Pelvic Inflammatory Disease

Cause Infertility
A
Condition
Requiring
Closer Attention
What is Pelvic Inflammatory
Disease?
(known to medical professionals) as PID is an
infection that affects a womans reproductive
system.
Exists when disease causing organisms (bacteria)
migrate from the urethra & cervix into upper genital
tract.
PID only occurs in women, primarily in Caucasian
women & is contracted by the STDs gonorrhea &
Chlamydia.


Upper Genital Tract Infections
The Cervix is
considered the boundary
between the lower and
upper genital tracts.
Upper genital tract
infections affect
primarily the cervix,
uterus, or fallopian tubes
Severe infections may
affect one or both
ovaries.
Symptoms of PID:
Pain in lower
abdominal region
disassociated with a
period.
Fever
Can range from subtle
&mild to sudden
onset of moderate to
severe pain
Unusual vaginal
discharge that may
have a foul odor

Pain during
intercourse
Irregular menstrual
bleeding.
Back pain
Urinary discomfort
Pain during a pelvic
exam
Chlamydial Pyosalpinx
Pelvic inflammatory disease, proven Chlamydial Pyosalpinx.
Right tube is swollen and tortuous (arrow)
(Holmes, 1999, Plate 17; reprinted with permission from McGraw Hill.)
Cervicitis
The cervix appears red
and bleeds easily when
touched with a spatula or
cotton swab.
Mucopurulent discharge
is yellow-green
Contains >10
polymorphonuclear WBCs
per oil immersion field
(using Gram stain)
Salpingitis and Related Diseases
Etiology
Risk Factors
Diagnosis and DDx
Management
Treatment
Complications
References
Etiology
Salpingitis is really part of the larger family of
pelvic inflammatory disease (PID).
PID is a polymicrobial infection of the upper
female genital tract (uterus, fallopian tubes,
ovaries) caused by an ascending infection of the
vagina or cervix.
N. gonorrhea and C. trachomatis cause the
majority but endogenous bacteria can also be
present.


Etiology
N. gonorrhea
Causes roughly 50% of salpingitis.
15% of GC cervicitis progresses to PID.
C. trachomatis
More common than GC by up to 10:1, but only
accounts for 20-35% of PID.
Classically produces a more mild form of PID with
insidious onset.
Other bugs
Strep., Staph., E. coli, Bacteroides, Actinomyces,
Peptococcus, Clostridium, Gardnerella, Haemophilus,
CMV, etc.

Risk Factors
Young age (<25)
Prior history of STD
IUD or other non-barrier contraception
Multiple partners
Promiscuous partners
Iatrogenic factors
Clinical Criteria for Diagnosis of PID
All 3 of the following:
Abdominal tenderness with or without rebound.
Adnexal tenderness
Cervical motion tenderness
Plus 1 of the following:
Temp. of >101F
WBC >10,000 or elevated CRP or ESR
Gram stain with gram neg. intracellular diplococci
Inflammatory mass
Purulent material from peritoneal cavity

Acute Salpingitis
Onset is usually shortly after menses.
Lower abdominal pain becomes
progressively more severe, with guarding,
rebound tenderness, and cervical motion
tenderness.
Involvement is usually bilateral.
Nausea and vomiting occur with severe
infection.
In the early stages, acute abdominal signs
are often absent
Acute Salpingitis (PID)
Bowel sounds are
present unless peritonitis
with ileus has developed.
Fever, leukocytosis,
and mucopurulent
cervical discharge are
common
Irregular bleeding and
bacterial vaginosis often
accompany the pelvic
infection.
Acute Salpingitis (PID)
Pelvic infection due to N. Gonorrhoeae is
usually more acute than that due to C.
trachomatis
Onset is rapid, and pelvic pain develops shortly
after menses starts.
Although the pain is often localized to one side,
both tubes are probably infected.
The infection produces a diffuse exudate,
leading to agglutination, adhesions, and tubal
occlusion.
Peritonitis may occur, causing upper abdominal
pain and adhesions
Acute Salpingitis: Chlamydia & Gonorrhea
C. trachomatis produces symptoms that often
seem mild, but it can cause more damage than
N. Gonorrhoeae in the long term.
Chlamydial organisms may remain in tubal
mucosa for many months before clinical
manifestations of acute disease appear.
Untreated or inadequately treated acute
infection can lead to chronic salpingitis, with
tubal scarring and possible adhesion
formation.
Chronic pelvic pain, menstrual irregularities,
and infertility are long-term sequelae
Management
Lab studies
CBC to look for leukocytosis
-HCH to r/o ectopic pregnancy
Gonorrhea and Chlamydia cultures
ESR/CRP
UA to r/o cystitis or pyelonephritis
Fecal occult blood test
Wet mount
R/o other concurrent STDs with RPR/VDRL
and HIV test

Management
Imaging Studies
Pelvic ultrasound to r/o tubo-ovarian abscess,
ectopic pregnancy and ovarian torsion.
Procedures
Laparoscopy if still unsure of diagnosis
Culdocentesis is now rarely required
Indications for Hospitalization
Pregnancy
Immunodeficient
Nausea/Vomiting and high fever
Unpredictable compliance
Poor response to outpatient therapy
Tubo-ovarian abscess

Complications of PID
Tubo-ovarian abscess develops in about 15% of
women with salpingitis.
It can accompany acute or chronic infection
The tube and ovary can become completely
matted together.
May require prolonged hospitalization,
sometimes with surgical percutaneous drainage.
Rupture of the abscess is a surgical emergency
Rapidly progressing from severe lower
abdominal pain to N & V, generalized
peritonitis, and septic shock
Complications
Infertility 2 tubal scarring
10% risk after a single episode of PID
30% risk after 2 episodes
50% risk after 3 or more episodes
Complications
Chronic pelvic pain
Found in up to 18% of women after resolution of PID.
Adhesions
Dyspareunia
Complications
Ectopic Pregnancy
Also 2 to tubal scarring
7-10 fold increased risk after a single episode
Complications
Ectopic Pregnancy
Tubo-ovarian abscess
Pyosalpinx, in which one or both fallopian tubes are
filled with pus, may also be present.
Hydrosalpinx (fimbrial obstruction and tubal
distention with nonpurulent fluid) develops if
treatment is late or incomplete.
The consequent mucosal destruction leads to
infertility.
Hydrosalpinx is generally asymptomatic but can
cause pelvic pressure, chronic pelvic pain, or
dyspareunia.
Women with HIV infection are more likely to have
tubo-ovarian abscess
Tubo-ovarian abscess
Here at least the ovaries, tubes and uterus
can still be recognized as separate
structures
Complications
Tubo-ovarian abscess
Serious sequelae of PID causing 350,000 hospitalizations
and 150,000 surgeries/yr.
Occurs in 15-30% of women requiring hospitalization for
PID treament.
Ruptured TOA has a mortality rate as high as 9%.
Fitz-Hugh-Curtis syndrome
Can be a complication of gonococcal or
chlamydial salpingitis.
Characterized by right upper quadrant
pain in association with acute salpingitis,
indicating perihepatitis.
Acute cholecystitis may be suspected,
but signs and symptoms of PID are
present or develop rapidly.
Complications

Complications
Patho-physiology of PID:
Bacterial Chlamydia & gonorrhea
enter womans genital tract &
move toward the cervix.
Penetrates cervical mucus which
protects against spread of
microorganisms, having access to
upper genital tract of women,
infecting uterus, ovaries, fallopian
tubes, & other structures in the
pelvic cavity.


Pathologic Processes of PID
PID has a broad clinical spectrum that includes
a) acute PID
b) silent PID
c) atypical PID
d) the PID residual syndrome or chronic PID and
e) postpartum/postabortal PID
Risk Factors Associated with
PID,
Women who are at risk
of PID are those who
engage in unprotected
sexual activity.
Women who have
multiple sex partners.
Women who have sex
with partner who reports
symptoms of an STD.
Women who have
experienced previous
pelvic infections
Sexually active
women under age
25; statistics show
sexually active
teenage girls are
more likely to
develop PID than
are older women
Diagnosing PID:
Often difficult
because symptoms
can be mild
Perform physical
exam (pelvic exam),
pelvic ultrasound, &
sometimes
laparoscopy
In U.S. PID affects
11% of women of
reproductive age

1 million women
experience an episode of
PID per year
20% of PID diagnosed
women are hospitalized
for treatment
Medical reports indicate
PID causes 2.5 million
office visits & 125-
150,000 hospitalizations
a year
Diagnosis
And one or more minor criteria
Temperature over 100.9F or 38.3 C
White Blood Cell count > 10,000
Elevated ESR
Elevated C-reactive protein
Pus in cul-de-sac
Pelvic abscess or inflammatory complex
Cervical Mucus findings
Gram Stain: Gram Positive diplococci
Intracellular parasites

Diagnosis
ESR and C-reactive protein are elevated
in many disorders and are therefore not
specific for PID.
Endometrial biopsy with aerobic and
anaerobic culture may assist in the
diagnosis.
All three major criteria and at least one
minor criterion must be present to
diagnose PID.

Treatment Goals &
Benefits
Therapeutic goals include complete
resolution of the infection and
prevention of infertility and ectopic
pregnancy.
Management Outpatient
Regimen A:
Initial Treatment at Diagnosis
Ofloxacin 400 mg orally BID for 14 days
(95% cure)
Or
Levofloxacin 500 mg orally once daily for 14
days
With or without:
Metronidazole 500 mg orally twice a day for 14
days.
Management Outpatient: Regimen B

Ceftriaxone 250 mg IM in a single dose
Or
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g
orally administered concurrently in a single dose
Or
Other parenteral third-generation cephalosporin
(ceftizoxime or cefotaxime)
Plus
Doxycycline 100 mg PO BID for 14 days (75% cure)
With or without
Metronidazole 500 mg PO BID for 14 days
Management Inpatient
Toxic
appearance
Unable to take
oral fluids
Unclear DX
Appendicitis
Ectopic
Pregnancy
Ovarian torsion
Pelvic abscess
Pregnancy
HIV positive
Adolescents
Outpatient
TX failure
Unreliable
patient


Inpatient Treatment Regimens:
General: Treat for at least 48 hours IV
Regimen A
Cefotetan 2g IV q12 hours
OR
Cefoxitin 2g IV q6 hours
Plus
Doxycycline 100 mg orally or IV every 12
hours
Inpatient Treatment
Regimen B
Clindamycin 900 mg IV q8 hours
Plus
Gentamicin 2 mg/kg IV loading dose, then 1.5
mg/kg IV q8h

Discharge Regimen (after IV antibiotics)
Doxycycline 100mg PO BID for 10 days
or
Clindamycin 450mg PO QID for 14 days
Alternative Parenteral Regimens
Ofloxacin 400 mg IV q 12 hours
Or
Levofloxacin 500 mg IV once daily
With or without
Metronidazole 500 mg IV every 8 hours
Or
Ampicillin/Sulbactam 3 g IV every 6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours
Prognosis
Therapy using antibiotics alone is
successful in 33-75% of cases.
If surgical therapy is warranted, the current
trend in therapy is conservation of
reproductive potential with simple drainage
and copious irrigation or unilateral
adnexectomy, if possible.
Further surgical therapy is needed in 15-
20% of cases so managed.
Results of PID:
Can be life threatening
Causes complications of conception, pregnancy,
& fertility
Inflammation of fallopian tubes
Scarring of abdominal cavity tissue
Scarring of fallopian tubes, causing blockage
which can lead to ectopic pregnancy (tubal
conception)
Diagnosed women have 6-10 times increase of
ectopic pregnancy
Causes high pregnancy-related deaths among
African American
46
Definition: Accumulation of pus in uterine cavity, caused
by interference with natural drainage of uterus is
pyometra.

First case was described by John & Clarke of London in
1812. Attention was drawn by Whiteley and Hemlat l
(1971) of more frequent association of pyometra with
benign as compared to malignant disease of genital tract.

Diversity in methods of management of these cases indicate
that a logical approach is needed for their management.

Attention is focused to review on etiology, improving clinical
diagnosis, applying newer technology and early diagnosis.
Pyometra: History:
47
Etiology of pyometra
Senile Endometritis
Malignant-endometrial carcinoma
Ednocervical carcinoma
Ectocervical carcinoma
Previous gynae surgery
Obstetrical puerperal sepsis
Foreign body (IUCD)
Others:
Radiation effect for uterine
carcinoma
Tubercular endometritis
Uterovaginal prolapse
Submucous fibroid polyp
48
Newer mechanisms
Detection of pyometra after ovum retrieval
for IVF with the routine use of ultrasound-
guided embryo transfer.


(Fertil Steril: 2004 Apr;81(4) 1156(4); author reply 1156-7.)
49
contd.. Etiology of pyometra
It can also occur
secondary to intrauterine
infection. Actinomycotic
pyometra has been
reported as a complication
of a forgotten intra-uterine
device. Recently there has
been an increase in genital
tuberculosis, and this
occasionally presents with
pyometra.
50
Pathogenesis
Association with squamous metaplasia of
endometrium - reported with varying
frequency. It may precede squamous
carcinoma of endometrium.
Pyometra chiefly appears to be result of
malignancy as cervical canal is blocked by
big tumor growth or presence of big
necrotic growth in endometrium itself
predisposes to formation of pyometra.

51
Pyometra
After menopause, when endometrium loses its
resistance - not shed repeatedly, infection which
gains entrance to uterus persists as senile
endometritis.
The pus which tends to collect in uterus forms
pyometra, as cervix is narrowed by senile change
& atrophied myometrium unable to expel it.
Hysterectomy is recommended in pyometra due to
senile endometritis.
52
Pyometra
In cases where surgery is not done for
various reasons, cyclic oestrogen therapy
has definitely shown to reduce the risk of
recurrence of pyometra.
Oestrogen therapy helps in healing of
senile endometritis lesion thus preventing
recurrence of pyometra.
Dr.Uma Gupta, Dr.NK Gupta 53
Uterine:
Leiomyomata
Adenomyosis
Adenomyoma
Stromatosis
Hemangiopericytoma
Endometrial:
Polyps
Endometrial cancer
Adenomatoid tumor
Plexiform tumorlet
Lipoma
Vascular tumors
Hematometra
Pyometra
Hydrometra
Gestational trophoblastic
neoplasia
Congenital abnormalities
Differential Diagnosis
Dr.Uma Gupta, Dr.NK Gupta 54
Investigations
Vaginal swabs may be negative in up to 50%
of cases, since the principle organisms are
anaerobes and these are difficult to culture.
If tuberculosis is suspected, tuberculin
testing, culture, histology,
hysterosalpingogram and nucleic acid
amplification testing may be indicated.
55
Contd.Investigations
The mainstay of investigation is imaging.
Ultrasound scanning has been employed for
over 20 years, and remains the chosen
modality in most cases.
It can also complicate endometrial
carcinoma and Doppler scanning may be
used to detect blood flow changes in this
event.
56
Pyometra
Diagnostic USG to gynaecological field makes
correct diagnosis.
Frequent association of pyometra with uterine
malignancy reported.
CT scanning seems as sensitive to ultrasound, but
the latter is often easier to access.
57
Most women are treated with dilation of the cervix and
drainage, with regular monitoring to detect recurrent
or persistent disease. Antibiotics are only necessary if
there is evidence of invasive infection, in the form of
generalized malaise, pyrexia, or altered laboratory
parameters.
If antibiotics have to be used, preparations covering
aerobic and also anaerobic bacteria should be used,
Current research is focused on a group of drugs called
carbapanems, which have an exceptionally wide
spectrum of activity.
Tubercular pyometra should be treated with
appropriate anti-tubercular chemotherapy.
Management
58
Drainage of pus by repeat dilatations, usually done
biweekly or putting a Foleys catheter/drainage
tube followed by curettage under antibiotic was
the primary treatment.
Time required for drainage of pus was found to be
significantly shortened in cases of foleys catheter
tube were inserted into the uterine cavity. Pus
around 15-500 ml average of 65 ml collects.
Primary Treatment
59
When cause of pyometra was malignant or other
specific disease management is as per case.
Management of pyometra because of senile
endometritis Panhysterectomy within one month
under routine antibiotic coverage. Those not fit for
surgery medical management by prolonged cyclic
oestrogen therapy (premarine0.625 mgm daily) for
4-6 months.
Recurrences occur 2-11 months.
Secondary Treatment
60
Prognosis

The prognosis in pyometra will depend both
on the underlying cause (e.g. malignancy)
and of the possibility of spontaneous
perforation. Prompt recognition and
treatment of the condition improves the
prognosis considerably.