6/10/2012
Pelvic Inflammatory disease
Adity Bhattacharyya, MD, FAAFP.
RWJMS Family Medicine Residency at Capital Health.
Disclosure
• Dr. Bhattacharyya has indicated that she has nothing to disclose relative to this presentation. Pelvic inflammatory disease
• Pelvic inflammatory disease is a polymicrobial disease of the upper genital tract
• Primarily affects young sexually active women
• Diagnosis is made clinically
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Pelvic inflammatory disease
• 750,000 cases a year of PID, mostly in women under 30 yrs
• It costs about $1.5 billion annually to treat PID
• 80 – 90% of women with Chlamydia infection are asymptomatic
• Women with PID have a 20% chance of infertility from tubal scarring
Pelvic inflammatory disease
• Case 1: 22 year old patient presents to your office with pain in the lower abdomen for the past week which has gotten worse over the last 2 days. Pain is constant, 8/10 in severity, does not radiate and some times gets worse on movement
Pelvic inflammatory disease
• Urgent conditions that should not be missed:
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Ectopic pregnancy
Ovarian torsion
Pelvic inflammatory disease
Appendicitis
Ruptured ovarian cyst
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Pelvic inflammatory disease
• RISK FACTORS:
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Age less than 25
Intercourse before age 15
Non Barrier contraception
New or multiple sexual partners
H/O PID or any STD
Vaginal douching
Pelvic inflammatory disease
• History:
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Pain
Relation to menstruation
Relation to sexual intercourse
Vaginal bleeding
Vaginal discharge
Urinary and bowel symptoms
Past History
Sexual history
Case 1
• Patient’s LMP was 6 weeks ago but she usually has irregular cycles.
• She has been having a yellowish vaginal discharge for the past week which is not foul smelling.
• It is painful to have sex for the past week. She is sexually active with her partner for the past 4 weeks. They uses condoms off and on.
• She has some mild dysuria, but no urgency. She is usually constipated.
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Pelvic inflammatory disease
• Physical Examination:
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Vital Signs
Abdominal examination
Pelvic examination: Speculum and bimanual Rectal examination if needed
Musculoskeletal exam of lower back, hip
Case 1
• VS: P 120/min, RR 20/min, BP 100/60. Temp 101 degree F. BMI 30.
• ABDOMEN: Tenderness in lower abdomen with guarding in the RLQ. BS +, no clear mass palpable
• PELVIC: Ext gen normal, copious yellow discharge from cervix which is inflamed Cultures sent
• Bimanual:‐ CMT+, Right adnexa tender with some fullness, Left adnexa tender
Pelvic inflammatory disease
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Pelvic inflammatory disease
• LABORATORY TESTING/ IMAGING:
• Vaginal wet mount
• GC and Chlamydia testing
• ESR/ C reactive protein
• Ultrasonography
• Laparoscopy/ Laparotomy
• Endometrial biopsy
Pelvic inflammatory disease
Case 1
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Urine pregnancy test : negative
UA: Leukocytes present, with trace blood
GC/Chlamydia Pending
CBC: WBC count 12,000
• Pelvic Ultrasound: normal sized uterus and cervix. Bilateral tubal thickening, right side more than left. Large 4 cm fluid filled mass in rt
adnexa, possible TO abscess. Free fluid in the cul de sac
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Pelvic inflammatory disease
Pelvic inflammatory disease
Pelvic inflammatory disease
CDC criteria for diagnosis for PID:
1. At least one of the following must be present: Adnexal tenderness, cervical motion tenderness, uterine tenderness.
2. Additional Diagnostic criteria: Cervical mucopurulent discharge, elevated ESR /CRP, Fever, positive GC/Chlamydia, WBC on vaginal wet mount.
3. The most specific criteria: EMB, Laparoscopic evidence of PID, Classic US findings of TO abscess. 6
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Pelvic inflammatory disease
CRITERIA FOR HOSPITALIZATION
1. Inability to follow or tolerate an outpatient oral regimen
2. No clinical response to oral therapy
3. Pregnancy
4. Severe illness
5. Surgical emergencies cannot be excluded
6. Tubo‐Ovarian abscess
Pelvic inflammatory disease
• Recommended Parenteral Regimen A
• Cefotetan 2 g IV every 12 hours
OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
• Recommended Parenteral Regimen B
• Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing (3–5 mg/kg) can be substituted
Pelvic inflammatory disease
• Alternative Parenteral Regimens
• Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
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Pelvic inflammatory disease
• 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
Pelvic inflammatory disease
• OR Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently 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
Pelvic inflammatory disease
• OR Other parenteral third‐generation cephalosporin (e.g., ceftizoxime or cefotaxime)
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
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Pelvic inflammatory disease
• Clinical recommendations for practice:
• No Clinical or Laboratory test is sensitive or specific enough to definitely diagnose PID: C
• Empiric antibiotics should be initiated at the time of presentation in patients with symptoms suspicious of PID, even if the diagnosis has not been confirmed: B
Pelvic inflammatory disease
• Women with mild to moderate PID may receive out patient oral treatment without increased risk of long term sequelae: B
• Screening for lower genital tract Chlamydial
infection in younger and high risk population is recommended to educe the incidence of PID: A
• Asymptomatic disease should be treated: A
Pelvic inflammatory disease
• Unless there is proven sensitivity, fluoroquinolones should not be used in women with PID because of widespread resistance in Neisseria gonorrhoeae: C
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Pelvic inflammatory disease
• Questions
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