May be sourish.

 Severe pruritus
 Irritant discharge
 Inflammed and tender vagina

 Vaginal examination :
 Removal of the plaque reveals a read inflammed area.
 White plaques resembling curdled milk adhering to the vaginal
wall and vulva.
DIAGNOSIS
● Perineal / vaginal swab
● Gram stain / wet film
examination

MANAGEMENT ( NON-PHARMACOLOGICAL)
● Avoid using any soaps, perfumes and synthetic
underwear
● High-dose oestrogen COCP should change to low-dose
● Monitor blood glucose level
● Avoid recurrent courses of broad spectrum antibiotics
 TREATMENT
UNCOMPLICATED INFECTION
● Azoles / imidazoles can be used either as local topical / oral
preparations
● Common imidazole
○ Clotrimazole
○ Econazole
○ Miconazole
○ Fluconazole (Oral) - single dose at 150mg (avoid in pregnancy)
○ Itraconazole 200 mg twice/ day for 1 day (avoid in pregnancy)
● Antifungal
○ Nystatin cream
○ Pessary
COMPLICATED INFECTION
● Common seen in acute severe
infection in pregnancy, DM, or
immunosuppression.
● Topical treatment can be extended
up 2 weeks.
 ATROPIC VAGINITIS

➔ Vaginitis in postmenopausal women is called atrophic vaginitis. The term is preferable to senile
vaginitis.
➔ There is atrophy of the vulvovaginal structures due to estrogen deficiency.
➔ Oestrogen deficiency causing reduction in the number of glands producing mucus.
➔ Loss of fat tissue around genital area.
➔ The vaginal defence is lost. Vaginal mucosa is thin and is more susceptible to infection and
trauma.
➔ There may be desquamation of the vaginal epithelium which may lead to formation of adhesions and
bands between the walls.
➔ Changes can take months to years after onset of menopause.
 ON HISTORY
• Abdominal discomfort or pain – vagina or vulva inflamed
• Yellowish or blood-stained vaginal discharge
• Discomfort, dryness, soreness in vulva
• Dyspareunia
• Pruritis
• Urinary symptoms – due to thickening and weakening of tissues around the neck
of the bladder and urethra (e.G urgency, dysuria, recurrent uti)

➔ ON EXAMINATION
◆ Evidences of pruritus vulvae.
◆ Vaginal examination is often painful and the walls are found inflamed. On inspection, the
wall will be pale, thin, atrophic and evidence of bleeding when opening the speculum.
 CAUSES
● Decrease in estrogen after menopause.

● It can also occur after childbirth, and it can happen when anti-
estrogen drugs are used to treat other conditions.

● Medications or hormones can be used as part of the treatment

for breast cancer, endometriosis, fibroids, or infertility to reduce
estrogen levels.

● This decrease can lead to atrophic vaginitis.

 TREATMENT
● Improvement of general health and treatment of infection if present should be
done.
● Lubricating gels – for the Vaginal dryness and dyspareunia.
● Systemic estrogen therapy may be considered if there is no contraindication.
This improves the vaginal epithelium, raises glycogen content, and lowers
vaginal pH.
● Intravaginal application of estrogen cream by an applicator is also effective.
● About one-third of the vaginal estrogen is systemically absorbed.
• Oestrogen creams – Cream, pessary, vaginal ring.
 Everyday for 2 weeks and twice weekly for further 3 months
 Localised treatment

• HRT – If menopausal symptoms also a problem.