PID

BEREKET .W GYN/OBS RII

NOV 2017 GC
• Pelvic inflammatory disease (PID) is an inflammatory
disorder of the uterus, fallopian tubes, and adjacent
pelvic structures

• acute salpingitis.

• its true magnitude is unknown

etiology
• C. trachomatis
• N. gonorrhoeae
• Cytomegalovirus (CMV)
• Endogenous microflora
• Gardnerella vaginalis
• Haemophilus influenzae
• Enteric gram-negative organisms (Escherichia coli)
• Peptococcus species
• Streptococcus agalactiae
• Bacteroides fragilis
• Pregnancy: PID is rare in pregnancy.
• Mycoplasma genitalium etc
• N. Gonnorrhea • C.Trachomatis
• Gram-negative IC • is a slow-growing
diplococcus intracellular organism.
• rapid cycle 20 to 40 • lack of mitochondria
minutes to divide • growth cycle 48 to 72
• rapid and intense hours
inflammatory response • does not induce a rapid
or violent inflammatory
response
• Less complication
• Early Rx • destruction by rupture
• Delayed Rx
• MICROBIOLOGY — The known initiating pathogens in PID are Neisseria
gonorrhoeae and Chlamydia trachomatis. Complete disruption of the vaginal
ecosystem can occur, in which anaerobic bacteria assume predominance over the
desirable strains of lactobacilli. This condition is known as bacterial vaginosis, which
is not associated with an inflammatory response [5] . Bacterial vaginosis affects 15
to 30 percent of American women, one-half of whom are asymptomatic [6] . Its
significance is not clearly understood but when found in pregnancy, bacterial
vaginosis was an independent risk factor for preterm delivery of a low birthweight
infant in a study of 10,397 women of whom 16 percent had the diagnosis [7] .

• An intermediate situation in which H202-producing lactobacilli and anaerobes

coexist in roughly equal numbers is called a transitional flora.

• N. gonorrhoeae accounts for approximately one-third of cases of PID overall:

somewhat more in the southeastern United States, less in the western United
States, and much less in western Europe. Mixed infection — Regardless of the
initiating event, the microbiology of PID, especially for clinical purposes, should be
viewed and treated as a mixed (facultative and anaerobic) polymicrobial infection.
Older studies isolated groups A and B streptococci (rarely enterococci), E. coli,
Klebsiella spp, Proteus mirabilis, Haemophilus spp, Bacteroides/Prevotella spp,
Peptococcus, and Peptostreptococcus spp [15,32,33] .
• A more recent study with comprehensive microbiologic methodology
in 102 patients confirmed the older findings and emphasized the
association of H. influenzae and Streptococcus pyogenes with
clinically severe disease [29] . These studies found that, among cases
of PID initiated by the gonococcus, a mixed polymicrobial infection
was seen in approximately 35 percent. Another study, which
employed particularly stringent microbiologic techniques, identified
other organisms in more than 50 percent of patients with
gonococcal PID [34] . Microbiologic findings at different levels of the
genital tract of a given patient with PID often show poor correlation

• Intrauterine device and tubal ligation — Modern intrauterine devices

cause little, if any, increased risk for PID [43,56,57] .
• The risk of PID is primarily limited to the first three weeks after IUD
insertion and is uncommon thereafter [57] .
• No evidence suggests that IUDs should be removed in women
diagnosed with acute PID
 Mode of infection
 Ascending : most common route
E.g.. Gonococus

 lymphatic & pelvic viens

E.g. post abortal & puerperium

 Blood steam . E.g. tuberculosis

 from a adjacent inflammatory structure like

appendix
 Risk factors
• Douching
• Single status
• Substance abuse
• Multiple sexual partners
• Lower socioeconomic status
• Recent new sexual partner(s)
• Younger age (10 to 19 years)
• Other sexually transmitted infections
• Sexual partner with urethritis or gonorrhea
• Previous diagnosis of pelvic inflammatory disease
• Not using mechanical and/or chemical contraceptive barriers
• Endocervical testing positive for N gonorrhoeae or C trachomatis
 Classification:-
 Primary= infection that ascend from lower genital tract
• Post STI / menustral
• Post abortal
• Post Partum
• Post Instrumentation
• IUD – Related
• Silent PID
 Secondary PID= direct spread or associated with other
diseases like filiariasis
• Acute PID
• Chronic PID
• Secondary PID
– PID following predisposing conditions
• Pregnancy
–Postabortal PID,postpartal PID,infected EP
• Direcct extension from other infected sites as
appendicitis
• Postsurgical following D&C,posthysterectomy
• FB as IUCD
Clinical features
• Pain is present in more than 90% of documented cases and is
by far the most common presenting symptom.
– Usually, pain is described as dull, aching, and constant;
– it begins a few days after the onset of the last menstrual
period and tends to be accentuated by motion, exercise, or
coitus.
– Pain from PID usually lasts less than 7 days;

• Abnormal vaginal discharge is present in

approximately 75% of cases.

• Unanticipated vaginal bleeding coexists in about 40% of cases.

• Yellow vaginal discharge,
• Menorrhagia,
• Dysmenorrhea, and dyspareunia.
• fever, chills,
• anorexia, nausea, vomiting,
• diarrhea,
• Patients also may have infective urinary symptoms.

Unfortunately, there is no single symptom or

symptoms associated with a physical finding that is
specific for diagnosis.
 CDC diagnostic criteria
Major criteria
-uterine tenderness,
-adnexal tenderness, or
-cervical motion tenderness.

Minor criteria
-oral temperature >38.3°C (101.6°F),
-mucopurulent cervical or vaginal discharge,
-abundant WBCs on saline microscopy of cervical secretions,
-elevated erythrocyte sedimentation rate (ESR) or
-C-reactive protein (CRP), and
-presence of cervical N gonorrhoeae or C trachomatis.
 The most specific criteria:-
 Endometrial biopsy with histopathologic evidence of
endometritis
 Transvaginal sonography or MRI

 Laparoscopic abnormalities consistent with PID

 Doppler studies suggesting pelvic infection (e.g.,
tubal hyperemia)
 Investigation
• Recommended lab Ix
– Pregnancy test
– Microscopic exam of vaginal discharge in saline
– Complete blood counts & ESR
– Nucleic acid amplification tests for chlamydia and gonococcus
– Urinalysis
– Serology test for syphilis
– C-reactive protein (optional)
– Endometrial biopsy

• Imaging studies
– Ultrasound
– MRI
– Laparoscopy
 Laparoscopy
 Tubal serosal hyperemia,
 Tubal wall edema, and
 Purulent exudate issuing from the fimbriated ends of the
fallopian tubes and
 Pooling in the cul-de-sac

= Sonography
= CT scan
= Endometrial biopsy
- Polymorphonuclear leukocytes
Grading of severity
Clinical system
Grade I: Disease limited to the adnexae
Grade II: PID with an inflammatory mass
Grade III: Ruptured tubo-ovarian abscess pelvic
peritonitis

laparoscopic system
Mild: Erythema and edema of the adnexae
Moderate: Purulent exudate from fallopian tubes
Severe: Pyosalpinx, inflamatory complex, TOA
 Gainesville staging of acute salpingitis
Stage
I—Acute salpingitis without
peritonitis (ES)
II—Acute salpingitis with
peritonitis (ESP)
III—Acute salpingitis with
evidence of tubal occlusion
or tubo-ovarian complex
IV— Ruptured tubo-ovarian
complex
Therapeutic goal
Eradication of symptomatology
and Ineffective
Preservation of fallopian tube
structure and function
Primary therapeutic goal:
Preservation of ovarian
function
Primary therapeutic goal:
Preservation of life
 DDX
• Adnexal tumors
• Appendicitis
• Ectopic pregnancy
• Endometriosis
• Rupture of an adnexal mass
• Adnexal torsion
• Perihepatic inflammation (fitz-Hugh-cutis )
 Management
• goal of therapy is to eradicate bacteria, relieve
symptoms, and prevent sequelae

• Out patient

• Inpatient
Treatment
• based on the consensus that PID is
polymicrobial in cause.

• Empirical antibiotic protocols should cover a

wide range of bacteria

• Oral therapy can be considered for women

with mild to moderately severe acute PID.
 OUTPATIENT TREATMENT
• Regimen A
- Levofloxacin 500 mg orally once daily for 14 days
OR
- Ofloxacin 400 mg orally once daily for 14 days
WITH OR WITHOUT
- Metronidazole 500 mg orally twice a day for 14 days

• Regimen B
- Ceftriaxone 250 mg IM in a single dose
PLUS
- Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
- Metronidazole 500 mg orally twice a day for 14 days
• PATIENT MONITORING — patient should be seen within 48 to 72 hours
Criteria for inpatient RX
• Adolescents
• Drug addicts
• Severe disease
• Suspected abscess
• Uncertain diagnosis
• Generalized peritonitis
• Temperature >38.3° C
• Failed outpatient therapy
• Recent intrauterine instrumentation
• White blood cell count >15,000/mm3
• Nausea/vomiting precluding oral therapy
Criteria for Hospitalization (CDC 2002)

• Surgical emergencies not excluded

• Severe illness/ nausea/ vomit/ high fever
• Tubo-ovarian abscess
• Clinical failure of oral anti-microbials
• Inability to follow/ tolerate oral regimen
• Pregnancy

• Immunodeficient (HIV ē low CD4 counts,

immunosuppressive therapy)
 CDC-Recommended Parenteral Treatment
Regimen A
- Cefotetan 2 g IV every 12 hours it is 2 nd generation cephalosporin
OR
- Cefoxitin 2 g IV every 6 hours it is 2 nd generation cephalosporin
PLUS
- Doxycycline 100 mg orally or IV every 12 hours
Regimen B
- Clindamycin 900 mg IV every 8 hours
PLUS
- Gentamicin
• D/C IV 24 hours after a patient improves clinically;
• Continue oral therapy
– doxycycline 100 mg orally twice a day or
– Clindamycin 450 mg orally four times a day
• complete a total of 14 days of therapy
• Other alternative
Augumentin + doxycycline
Surgical managemnet
• Colpotomy

• Percutaneous drainage

• Laparascopy

• Laparatomy
 Indication for surgery

1. TOA not responding to antibiotics

2. Ruptured TOA
3. Generalized peritonitis
4. Unsettled diagnosis
• TOA not responding to antibiotics, consider:
1. Resistant organisms
2. Re-infection
3. Wrong diagnosis
4. Abscess formation
Surgery in PID
Indications
Acute PID
- Ruptured abscess
- Failed response to medical treatment
- Uncertain diagnosis
Chronic PID
- Severe, progressive pelvic pain
- Repeated exacerbations of PID
- Bilateral abscesses / > 8 cm. diameter
- Bilateral uretral obstruction
• Complication:-
Early
• Sepsis → MOF → Death ( ruptured TOA = 10 %)
• Surgical morbidity (TOA)
• Arthritis /myocarditis
Late
• Infertility = 20%
• Ectopic Pregnancy = 6-10X higher; 12 %
• Chronic pelvic Pain = 20%
• Chronic PID
• Psychological consequences
• Dyspareunia
• Early dx &RX ZE BETTER OUTCOME
THANK U