DR. EBTIHAG HASHIM
CONSULTANT OBS & GYNE
MINIMAL ACCESS ENDOPELVIC SURGERY

Pelvic Inflammatory Disease (PID)
Infection of the upper female genital tract.
Refers to the clinical syndrome among women resulting from infection.
Includes endometritis (infection of the uterine cavity).
Salpingitis (infection of the fallopian tubes)
Mucopurulent Cervicitis (infection of the cervix).
Oophoritis (infection of the ovaries ).

Pathologic Processes of PID
PID has a broad clinical spectrum that includes
A. acute PID
B. silent PID
C. chronic PID
D. postpartum/postabortal PID

Relevance to Women’s Health:
Commonly occurs in women <35 years.
Rarely occurs before menarche, after menopause or during pregnancy.
About 1.2 million women are treated for PID.
Over 100,000 women with PID are hospitalized each year.
About 15% are acutely ill that require intensive inpatient treatment.
Approximately 85,000 women with mild or moderate
PID who currently are being hospitalized, treating them as outpatients may save around $500 million each year.

Causative Agents of PID
Neiserria Gonorrhoeae and Chlamydia trachomatis are the
2 major causative organisms.
Chlamydia trachomatis is the predominant STD organism causing PID.
In the U.S., the role of Neisseria Gonorrhoeae as the primary cause of PID has decreased.
Other agents: Mixed infection caused by both aerobic and anaerobic organisms
Recent studies demonstrate the presence of Bacterial
Vaginosis and trichomoniasis in cases of confirmed PID

Causative Agents of PID
Cytomegalovirus (CMV) has been found in the upper genital tracts of women with PID.
Enteric gram-negative organisms (E-coli)
Peptococcus species
Streptococcus agalactiae
Bacteroides fragilis
Mycoplasma hominis
Gardnerella vaginalis
Haemophilus influenzae

Signs & Symptoms of PID
The patient presents with lower abdominal pain, fever, vaginal discharge, and/or abnormal uterine bleeding.
Symptoms frequently occur during or after menses.
Peritoneal irritation produces marked abdominal pain with or without rebound tenderness.
The abdomen should be palpated gently to prevent abscess rupture.

Relevance to Women’s Health
Is one of the major causes of gynecologic morbidity.
Infertility.
Ectopic pregnancy
Chronic pelvic pain
Diagnosis and treatment must be prompt to avoid these conditions .

Chlamydial Pyosalpinx
Pelvic inflammatory disease, proven Chlamydial Pyosalpinx.
Right tube is swollen and tortuous (arrow)

Cervicitis
The cervix appears red and bleeds easily when touched with a spatula or cotton swab.
Mucopurulent discharge is yellow-green.
Contains >10 polymorphonuclear WBCs per oil immersion field
(using Gram stain).

Acute Salpingitis
Onset is usually shortly after menses.
Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness, and cervical motion tenderness.
Involvement is usually bilateral.
Nausea and vomiting occur with severe infection.
In the early stages, acute abdominal signs are often absent

Acute Salpingitis (PID)
Bowel sounds are present unless peritonitis with ileus has developed.
Fever, leukocytosis, and mucopurulent cervical discharge are common
Irregular bleeding and bacterial vaginosis often accompany the pelvic infection.

Complications of PID
Tubo-ovarian abscess develops in about 15% of women with salpingitis.
It can accompany acute or chronic infection
The tube and ovary can become completely matted together.
May require prolonged hospitalization, sometimes with surgical percutaneous drainage.
Rupture of the abscess is a surgical emergency
Rapidly progressing from severe lower abdominal pain to
N & V, generalized peritonitis, and septic shock

Tubo-ovarian abscess
Pyosalpinx, in which one or both fallopian tubes are filled with pus, may also be present.
Hydrosalpinx (fimbrial obstruction and tubal distention with nonpurulent fluid) develops if treatment is late or incomplete.
The consequent mucosal destruction leads to infertility.
Hydrosalpinx is generally asymptomatic but can cause pelvic pressure, chronic pelvic pain, or dyspareunia.
Women with HIV infection are more likely to have tuboovarian abscess

Tubo-ovarian abscess
Here at least the ovaries, tubes and uterus can still be recognized as separate structures

Fitz-Hugh-Curtis syndrome
Can be a complication of gonococcal or chlamydial salpingitis.
Characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis.
Acute cholecystitis may be suspected, but signs and symptoms of PID are present or develop rapidly.

Diagnostic Studies:
CBC with differential
Erythrocyte Sedimentation Rate
Cervical cultures
Blood Cultures
Urine Pregnancy Test
Rapid Plasma Reagin (RPR)
Cervical infection due to N. Gonorrhoeae can also be diagnosed by Gram stain showing intracellular gram-negative diplococci

Diagnostic studies
Leukocytosis is typical.
Pelvic ultrasonography may be used when a patient cannot be adequately examined because of tenderness or pain.
When a pelvic mass may be present, or when no response to antibiotic therapy occurs within 48 to 72 h.
Laparoscopy should be performed only if the diagnosis is uncertain or if the patient does not promptly improve with medical therapy.

CDC’s Minimum Criteria for
Empiric Treatment of PID
Lower Abdominal
Tenderness.
Adnexal Tenderness.
Cervical Motion
Tenderness.

Diagnosis
And one or more minor criteria
Temperature over 100.9F or 38.3 C
White Blood Cell count > 10,000
Elevated ESR
Elevated C-reactive protein
Pus in cul-de-sac
Pelvic abscess or inflammatory complex
Cervical Mucus findings
Gram Stain: Gram Positive diplococci
Intracellular parasites

Diagnosis
ESR and C-reactive protein are elevated in many disorders and are therefore not specific for PID.
All three major criteria and at least one minor criterion must be present to diagnose PID.

Renal calculus
Adnexal torsion
Proctocolitis
Differential Diagnosis
Condition
Acute Appendicitis
Ectopic Pregnancy
Ruptured Ovarian Cyst
Endometriosis
Urinary Tract Infection
Hemorrhaging corpus luteum
Characteristic Signs/Symptoms
Anorexia, N & V, decreased or absent bowel signs, unilateral pain limited to right or left lower quadrant
Unilateral pain; missed menstrual period usually warrants hCG test
Unilateral pain
Constant pain begins 2-7 days before menses
Dysuria, abnormal urinalysis. No cervical motion tenderness
Severe unilateral pain, hematuria
Unilateral pain
Anorectal pain, tenesmus, rectal discharge or bleeding
Unilateral pain

Treatment Goals & Benefits
Therapeutic goals include complete resolution of the infection and prevention of infertility and ectopic pregnancy .

Management Outpatient
Regimen A:
Initial Treatment at Diagnosis
Ofloxacin 400 mg orally BID for 14 days
(95% cure)
Or
Levofloxacin 500 mg orally once daily for 14 days
With or without:
Metronidazole 500 mg orally twice a day for 14 days.

Management Outpatient: Regimen B
Ceftriaxone 500 mg IM in a single dose
Or
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose
Or
Other parenteral third-generation cephalosporin
(ceftizoxime or cefotaxime)
Plus
Doxycycline 100 mg PO BID for 14 days (75% cure)
With or without
Metronidazole 500 mg PO BID for 14 days

Management Inpatient
Toxic appearance
Unable to take oral fluids
Unclear DX
Appendicitis
Ectopic Pregnancy
Ovarian torsion
Pelvic abscess
Pregnancy
HIV positive
Outpatient TX failure

Inpatient Treatment Regimens:
General: Treat for at least 48 hours IV
Regimen A
Cefotetan 2g IV q12 hours
OR
Cefoxitin 2g IV q6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours

Inpatient Treatment
Regimen B
Clindamycin 900 mg IV q8 hours
Plus
Gentamicin 2 mg/kg IV loading dose, then 1.5 mg/kg IV q8h
Discharge Regimen (after IV antibiotics)
Doxycycline 100mg PO BID for 10 days or
Clindamycin 450mg PO QID for 14 days

Alternative Parenteral Regimens
Ofloxacin 400 mg IV q 12 hours
Or
Levofloxacin 500 mg IV once daily
With or without
Metronidazole 500 mg IV every 8 hours
Or
Ampicillin/Sulbactam 3 g IV every 6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours

Therapy using antibiotics alone is successful in
33-75% of cases.
If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage and copious irrigation or unilateral adnexectomy, if possible.
Further surgical therapy is needed in 15-20% of cases so managed.

Chronic pelvic pain occurs in approximately 25% of patients with a history of PID.
This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or
Hydrosalpinx.
Impaired fertility is a major concern in women with a history of PID.
The rate of infertility increases with the number of episodes of infection.
The risk of ectopic pregnancy is increased in women with a history of PID.
Ectopic pregnancy is a direct result of damage to the fallopian tube.

Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID.
Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide.
Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs.
Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended

At all levels, PID surveillance is affected by four main constraints:
PID is difficult to diagnose accurately.
PID is diagnosed in a wide variety of clinical settings.
Microbiology test results are needed to determine the etiology of PID.

When medical-care messages are clear, explicit, relevant, and rigorously delivered by providers, patients are likely to comply.
Reinforcement of these messages can be achieved by providing written information.
Information on written materials for patient distribution can be obtained from CDC or local and state health departments

The exact incidence of PID is unknown
The disease cannot be diagnosed reliably from clinical signs and symptoms.
Laparoscopy exam of the pelvic organs continues to be the
"gold standard" approach to diagnosis of PID.
But, because this is a surgical procedure which requires an incision in the abdomen, the high priority is to design and development of non-invasive techniques, with smaller costs and fewer risks.
OC may reduce the risk of PID that is not attributable to C. trachomatis.

Pelvic inflammatory disease (PID) in women is most commonly caused by:
A. Leptotrichia buccalis
B. Treponema pallidum
C. Chlamydia trachomatis
D. Bacillus anthracis
E. Borelia burgdorferi

The correct answer is #C. Chlamydia
Trachomatis

IUD use has been linked with:
A. pelvic inflammatory disease
B. tubal infections
C. uterine infections
D. all of the above
E. none of the above

The correct answer is #D. All of the above

Which of the following conditions is not a risk factor for pelvic inflammatory disease
(PID)?
A. Smoking
B. Multiple sexual partners
C. Young age at first intercourse
D. Hepatitis B
E. Intrauterine device (IUD)insertion

The correct answer is D:
Hepatitis B is not a known risk factor for PID.

Which of the following is not used to treat symptoms associated with pelvic inflammatory disease (PID)?
A: Nitrofurantoin
B: Ceftriaxone
C: Ampicillin
D: Ofloxacin
E: Cefoxitin

The correct answer is A:
No data suggest that Nitrofurantoin is an appropriate oral regimen for the tx of PID.
Most patients are now managed as outpatients.
One outpatient regimen is Cefoxitin and probenecid taken orally in a single dose.
Alternatively, ceftriaxone (less active against anaerobic bacteria compared to Cefoxitin) can be taken once IM with doxycycline orally twice daily for 14 days.
Another regimen is ofloxacin taken orally for 14 days with either clindamycin or metronidazole, which also are taken orally for 14 days.

(T/F): The major criteria for the diagnosis of pelvic inflammatory disease (PID) include
Leukocytosis elevated C-reactive protein (CRP) elevated erythrocyte sedimentation rate
(ESR) fever.

The correct answer is False:
The major criteria for the diagnosis of PID include:
Cervical motion tenderness
Adnexal tenderness
Lower abdominal tenderness.
ESR, CRP, and laboratory documentation of
Neisseria gonorrhea or Chlamydia trachomatis cervical infection, among others, can aid in increasing the specificity of diagnosis

(T/F): All of the following are indications for hospitalization for treatment of pelvic inflammatory disease (PID): failed outpatient therapy
Inability to tolerate oral therapy
Pregnancy pelvic abscess.

The correct answer is True:
These are circumstances in which women should be hospitalized for treatment of PID.
Other conditions that may require hospitalization are: uncertain diagnosis severe illness
Severe N & V
Immunodeficiency (HIV, immunosuppressive medications).

(T/F): In the initial workup, laparoscopy should be used to confirm the diagnosis of pelvic inflammatory disease (PID).

The correct answer is False:
Laparoscopy is costly and not always available.
It should be used if the diagnosis is in doubt.

(T/F): Consider hospitalizing patients who do not improve clinically after 72 hours with outpatient therapy for pelvic inflammatory disease (PID).

The correct answer is True:
While most patients are now treated on an outpatient basis, these patients should be admitted to the hospital and treated appropriately.