Pelvic Inflammatory

Disease

Bibo Yuan M.D.,Ph.D

yuanbibo@hotmail.com
Pelvic Inflammatory Disease
PID comprises a spectrum of
inflammatory disorders of the upper
female genital tract, including any
combination of endometritis, salpingitis,
tubo-ovarian abscess, and pelvic
peritonitis.
It could be acute, subacute, recurrent, or
chronic.
Pelvic Inflammatory Disease
Cause:
bacteria, virus, fungi, and parasites.

 Sexually transmitted organisms, are implicated in many

cases; especially N. gonorrhoeae and C. trachomatis,
 Microorganisms that comprise the vaginal flora also have
been associated with PID. (e.g., anaerobes, G. vaginalis, Haemophilus
influenzae, enteric Gram-negative rods, and Streptococcus agalactiae)
 In addition, cytomegalovirus might be associated with some cases of PID.
(CMV), M. hominis, U. urealyticum, and M. genitalium)

All women who are diagnosed with acute PID should be tested for N.
gonorrhoeae and C. trachomatis and should be screened for HIV infection.
 Pelvic Inflammatory Disease
Three proposed pathways of dissemination of
microorganisms in pelvic infections:

 Lymphatic spread of bacterial infection: typified by

postpartum, post-abortal, some IUD-related infection
 Intro-abdominal spread of microorganisms (gonorrhea
and other pathogenic bacteria): represents more common
forms of nonpuerperal PID, pathogenic bacteria gain
access to the lining of the uterine tubes, then result in
purulent inflamation;
 Hematogenous spread of bacterial infection(tuberclosis)
 Acute salpingitis-peritonitis
 Acute onset of pelvic infection.
 Often associated with invasion by N.
gonorrhoeae and involving the uterus,
tubes, and ovaries, with varying degrees
of pelvic peritonitis.
 Acute stage, redness and edema of tubes
and ovaries with purulent discharge
oozing from the ostium of the tube.
 Acute salpingitis-peritonitis
 Symptoms and signs
The symptoms of PID can range from none to mild to
severe.

 Acute onset of lower abdominal and pelvic pain, usually is bilateral

 Fever.
 Unusual vaginal discharge that may have a foul odor.
 Painful sexual intercourse.
 Irregular menstrual bleeding.
 Pain during a pelvic exam.
10. cervical motion tenderness
11. uterine tenderness
12. adnexal tenderness
 Acute salpingitis-peritonitis
 Lab findings:
 Leukocytosis with a shift to the left is usually present.
 Gonococci may be find in abnormal vaginal or cervical
discharge.
 Culdocentesis samples should be sent for smear, culture
and sensitivity testing of organisms.
 Ultrasound:
A pelvic ultrasound may be done to view the pelvic area
to see whether the fallopian tubes are enlarged or an
infection is present. Sometimes a laparoscopy may be
needed. Ultrasonography is most valuable in following
the progression or regression of an abscess.
 Acute salpingitis-peritonitis
 Culdocentesis:

 It may be very helpful in

diagnosis of suspected pelvic
infection. Generally, culdocentesis
samples is production of “reaction
fluid” when stain, reveals
leukocytes with or without
gonococci or other organisms.
culture and sensitivity testing of
organisms from culdocentesis
samples are recommended
 Culdocentesis:
 Provide emotional support  Diagnostic puncture of the
and encouragement. If cul-de-sac
necessary,
use local infiltration with
lignocaine.
 Gently grasp the posterior
lip of the cervix with a
tenaculum and gently pull to
elevate the cervix and
expose the posterior
vagina.
 Place a long needle (e.g.
spinal needle) on a syringe
and insert it through the
posterior vagina, just below
the posterior lip of the
cervix.
 Acute salpingitis-peritonitis
Diagnostic Considerations
Acute PID is difficult to diagnose because of the wide variation in
the symptoms and signs. Many women with PID have subtle or mild
symptoms. a diagnosis of PID usually is based on clinical
findings.
Diagnostic Criteria for PID (based on
CDC2006)
minimum criteria :
cervical motion tenderness OR
uterine tenderness OR
adnexal tenderness.
 Acute salpingitis-peritonitis
Additional criteria can be used to enhance
the specificity of the minimum criteria and
support a diagnosis of PID:

• oral temperature >101°F (>38.3°C),

• abnormal cervical or vaginal mucopurulent
discharge,
• presence of abundant numbers of WBC on saline
microscopy of vaginal secretions,
• elevated erythrocyte sedimentation rate,
• elevated C-reactive protein, and
• laboratory documentation of cervical infection with
N. gonorrhoeae or C. trachomatis.
 Acute salpingitis-peritonitis
The most specific criteria for diagnosing
PID include the following:
 endometrial biopsy with histopathologic
evidence of endometritis;
 transvaginal sonography or magnetic resonance
imaging techniques 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) and
 laparoscopic abnormalities consistent with PID.
 Acute salpingitis-peritonitis
Differential Diagnosis :
 Acute appedicitis,
 Ectopic pregnancy;
 Endometriosis;
 Diverticulitis;
 Infected septic abortion;
 Torsion of an adnexal mass;
 Degeneration of a leiomyoma, etc.
 Acute salpingitis-peritonitis

Treatment
 PID can be cured with antibiotics. But any damage
that has already been done to a woman's pelvic organs
(uterus, fallopian tubes, and ovaries) before treatment will
not be reversed.
 Early treatment for PID is very important. Positive
treatment should be initiated as soon as the presumptive
diagnosis has been made because prevention of long-
term sequelae is dependent on immediate administration
of appropriate antibiotics.
 PID treatment regimens must provide empiric,
broad spectrum coverage of likely pathogens.
 Acute salpingitis-peritonitis
 Outpatient Therapy:

3. Acute salpingitis, but temperature is less than 39C

4. Lower abdominal findings are minimal
5. The patient is not toxic and can take oral medication
6. Treat with antibiotics, IUD removal ,analgesics, and bed rest
 Acute salpingitis-peritonitis
The following criteria for hospitalization are
suggested:

 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; and
 the patient has a tubo-ovarian abscess.
 Acute salpingitis-peritonitis
Prognosis:

Outcome is directly related to the

promptness with which adequate therapy
is begin.
 Acute salpingitis-peritonitis
Complication
 Pelvic peritonitis or generalized peritonitis;
 Prolonged adynamic ileus;
 Pelvic cellulitis with thrombophlebitis;
 Abscess formation with adnexal
destruction and subsequent infertility;
 Intestinal adhesions and obstruction…
 Chronic Pelvic Infection
 Chronic pelvic infection implies the
presence of tissue changes in tubes and
ovaries.
 Adhesions of peritoneal surfaces to the
adnexa, fibrotic changes in the thubal
lumen are common.
 It usually are secondary to acute
salpingitis.
 Chronic Pelvic Infection
Symptoms and signs
 History of pelvic infection;
 Abdominal pain unilateral or bilateral;
 Low fever;
 Tenderness upon movement of the
uterus, cervix, adnexa;
 Adnexal mass.
 Chronic Pelvic Infection
Differential diagnosis
 Ectopic pregnancy;
 Endometriaosis;
 Appendicitis;
 Ovarian cyst or neoplasm;
 Acute or chronic cystourethritis, etc.
 Chronic Pelvic Infection
Complication
 Hydrosalpinx;
 Pyosalpinx;
 Tuboovarian abscess;
 Infertility or ectopic pregnancy;
 Chronic pelvic pain.
 Chronic Pelvic Infection
Prevention

 Prompt and adequate treatment of acute

PID is essential preventive measure.
 Education about avoidance of sexually
transmitted diseases (STD) is also
important.
 Chronic Pelvic Infection
Treatment
 Long-term antibiotics is worthy of trial in young woman of low parity,
ibuprofen can be used for symptoms relief; if symptoms still remain
after 3 weeks of antibiotic treatment, laparoscopy and exploratory
laparotomy are needed to rule out other causes;
 If infertility is a problem, verify tubal patency by
hysterosalpingography or laparoscopy are recommended; priscrible
antibiotics before and after procedure;
 Total abdominal hysterectomy with bilateral adnexectomy may be
indicated if disease is far advanced and the woman is symptomatic
or if an adenexal mass is demonstrated.
 Chronic Pelvic Infection
 Prognosis
 Depend on damage of pelvic organ;
 Multiple recurrence pelvic infection will
increase infertility and ectopic pregnancy
incidence; as well as tubo-ovarian and
other pelvic abscesses.
 Pelvic (CUL-DE-SAC) Abscess
 May occur as sequela to acute pelvic or
postabortal infection;
 Abscess formation is frequently
associated with anaerobic species,
especially Bacteroides. Occasionally.
ressistant gram-negative bacteria can be
found.
 Pelvic (CUL-DE-SAC) Abscess
Clinical findings
 Any symptoms of acute or chronic pelvic
inflammation may be present;
 Usually have more severe symptoms, (painful
defecation, severe back pain, rectal pain);
 Fluctuant mass filling cul-de-sac and dissecting
into the rectovaginal septum;
 Pelvic (CUL-DE-SAC) Abscess
Differential Diagnosis :
 Tuboovarian abscess;
 Periappendiceal abcess;
 Adnexal torsion;
 Ectopic pregnancy;
 Endometriosis;
 Diverticulitis with perforation;
 Ovarian tumor;
 Torsion of an adnexal mass;
 Degeneration or torsion of a leiomyoma, etc.
 Pelvic (CUL-DE-SAC) Abscess
Treatment
 Antibiotics target to anaerobic and aerobic pathogen;
 Drainage:
4. Colpotomy drainage- if the abscess is dissecting the
rectovaginal septum;
5. Percutaneous drainage-If fever persists in the face of
altered antimicrobial therapy, but there is no evidence of
abscess rupture or dissecting the rectovaginal septum;
 Reevaluate abdominal findings frequently to detect
peritoneal involvement; Exploratory laparotomy is
needed if the patient’s condition deteriorates.
 Pelvic (CUL-DE-SAC) Abscess
Prognosis

 The prognosis for the patient with well

localized abscess is good with early
treatment ;
 The prognosis for fertility is very poor.
 Tubo-ovarian abscess
 Tuboovarian abscess (TOA) involving the ovary and
fallopian tube most often arises as a consequence of
pelvic inflammatory disease (PID). However, TOA can
also develop following pelvic surgery, or as a
complication of an intraabdominal process, such as
appendicitis or diverticulitis.
 Organisms recovered from TOA are those found in PID,
namely, a mixed polymicrobial infection with a high
prevalence of anaerobes.
 Treatment modalities for TOA include antibiotics, guided
drainage, and surgery.
 Tubo-ovarian abscess
DIAGNOSIS
Symptoms and signs
 History of previous PID;
 Abdominal and/or pelvic pain are reliable features,
present in over 90 percent of patients with TOA;
 Fever and leukocytosis are found in approximately 60 to
80 percent of such patients;
 Nausea and vomiting are common;
 Abdominal tenderness and guarding may present,
adequate pelvic examination is often impossible due to
tenderness, but an adnexal mass maybe palpated.
 Tubo-ovarian abscess
DIAGNOSIS
Ultrasonography
3. The test of choice to confirm or exclude TOA is
ultrasonography.
4. Most importantly, ultrasound is emerging as the
imaging technique best suited to guide drainage of
these abscesses, which may be a central element of
therapy.
 Tubo-ovarian abscess
Ultrasonography

 TOA appears by sonogram classically as one or more relatively

homogeneous, somewhat symmetrical, cystic, thin-walled, well-
demarcated mass(es) which are usually contiguous. An air fluid
level may be seen; septations are present in multiloculated TOAs.

 Ultrasound examination is indicated in these patients suspected of

PID:
6. Those with a palpable mass
7. Those who are severely ill and/or for whom inpatient therapy is
planned
8. Those failing to respond to appropriate medical therapy
9. Those in whom tenderness or other factors preclude an adequate
rectovaginal pelvic examination.
 Tubo-ovarian abscess
Differential diagnosis

The differential diagnosis of TOA is

extensive; ectopic pregnancy, all of the
pelvic neoplasms, ovarian hematoma or
torsion, appendiceal and diverticular
abscesses, and uterine pyomyoma all
must be considered.
 Tubo-ovarian abscess
TREATMENT CONSIDERATIONS
Potent new antibiotics, earlier presentation for
medical care, improved imaging capabilities
have all contributed to a better therapeutic
outcome for TOA in recent years.
The majority of clinicians recommend at least 24
hours of direct inpatient observation for patients
who have tuboovarian abscess
 Tubo-ovarian abscess
 Long-term antimicrobials therapy with anaerobic
coverage;
 When medical therapy alone is not successful, or a large
abscess is identified, drainage procedures need to be
employed. Since most women with tubo-ovarian abscess are of
reproductive age, the primary aim of management is to be as conservative
as possible when considering percutaneous drainage versus open surgery.
 Almost all patients failing to respond within four days
require surgery. Laparoscopy or laparotomy is mandatory
in all cases of suspected leakage or rupture as well as in
all cases that do not respond to medical management
and percutaneous drainage.
 Tubo-ovarian abscess
 Transvaginal drainage — Drainage of
TOA using ultrasound guidance or
laparoscopy is a major therapeutic
advance in the treatment of this disorder.
 Laparoscopic drainage — Use of the
laparoscope for preemptive drainage is an
alternative approach.
 Tubo-ovarian abscess
 There is no current indisputable standard
of care for TOA.
 The following protocol can serve as a
general guideline for the safe and cost
effective treatment of TOA following first
diagnosis.
 Tubo-ovarian abscess
Treatment of tubo-ovarian abscess
1. Begin intravenous fluids
2. Begin potent broad-spectrum antibiotics
a. Ampicillin (2 g IV Q4h) PLUS gentamicin (standard doses) PLUS metronidazole (500 mg PO or IV Q8h), OR
b. Ofloxacin (400 mg IV Q12h) PLUS metronidazole (500 mg PO or IV Q8h), OR
c. Single agent therapy with one of the following: ticarcillin clavulanate (3.1 g IV Q4h), piperacillin tazobactam (4
g/0.5 g IV Q8h), or imipenem cilastatin (500 mg IV Q6h)
3. Survey for sepsis syndrome including:
a. Vital signs, examination (including mental status)
b. Blood cell counts and chemistries
c. Coagulation studies
d. Chest x-ray, EKG
e. Urine output
4. Place nasogastric tube to suction if ileus has developed
5. Guided drainage of TOA within 24 to 48 hours should be strongly considered
a. Transvaginal approach using an endovaginal sonographic probe with needle guide should be considered first; if
not possible proceed to CT or US guided transcutaneous approach, or laparoscopic approach
b. Place indwelling catheter if contents too viscous to aspirate
c. Colpotomy drainage may be used only if the abscess is fixed and distending the low rectovaginal septum in the
midline
d. Send aspirate for microbiologic evaluation (and cytologic analysis if fluid is serous or cloudy)
6. Correct any underlying medical derangements (eg, anemia, hyperglycemia, hypoproteinemia, hypoxia)
 Pelvic Tuberculosis

 Pelvic Tuberculosis is becoming rare;

 Usually represents secondary invasion from a
primary lung infection via the
lymphohematogenous route;
 The oviducts were the most frequently involved,
and the endometrium next most frequently.
 Pelvic Tuberculosis
Symptoms and signs
 Infertility-maybe the only complaint;
 Dysmenorrhea; amenorrhea; some other
disturbance of cycle;
 Pelvic pain; low-grade fever; asthenia;
weight loss;
 Evidence of Tuberculosis peritonitis.
 Pelvic Tuberculosis
Diagnosis
 Base on complete history, physical examination, chest X-
ray and lung scan, tuberculin test, sputum smears and
sputum culture.
 Gross ascites with fluid containing more than 3 g of
protein per 100 ml of peritoneal fluid is characteristic of
tuberculosis peritonitis.
 Pelvic tuberculosis is usually encountered in the course
of gynecologic operation done for other reasons. some
distinguishing features include: extremely dense
adhesions without planes of cleavage, segmental
dilatation of the tubes.
 Pelvic Tuberculosis
Lab findings

 Best direct method of diagnosis is detection of

acid-fast bacteria from menstrual discharge, or
from curettage or biopsy, or from peritoneal
biopsy.
 Pelvic Tuberculosis
X-ray Findings
 A chest X-ray should be taken in any patient
with proved or suspected tuberculosis of
other organs or tissues;
 Hysterosalpingography: the tubal lining may
be irregular, and areas of dilatation may be
present.
 Pelvic Tuberculosis
Special Examination

Laparoscopy and aspiration of fluid for culture

and biopsy of affected area is possible and
often diagnostic.
 Pelvic Tuberculosis
Differential diagnosis
 Schistosomiasis;
 Enterobiasis;
 Lipoid salpingitis;
 Carcinoma;
 Chronic pelvic inflamation.
 Pelvic Tuberculosis
Complications

Sterility and tuberculous peritonitis are

possible sequelae of pelvic
tuberculosis.
 Pelvic Tuberculosis
Treatment
Medical measures:
 Initial therapy should include 4 drugs to prevent the
emergence of drug-resistant strains. The drug for 1st 2
months of treatment should include: isoniazid,
rifampin,pyrazinamide,and streptomycin or ethambutol.
Once drug susceptibility results are available,the drug
can be appropriately changed,tratment should continued
for 2-3 years.
 Pelvic Tuberculosis
Treatment
Specific measures:
 Surgical intervention may be necessary if
the following conditions are present:
4. Masses not resolving after medical therapy;
5. Resistant or reactived disease;
6. Persistent menstrual irregularities;
7. Fistula formation.
 Objectives
 Master the cause, pathology, clinical manifestations,
diagnosis, and differential diagnosis of pelvic
inflammatory diseases;
 Know about the significance of prevention and
thorough treatment of pelvic inflammatory diseases.
 Master spread, pathologic changes and clinical
manifestation of tuberculosis of the female reproductive
system;
 Know about assisting tests for tuberculosis of the
female reproductive system;
 Be familiar with diagnosis, differential diagnosis and
treatment of tuberculosis of the female reproductive
system.