Pelvic Inflammatory Disease

KABERA René,MD
PGY III Resident
Family and Community Medicine
National University of Rwanda
PLAN
• Introduction
• Causes
• Risk factors
• Diagnosis
• Differential Diagnosis
• Treatment
• Complications
• Prognosis

OCT 2010 2
INTRODUCTION
• PID is a clinical syndrome caused by the ascent of microorganisms from the
vagina and endocervix to the endometrium, fallopian tubes, ovaries, and
contiguous structures.
• PID is a broad term that includes a variety of upper genital tract infections
unrelated to pregnancy or surgical procedures, such as salpingitis, salpingo-
oophoritis, endometritis, tubo-ovarian inflammatory masses, and pelvic or
diffuse peritonitis

OCT 2010 3
CAUSES

• Chlamydia trachomatis
• Neisseria gonorrhoeae,
• Mycoplasmas have also been implicated but their role is less clear.
• Groups A and B streptococci, staphylococci, gram-negative rods (commonly
Klebsiella species, Escherichia coli, and Proteus species)
• Wide variety of aerobic and anaerobic bacteria
• Vaginal flora, eg, anaerobes, G. vaginalis, H. influenzae, enteric gram-
negative rods, Streptococcus agalactiae, M. hominis, and U. urealyticum
have been implicated

OCT 2010 4
RISK FACTORS
• Sexually active, reproductive age
• Most common in adolescents
• Multiple sexual partners
• Use of an IUD, greatest risk in first few months after insertion
• Previous history of PID; 20-25% will have a recurrence
• Chlamydial or Gonococcal cervicitis; 8-10% will develop PID
• Gonococcal salpingitis occurs commonly within 7 days of onset of menses
• Condoms and vaginal spermicides lessen the risks of PID
• Oral contraceptives may reduce the risk of PID

OCT 2010 5
DIAGNOSIS

Signs and Symptoms
• Lower abdominal pain,
• Chills and fever,
• Nausea and vomiting
• Menstrual disturbances,
• purulent cervical discharge,
• Urinary discomfort
• Cervical and adnexal tenderness.
• Right upper quadrant pain (Fitz-Hugh and Curtis syndrome) may indicate an
associated perihepatitis.

OCT 2010 6
DIAGNOSIS

Laboratory tests
• Pregnancy test
• Leukocyte count greater than 10,000 cells per mm3
• Endocervical gram stain for gram-negative intracellular diplococci.
• ESR of 15 mm/hour or higher.
• Endocervical culture for gonorrhea.
• Endocervical culture or antigen test for chlamydia.
• Plasma cell endometritis on endometrial biopsy.
• Liver enzymes may be elevated in Fitz-Hugh-Curtis syndrome.

OCT 2010 7
DIAGNOSIS

Special tests
• Culdocentesis with culture of aspirated material
• Diagnostic laparoscopy with culture of fallopian tubes

Imaging
• Pelvic ultrasound

OCT 2010 8
DIAGNOSIS
 Diagnostic criteria for PID
• PID diagnosis is elusive and even asymptomatic patients are at risk for
sequelae.
• In general, wiser to over-treat lower tract genital infection than to miss an
upper tract infection.

Suggested criteria for diagnosis
Sufficient for empiric treatment
• Lower abdominal tenderness
• Uterine/adnexal tenderness
• Cervical motion tenderness

OCT 2010 9
DIAGNOSIS

Supportive criteria for diagnosis
• Fever >38.3°C (101°F).
• Abnormal cervical/vaginal discharge.
• Intracellular gram-negative Diplococci on Endocervical Gram stain
• Leukocytosis >10,000/mm3.
• Elevated ESR or C-reactive protein.
• WBCs or bacteria in peritoneal fluid obtained by Culdocentesis or
laparoscopy.

OCT 2010 10
DIFFERENTIAL DIAGNOSIS
• Appendicitis
• Ectopic pregnancy
• Septic abortion
• Hemorrhagic or ruptured ovarian cysts or tumors
• Twisted ovarian cyst
• Degeneration of a myoma
• Acute enteritis

OCT 2010 11
TREATMENT

 Outpatient
 Hospitalization
Recommended in the following situations
• Uncertain diagnosis
• Surgical emergencies cannot be excluded, e.g., appendicitis
• Suspected pelvic abscess
• Pregnancy
• HIV-infected

OCT 2010 12
TREATMENT
 General measures
• Avoidance of sex until treatment is completed
• Insure that sex partners are referred for appropriate evaluation and
treatment.
• Partners should be treated, irrespective of evaluation, with regimens
effective against chlamydia and gonorrhea.

OCT 2010 13
TREATMENT

 Medical treatment#

Manage ABCs and shock as indicated.

Parenteral-regimen A
• Cefoxitin IV 2 g every 6 hours or
• Cefotetan IV 2 g every 12 hours or
• Other Cephalosporins such as Ceftizoxime, Cefotaxime, and Ceftriaxone.
• Plus Doxycycline 100 mg orally or IV every 12 hours.

# CDC STD TREATMENT GUIDELINES

OCT 2010 14
TREATMENT

Parenteral-regimen B#
• Clindamycin 900 mg IV every 8 hours
• Plus Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by
a maintenance dose (1.5 mg/kg) every 8 hours.
• Therapy for 24 hours after clinical improvement with doxycycline after
discharge as above, or clindamycin 450 mg orally qid for a total of 14 days.

# CDC STD TREATMENT GUIDELINES

OCT 2010 15
TREATMENT

Outpatient treatment-regimen A#
• Ofloxacin 400 mg orally bid for 14 days or
• Levofloxacin 500 mg orally once daily for 14 days
• With or without Metronidazole 500 mg orally bid for 14 days.

Outpatient treatment-regimen B#
• Cefoxitin 2 g IM plus Probenecid, 1 g orally, concurrently or ceftriaxone 250
mg with or without metronidazole 500 mg orally bid for 14 days.
• Cephalosporin IM or equivalent plus Doxycycline 100 mg orally bid for 10-14
days.

# CDC STD TREATMENT GUIDELINES

OCT 2010 16
TREATMENT

 Surgical management
• Reserved for failures of medical treatment and for suspected ruptured
adnexal abscess with resulting acute surgical abdomen.
• Conservative surgery preferred this allows a 10-15% postoperative fertility
rate.
• Hysterectomy and adnexectomy for older patients with completed childbirth.
• Failure of medical therapy generally associated with adnexal abscess which
may be amenable to transabdominal or transvaginal drainage under
guidance by ultrasonography computerized tomography, or laparoscopy.

OCT 2010 17
COMPLICATIONS
• A tubo-ovarian abscess will develop in approximately 7-16% of patients.
• Recurrent infection occurs in 20-25% of patients.
• Risk of ectopic pregnancy increased by 7-10-fold to about 8% of women who
have had PID.
• Tubal infertility in 15, 35, and 55% of women after one, two, and three
episodes of PID, respectively.
• Chronic pelvic pain in 20% related to adhesion formation, chronic salpingitis,
or recurrent infections.

OCT 2010 18
PROGNOSIS
In spite of treatment, one-fourth of women with acute disease develop long-term
sequelae.
• Repeated episodes of infection,
• Chronic pelvic pain, dyspareunia
• Ectopic pregnancy
• Infertility.
 The risk of infertility increases with repeated episodes of salpingitis.
 Estimated at 10% after the first episode, 25% after a second episode, and
50% after a third episode.

OCT 2010 19
 THANK YOU

OCT 2010 20