PID
Definition
MO’s
Causes
Risk factors
Complications
Assessment
Investigation
Treatment
Syphilis
Spread of 1Y lower genital tract infection to upper (inc. endometritis, salpingitis, tubo-ovarian abscess, peritonitis)
Non-sexual: mixed pathogens from vaginal flora; anaerobes, facultative bacteria, mycoplasma, ureaplasma, gut coliforms (E coli, H influenzae); PV
discharge not usually STD (candida most common cause, bacterial vaginosis)
Sexual:
Chlamydia - most common cause of cervicitis; most common in hetero; usually asymptomatic in women
Intracellular parasite; incubation 1-3/52 or longer
More watery discharge, less painful than gonorrhoea; can also cause proctitis / prostatitis
Lymphogranuloma venereum (males get vesicles/ulcers on genitals  inguinal buboe after 1-4/52  fuse, breakdown,
discharge)
Gonorrohea – rates increasing; more common in homos / Maoris etc… / overseas sex; 50% have co-existant chlamydia; incr penicillin and
quinolone resistance
G-ive intracellular diplococci; incubation 3-7/7
Urinary Sx and penile discharge in men; 10-20% of untreated infections become PID; disseminated in 3%
Septic arthritis (2x more common in women, occurs in 0.2%, onset 3-17/7 after infection, may be preceded by migratory
polyarthritis; 75% poly, 80% asymmetric)
Rash (in 2/3; petechiae / painful red papules on digits; may become vesicular / pustular  grey necrotic centre, often on
haemorrhagic base; usually <20 lesions)
Can also cause pharyngeal, anal, conjunctivitis, tenosynovitis, meningitis, myocarditis, pericarditits
Trichomonas
Gardnerella; often polymicrobial
Direct; haematogenous (TB, mumps); iatrogenic (IUCD, RPOC); >50% have no cause detected for cervicitis
Incr with sexual activity; decr with progesterones and pregnancy (esp after 12/40)
Infertility (12-50%; 10% after first episode); chronic salpingitis (25%); chronic pain, adhesions, dysparaeunia (20%), ectopic (12-15% higher
incidence; incidence 1:120 normally, 1:16 with PID); tubo-ovarian abscess (5% mortality if rupture; occurs in 1/3 hospitalised patients); infertility
(risk doubles with each infection; 2 infections = 20%, 3 infections = >50%); Fitz-Hugh-Curtis syndrome (transcoelemic spread of inflammatory
peritoneal fluid to subphrenic and subdiaphragmatic spaces)
History: 90% pelvic pain (usually bilateral); 75% vaginal discharge; >30% irregular PVB; systemic toxicity
Examination: poor sens and spec; low grade fever, adnexal mass
Bloods: WBC >10 in 50%
Swab: gonorrhoea culture (urethral or endocervical) 97% sens
gram stain 50% sens
PCR 99% sens and spec
chlamydia culture 95% sens, 99% spec; self collected samples and urine samples as good
Urine: gonorrhoea PCR 90% sens, 99% spec
Chlamydia PCR in males
USS: if abscess suspected (ie. Toxic, asymmetrical findings)
Laparoscopy: will be +ive in 50% of those diagnosed with PID clinically
Commence if: lower abdo tenderness + uterine and bilateral adnexal tenderness + cervical motion tenderness
Admit if: toxic; severe pain; unable to tolerate PO meds; pregnancy; pre-pubertal; HIV +; poor likelihood of compliance; IUD or recent
instrumentation
Sexually acquired:
Mild
Azithromycin 1g PO single dose / doxycycline 100mg BD + metronidazole 400mg BD for 14/7
If gonorrhoea (always trt if community incidence high
+ ceftriaxone 250mg IM/IV stat
Severe
Doxycycline + metronidazole + ceftriaxone (continue for 48hrs after Sx improve)  PO
Non-sexually acquired: Mild
Augmentin
+ doxycycline
Severe
As per septicaemia (or treat as severe sexual)
Septicaemia
Ampicillin 2g IV Q6h + metronidazole 500mg BD + gentamicin 4-6mg/kg OD
Puerpueral
Mild
Augmentin BD 5-7/7 (add roxithromycin 300mg OD / clindamycin 300mg TDS if ongoing >48hrs)
Severe
As per septicaemia
Pregnant / Bfing
Roxithromycin instead of doxy
If penicillin allergy
IV gentamicin + clindamycin
Gonorrhoea, no PID Ceftriaxone (covers gonorrhoea) + doxycycline 100mg BD 7/7 or azithromycin 1g single dose
Chlamydia, no PID
Doxycycline 100mg BD 7/7 or azithromycin 1g single dose (both have 95% cure rate)
Remove IUCD or RPOC; consider sexual abuse; trt sexual contacts (partner infected in 40%); counselling; always FU at 72hrs; refer to sexual health
clinic; abstain from sex at least 2/52; candida prophylaxis; gonorrhoea and chlamydia = reportable disease
Very uncommon (incr in homos); usually detected in latent phase
Treponema pallidum: spirochete; STD
1Y syphilis: 2-6/52 after contact  1 firm, nontender, raised red lesion (chancre) on penis, cervix,
vagina, anus in 70% men, 50% women; up to 7eral cm diameter; erodes to create shallow based ulcer;
regional LN  heals in 3-6/52 without trt
2Y syphilis: 2-10/52 after 1Y, in 75%  dissemination in skin and mucocutaneous tissues;
lasts several weeks  latent phase
1. maculopapular / scaly / pustular lesions on soles of feet / palms – discrete
red/brown spots <5mm diameter
2. condylomata lata on moist areas (eg. Anogenital / axilla / inner thigh) – broad
based, elevated plaques, painless, highly infectious
3. silver/gray superficial erosions on mm's (esp mouth / ext genitalia / oropharynx)
 ulcerate – these are most infectious
4. fever, malaise, weight loss, LN’s, arthralgia
5. Maybe: asceptic meningitis (1-2%), hepatitis, nephrotic syndrome
3Y syphilis: in 1/3 untreated after >5yrs
1. CV syphilis: aortitis --> dilatation of aortic root and arch --> aortic valve regurg,
aneurysms; accounts for 80%
2. Neurosyphilis: may be asymptomatic (1/3); chronic meningovascular disease, tabes
dorsalis, general paresis; dementia, psychosis, CN palsy, SC syndrome; in 5-10%
3. Benign 3Y syphilis: gummas in various sites; white/gray rubbery/
single/multiple/small/large nodular lesions due to delayed hypersensitivity; mostly in bone
(--> pain, tenderness, swelling, pathological fracture), skin, subC tissue; mm of URT and
mouth, testes; rarely causes destructive ulcerative lesions
Congenital syphilis: during 1Y/2Y in mother; 25% intrauterine / perinatal death
--> infantile (early): first 2yrs; nasal discharge and congestion; desquamating / bullous rash --> sloughing of skin (esp hands, feet, mouth, anus);
hepatomegaly, skeletal abnormalities (syphilitic osteochonritis and periostitis – esp nose with saddle nose deformity and lower leg --> new bone
growth on ant tibia --> sabre shin)
--> tardive (late): later; occur in >50% untreated; Hutchinson triad: notched central incisors (may be screwdriver shaped), interstital keratitis (or
choroiditis) with blindness, deafness due to VIII injury (and optic nerve atrophy); skeletal, neurological and facial abnormalities
Investigation: identified on MC+S of 95% chancres; VDRL 80% sens (>95% in stage 2 and 3), 1-2% false +ive  if +ive, need to confirm with
treponeal ab test (80% sens 1Y, 100% later)
Mng: penicillin (doxycycline if allergy)
Notes from: Dunn, Cameron, TinTin