Pelvic Inflammatory Disease

1. Pelvic Inflammatory Disease By: Kallianpur Vaibhav Vinayanand. ML- 610 2012

2. Upper Genital Tract Infections • The Cervix is considered the boundary between the lower and upper genital tracts. • Upper genital tract infections affect primarily the cervix, uterus, or fallopian tubes • Severe infections may affect one or both ovaries.

3. Topic Defined: 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).

4. Pathway of Ascendant Infection Cervicitis Endometritis Salpingitis/ oophoritis/ tubo-ovarian abscess Peritonitis

5. Pathologic Processes of PID • PID has a broad clinical spectrum that includes • acute PID • silent PID • atypical PID • the PID residual syndrome or chronic PID and • postpartum/postabortal PID

6. PID Classification Overt 40%

7. PID Specifically defined: • Individual cases of PID can also be more specifically defined by • a) the site (s) of disease (i.e., endometritis, salpingitis, salpingo-oophoritis) • b) the etiologic agent (s) involved (those that cause chlamydial endometritis, gonococcal salpingitis, nonchlamydial/nongonococcal salpingo-oophoritis).

8. 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.

9. 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.

10. PID: Etiology • PID results from microorganisms transmitted during intercourse. • Certain procedures that open the cervix and allow possible bacteria to pass through (D&C, abortion, cesarean birth, miscarriage, I.U.D. insertion) • The infection is usually multifactorial, involving aerobic and anaerobic organisms

11. PID: Risk Factors • Multiple sexual partners or partner with multiple sexual partners • Intercourse with partner with untreated urethritis • Previous history of PID • Use of an IUD • Presence of bacterial vaginosis or an STD • Nulliparity • Recent instrumentation of the uterus • Douching • Cigarette smoking • Sex with menses

12. 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

13. C. trachomatis Infection (PID)

14. 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

15. 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

16. Chlamydial Pyosalpinx • Pelvic inflammatory disease, proven Chlamydial Pyosalpinx. • Right tube is swollen and tortuous (arrow) (Holmes, 1999, Plate 17; reprinted with permission from McGraw Hill.)

17. 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)

18. 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

19. 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.

20. Acute Salpingitis (PID) • Pelvic infection due to N. Gonorrhoeae is usually more acute than that due to C. trachomatis • Onset is rapid, and pelvic pain develops shortly after menses starts. • Although the pain is often localized to one side, both tubes are probably infected. • The infection produces a diffuse exudate, leading to agglutination, adhesions, and tubal occlusion. • Peritonitis may occur, causing upper abdominal pain and adhesions

21. Acute Salpingitis: Chlamydia & Gonorrhea • C. trachomatis produces symptoms that often seem mild, but it can cause more damage than N. Gonorrhoeae in the long term. • Chlamydial organisms may remain in tubal mucosa for many months before clinical manifestations of acute disease appear. • Untreated or inadequately treated acute infection can lead to chronic salpingitis, with tubal scarring and possible adhesion formation. • Chronic pelvic pain, menstrual irregularities, and infertility are long-term sequelae

22. 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

23. 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 tubo-ovarian abscess

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

25. 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.

26. 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

27. 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

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

30. 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

31. Diagnosis • ESR and C-reactive protein are elevated in many disorders and are therefore not specific for PID. • Endometrial biopsy with aerobic and anaerobic culture may assist in the diagnosis. • All three major criteria and at least one minor criterion must be present to diagnose PID.

32. Endometritis (thickened heterogenous endometrium)

33. Hydrosalpinx(anechoic tubular structure)

34. Hydrosalpinx.

35. Pyosalpinx (tubular structure with debris in adnexa

36. Tuboovarian abscess resulting from tuberculosis

37. Right hydrosalpinx with an occluded left fallopian tube

38. Differential Diagnosis

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

41. 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.

42. Management Outpatient: Regimen B • Ceftriaxone 250 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

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

44. 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

45. 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

46. 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

47. Prognosis • 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.

48. Prognosis • 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.

49. Sequelae • Infertility • ¼ of pt have acute salpingitis • occur 20% • infertility rate increase direct with number of episodes of acute pelvic infection

50. Sequelae • Ectopic pregnancy • increase 6-10 fold • 50% occur in fallopian tubes (previous salpingitis) • mechanism ; interfere ovum transport entrapment of ovum