Pelvic Inflammatory Disease

(PID)
PRESENTERS; KEYAGA Jonas Bill, SSEMPIJJA Dalausi
TUTOR; DR. NSIBAMBI DAVID
OBJECTIVES
• Definition & epidemiology
• Risk factors & Causative agents
• Pathogenesis & pathophysiology
• Clinical Presentation
• Investigations & diagnosis
• Management
• Complications
• Prevention
DEFINITIONS.

• PID is a spectrum of infections and inflammation of the upper genital

tract organs typically involving the uterus(endometrium), fallopian
tubes, ovaries, pelvic peritoneum and surrounding structures.
• It can also be defined as a polymicrobial infection caused by the
ascending spread of microorganisms from the cervicovaginal canal to
the contiguous pelvic structures.
EPIDEMIOLOGY
PID is a health hazard in both the developed and the developing countries,
but affecting the developing countries more. Its incidence has been noted to
have increased in the recent times due to the rise in sexually transmitted
diseases brought about by ready availability of contraception and permissive
sexual attitude, among the population.
Incidence is highest among sexually active women of reproductive age
accounting for 85% of the cases and the remaining 15% being iatrogenic.
Iatrogenic procedures include endometrial biopsy, uterine curettage,
insertion of IUD and hysterosalpingography.
Of the whole total two thirds are mostly young women of less than 30 years
and the one third remaining being contributed by women older than 30 years
RISK FACTORS
 Sexual behavior-related risk factors:
-Sexually active age group (highest rates in sexually active adolescents &
young adults)
-Multiple sexual partners
-Past history of sexually transmitted infections and acute PID.
 Uterine instrumentation:
-Termination of pregnancy
-Insertion of intrauterine device (IUD-insertion related infections usually
occur within the first 3 weeks following insertion)
-Hysterosalpingography
-In-vitro fertilization, intrauterine insemination
CAUSATIVE AGENTS
• Primary organisms (sexually transmitted);
• Neisseria gonorrhoeae (30%)
• Chlamydia trachomatis (30%)
• Mycoplasma hominis (10%)
• Secondary organisms;
• non-hemolytic Streptococcus
• E.coli, group B Streptococcus and Staphylococcus
• Peptococcus and Peptostreptococcus and
Bacteriodes species - fragilis and bivius
 PATHOGENESIS
Source of infection; STI, disruption of
1
Destruction of cervical barrier; initiation
Vaginal normal flora or Iatrogenic 2 of upward spread of orgasims

3
Spread of Infection; Canalicular or
Lymphatic inflammatory reaction with gross
4 destruction of epithelial cells cilia
and microvilli

closure of ostia; with exudate

5
entrapped in the tube; exudate spillage
results in spread of infection to the
peritoneal cavity and surrounding
organs
Pathophysiology
• PID-causing organism usually gains entry via the lower reproductive tract as a
result of sexual intercourse or uterine instrumentation. Acute cervicitis caused
by Chlamydia or gonococcus can lead on to PID in 30% & 15% of untreated cases
respectively
• Ascending infection subsequently involves more structures & regions:
Endometrium- Not usually a problem in non-pregnant women as the
endometrium is shed regularly. In pregnancy, infection of endometrium can result
in miscarriage, preterm labour, chorioamnionitis & post-partum endometritis.
Fallopian tubes- Results in acute salpingitis
Pelvic intraperitoneal cavity- Results in pelvic & tuboovarian abscesses
Abdominal intraperitoneal cavity- Distant abscesses, peritonitis (e.g. in
tuboovarian abscess rupture) - Fitz-Hugh-Curtis syndrome (perihepatic
inflammation & adhesions as a result of PID; classically can visualize “violin-string”
adhesions when mobilizing the liver intraoperatively)
CLINICAL FEATURES

Symptoms usually may appear at the time and or immediately after the
menstruation. These include;
• Bilateral lower abdominal and pelvic pain which is dull in nature. The onset of pain
is more rapid and acute in gonococcal infection (3 days) than in chlamydial infection
(5–7 days).
• There is fever, lassitude and headache.
• Irregular and excessive vaginal bleeding is usually due to associated endometritis.
• Abnormal vaginal discharge which may become copious and or purulent.
• Nausea and vomiting.
• Dyspareunia (painful intercourse)
• Pain and discomfort in the right hypochondrium due to concomitant perihepatitis
(Fitz-Hugh Curtis syndrome) may occur in 5–10 per cent of cases of acute salpingitis.
The liver is involved due to transperitoneal or vascular dissemination of either
gonococcal or chlamydial infection.
Signs
• The temperature is elevated to beyond 38.3°C.
• Abdominal palpation reveals tenderness on both the quadrants of lower
abdomen. The liver may be enlarged and tender.
• Vaginal examination reveals:
(1) Abnormal vaginal discharge which may become copious and or purulent.
(2) Congested external urethral meatus or openings of Bartholin’s ducts
through which pus may be seen escaping out on pressure.
(3) Speculum examination shows congested cervix with purulent discharge
from the canal.
(4) Bimanual examination reveals bilateral tenderness on fornix palpation,
which increases more with movement of the cervix. There may be thickening
or a definite mass felt through the fornices.
INVESTIGATIONS
• Urine pregnancy test (to exclude ectopic pregnancy)
• Routine hematological tests:
Full blood count (anemia, leukocytosis)
CRP & ESR
• Microbiological investigations:
Endocervical & high vaginal swabs for gram stain & cultures
Urine FEME & urine culture
Urine Chlamydia antigen test
Offer other STI screening (HIV, hep B, syphilis)
• Pelvic ultrasound: Visualize any adnexal masses suggestive of tubo-ovarian
abscesses & fluid in the pouch of Douglas
• Laparoscopy (Gold standard).
Clinical Diagnostic criteria of PID (CDC-
2015)
• Minimum criteria • Additional criteria
• Adnexal tenderness • Oral temperature > 38.3 0C
• Uterine tenderness • Abnormal cervical
mucopurulent discharge
• cervical motion
• Presence of abundant white
tenderness
blood cells on wet mount
• Elevated ESR and CRP
• Laboratory documentation
of cervical infection with N.
gonorrhoeae or C.
tranchomatidis
• Definitive criteria
• Histopathologic evidence of endometritis on biopsy
• Imaging study (TVS/MRI) evidence of thickened fluid filled tubes ±
tubo-ovarian complex.
• Laparoscopic evidence of PID
DIFFERENTIAL DIAGNOSIS
• Acute appendicitis
• Acute salpingitis
• Ectopic pregnancy
• Torsion of ovarian pedicle
• Hemorrhage or rupture of ovarian cyst
• Endometriosis
• Diverticulitis
• UTI (E.g. Cystitis)

The two conditions—acute appendicitis and ectopic pregnancy must be ruled out, because
both the conditions require urgent laparotomy whereas acute salpingitis is to be treated
conservatively.
MANAGEMENT
Out-patient
• Ceftriaxone 250mg IM (or
cefixime 400mg stat)
• Doxycycline 100mg oral bid x 14
days
• Metronidazole oral bid x 14 days
• Treat sexual partners
• In pregnancy; Erythromycin
500mg every 6hours instead of
Doxycycline
Inpatient
• Ceftriaxone IV/IM 1g once daily
• Doxycycline IV 100mg twice daily
• Metronidazole IV 500mg twice
daily until patient condition
improves, then continue on oral
therapy with:
• Doxycycline PO 100mg twice daily
+ metronidazole PO 500mg twice
daily x 14 days
• Indications for Hospitalization.
• suspected tubo-ovarian abscess
• Severe illness, vomiting, temperature >38⁰C
• Uncertain diagnosis and or unresponsive to outpatient
treatment
• Intolerance to oral antibiotics
• Co-existing pregnancy
• Patient with known HIV infection
Surgical intervention:
Indications for surgery in PID:
- Drainage of tubo-ovarian abscess
- Adnexal mass of uncertain diagnosis
- Treatment for other sequelae of PID (e.g. salpingectomy for
ectopic, hysterectomy for refractory chronic pelvic pain,
adhesiolysis for intestinal obstruction from adhesions)
FOLLOW UP
• Repeat smears and cultures from discharge are to be done after 7days
following the full course of treatment.
• Tests repeated following each menstrual period until it becomes
negative for 3 consecutive reports when the patient is declared cured.
• The only unequivocal proof of successful treatment after salpingitis is
an intrauterine pregnancy
PREVENTION
• Encouraging healthy sexual practices E.g. use of barrier contraception,
Abstinence from sex, Faithfulness to one partner (avoiding a sexual
network).
• Health worker training in behavioral science
• Mass media health education campaigns use in promoting prevention of
STDs
• Routine STI screening to Detect asymptomatic STIs
• Encourage sexual partners to be evaluated
• Do not do unnecessary vaginal exams in women
• Maintain aseptic technique in the Instrumentation and examination in
female genitalia.
COMPLICATIONS

Immediate Late
• Pelvic peritonitis • Tubal infertility due to tubal damage
or tubo-ovarian mass
• Septicemia;
• increased risk of Ectopic pregnancy
• Chronic pelvic pain
• Dyspareunia
• Formation of adhesions or
hydrosalpinx or pyosalpinx or tubo-
ovarian abscess
• Fitz-Hugh-Curtis syndrome
FITZ HUGH CURTIS syndrome; violin
string appearance
References
• Gynaecology by Ten teachers 20th edition.
• Pelvic inflammatory disease, CDC, Jan 2018.
• William’s text book of gynaecology, 2nd edition.
• Dc Dutta’s text book of Gynaecology