PELVIC INFLAMMATORY

DISEASE

Rujira Manorompattarasan, MD
13/03/2018
 Outline

 Introduction
 Epidemiology

 Risk factor

 Microbiologic

 Complication

 Diagnosis

 Treatment

 Summary
 Introduction : PID

 Target: upper genital tract in women endometritis,

salpingitis, pelvic peritonitis, tubo-ovarian abscess (TOA)

 Polymicrobial organism: at least two kinds

 25-50% of cases could not document organism

 Long-term sequelae ; chronic pelvic pain, ectopic

pregnancy, infertility
Epidemiology
 Risk factors

1. Multiple partners (>=4/6 months  inc. PID 3.4 times)

2. STI in partner : 30% of men with gonococcal or

chlamydial urethritis are asymptomatic

3. More common in 15-25 years : C.trachomatis are densely

concentrated

4. Previous PID : 25% recurrence

5. Contraception : non-condom
Pathogenesis

 Endocervical canal functions  barrier protecting from organisms

of the dynamic vaginal ecosystem
 Endocervical infection with STDs  disrupt this barrier
 Ascending infection  upper genital organs
Microbiologic etiology

Non-STD
1. N.gonorrhoeae (43.6%)
2. C.trachomatis ( 10%): co-incidence 12%
3. Smaller part ; CMV, M.hominis,
U.urealyticum , M.genitalium
4. Non-STD group (15%): anaerobic,
Bacteroides, peptostreptococcus, G.vaginalis,
Hemophilus influenza, gram-negative rods and
streptococcus alagactiae
Neisseria gonorrhea

 gram-negative intracellular diplococci

 Gonococcal PID : clinical more severe than Chlamydia PID
Chlamydia trachomatis

 1/3 of PID
 Asymptomatic subclinical infection  common

 Later  chronic pelvic pain and infertility

Clinical features

 PID during pregnancy is rare

 Because the mucus plug and decidua seal off the uterus
from ascending bacteria
 PID can occur In the first GA 12 weeks before this occur
Clinical features

 Women who undergo instrumentation of the cervix

(termination of pregnancy)
 higer risk of infection ascending to cause PID

 Older women less commonly present with PID

 If they do  more likely to be non- STI-related
Clinical features : Acute symptomatic PID

 Symptoms
 Acute onset of lower abdominal or pelvic pain
 Cardinal presenting symptoms of PID
 Usually bilateral

 Examination
 Abdominal tenderness on palpation, rebound tenderness, fever
 Decreased bowel sound in severe PID

 Laboratory
 Leukocytosis, elevated ESR, CRP

 Perihepatitis
 Tubo-ovarian abscess
 Perihepatitis
:Fitz-Hugh–Curtis syndrome

 Inflammation of the liver capsule and peritoneal surface

 Associated with N.gonorrhea and C.trachomatis
 Patchy purulent and fibrinous exudate adhesions (violin string )
 10% of PID , characterized by right upper quadrant abdominal
pain with pleuritic pain
Clinical features : Chronic PID

 An indolent presentation of PID

 Duration : months or years

 With low-grade fever , Weight loss, Abdominal pain

 Pain during intercourse or ovulation

 Association with actinomycosis ( IUD) and tuberculosis

Laboratory tests

 Pregnancy test
 Microscopy of vaginal discharge

 Saline : increased WBC

 WBC ( 3 or more/ HF) in vaginal wet smear : sensitivity around 90 %
 Gram stain : gram-negative intracellular diplococci
(N.gonorrhea) 50% of PID

 CBC : ↑ WBC , non specific ,only 44 % sensitivity

 HIV screening

 Serologic testing for syphillis

 Diagnosis

 PID should be suspected and treatment if

 Patient
is at risk of PID and pelvic or lower abdominal pain
 Minimum clinical criteria ( >=1 )
 Cervical motion tenderness
 Uterine tenderness
 Adnexal tenderness

No WBC = Diagnosis of
 Additional criteria ( >=1 ) PID unlikely
 Oral temperature > 101 F ( 38.3 C)
 Abdominal cervical mucopurulent discharge or cervical friability
 Presence of abundant numbers of WBC on saline microscopy of vaginal fluid
 Elevated ESR
 Elevated CRP
 Lab of cervical infection with N.gonorrhea or C.trachomatis
Diagnosis

 PID should be suspected and treatment if

 Specific criteria

 Endometrial biopsy with histopathologic evidence of endometritis

 TVS or MRI : showing thickend, fluid-filled tubes with or without

free pelvic fluid or Tubo-ovarian complex or Dopper studies
suggesting pelvic infection ( tubal hyperemia)

 Laparoscopic findings consistent with PID

Diagnosis : PID

 Transvaginal ultrasonogram
 Good specificity (97-100%) but poor sensitivity (32-85%)
 Incomplete septum fallopian tube
 Thick wall
 Thin wall and nodules within the wall ( subacute phase)
Ultrasound

Dilated fallopian tube Tubo-ovarian abscess

Tubo-ovarian complex

Dilated tubular mass and incomplete septum

MRI : Rt. TOA with pyosalpinx

T1 T2 (fat sat)
Laparoscopy

 Gold standard (50% sensitivity, 85% specificity)

 Finding : edematous, erythematous, adhesion,

pus from fimbria

 Invasive, expensive

 Indicated in unclear diagnosis, pus drainage

Laparoscopy

Normal pelvic organs Pyosalpinx

Diagnosis

 Endometrial biopsy
 Presence of leukocytes and plasma cells
 Subacute condition
 Equivocal diagnosis
 70-90% sensitivity, 67-90% specificity
Differential diagnosis

 Ob-gyn  Surgery
 Tubal pregnancy  Appendicitis

 Adnexal mass with  Diverticulitis

complication  Gut obstruction, volvulus

 Pelvic endometriosis  Urinary tract calculi

 Septic abortion

 Medicine
 Acute cystitis
 Gastroenteritis
 Cholecystitis

 Musculoskeletal disorder
Treatment
Treatment

 Goal :decrease acute symptom and prevent long-term

complication

 Medication is primary treatment

 Broad spectrum due to polymicrobial infection

 Parenteral antibiotic should be stopped within 24 hr after

improvement and followed by oral antibiotic to 14 days
Outpatient regimen :
Intramuscular/Oral Treatment

 For mild-to-moderately severe acute PID

 Failure to response after 72 hours

Should be reevaluated to confirm diagnosis
PV, USG

Should be given parenteral antibiotic

Treatment outpatient

Novak edition15
Indication for admission

1. Surgical emergencies cannot be rule out

2. Tubo-ovarian abscess
3. Pregnant patient
4. Severe illness: vomitting, high fever
5. Failure to oral antibiotic treatment
6. Poor compliance
Treatment : inpatient

Novak edition15
Parenteral Treatment

 Parenteral antibiotic should be switch to oral therapy within 24-

28 hours of clinical improvement

 Cefotetan or cefoxitin regimens

 Switch to doxycycline (100 mg) bid -14 days

 Clindamycin/gentamicin regimens
 Switch to clindamycin (450mg)qid -14 days
 Or doxycycline (100 mg) bid -14 days
Parenteral Treatment

 TOA
 Switch to clindamycin (450mg)qid Or
metronidazole (500mg) bid
 AND doxycycline (100 mg) bid
 At least 14 days
Follow up

 Clinical improvement : with in 72 hours

 Fever
 Abdominal tenderness
 Uterine, adnexal and cervical motion tenderness

 If no clinical improvement within 72 after outpatient or

parenteral antibiotic therapy
 Hospitalization
 Additional diagnostic test e.g. laparoscopy
 Surgical intervention
Complications

 Tubo-ovarian abscess (TOA) : 30% of hospitalized

patients

 Long-term sequelae
 infertility, chronic pelvic pain, ectopic pregnancy
Other Management Considerations

 To Abstain from sexual intercourse until

 Therapy is completed
 Symptoms have resolved
 Sex partners have been adequately treated

 All women with acute PID

 Should be tested for HIV, GC and chlamydia

 If GC or chlamydia is documented , repeated diagnostic

test should be done in 3-6 months
Management of Sex Partners

 All male partners who contact within 60 days before onset

of symptom should be examined and treated for chlamydia
and gonorrhea

 If last sexual contact >60 days, the most recent should be

examined and treated

 Male partners frequently are asymptomatic

Tubo-ovarian abscess
Tubo-ovarian abscess

 An inflammatory mass involving the fallopian tube , ovary ,

and other adjacent pelvic organs

 Typical Presentation : the same as PID alone

 Afebrile40%
 Chronic > acute abdominal pain 25%

 Normal WBC in CBC 23%

 Ruptured abscess
 Acute abdomen
 Sign of sepsis
Management of TOA

 Antibiotic therapy
 Response
70% of women ( due to avascular, not easily
permeated by antimicrobials, low pH)

 Regimen same as PID (include drugs with demonstrated

superior abscess wall penetration and activity within the
cavity)
Candidated for antibiotic therapy alone

 Hemodynamically stable with no signs of a

ruptured TOA
 Abscess < 9 cm in diameter

 Adequate response to antibiotic therapy

 premenopausal
Management of TOA

 Monitor therapy
 Close observe at least 48-72 hours

 Criteria for failure antibiotic therapy

 New onset or persistent fever
 Persistent or worsening abdominopelvic tenderness
 Enlarging pelvic mass
 New onset, persistent, or elevation of WBC
 Signs of sepsis
Minimally-invasive drainage procedure

 Drain intraabdominal abscess with USG guide

 Success 70-100%

 Approaches depend on location of abscess

 Percutaneous

 Transvaginal

 Transrectal

 Surgical exploration : suspected intraabdominal rupture

Complication of TOA

 Abscess rupture : 15%

 Sepsis : 10-20%
Special considerations
Pregnant patient

 Pregnant patient with acute PID should be hospitalization

and treated with parenteral regimen because
 High risk for maternal morbidity
 High risk for preterm labor

 Regimen :
 Second generation cephalosporin (cefoxitin or
cefotetan:
 And azithromycin 1 g oral (instead of doxycycline)
HIV patient

 Is likely to develop TOA but responses to standard regimen

equally to HIV-negative patient

 Is likely to have M. hominis and streptococcus  admit and

parenteral therapy
Intrauterine device and PID

 Risk of PID is confined within 3 weeks after insertion

 The IUD removal in PID patient is inconclusive, but close

monitor is essential , removal in TOA

 The rate of treatment failure and recurrent PID in IUD user

is unknown