Clinical considerations of pelvic inflammatory disease (PID)
Definition: A disease of women defined as the clinical syndrome resulting from the ascending spread of microorganisms from the vagina and endocervix to the endometrium, the fallopian tubes and / or to contiguous structures.
Different forms
• • • • Endometritis Salpingitis Tubo ovarian abscess Pelvic peritonitis
Infection can extend beyond the reproductive tract to causePelvic peritonitis Generalized peritonitis Perihepatitis (Fitz-Hugh-Curitis syndrome) Perisplenitis .
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Etiology:
N.gonorrhea- more common C. trachomatis- most common in USA Anaerobic bacteria- Bacteroides Facultative Gram negative rods- E. coli Mycoplasma hominis Actinomyces israelli- in women with long standing
intrauterine devices (IUD)
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About 10- 40% of women who are inadequately treated for chlamydial or gonococcal cervicitis can develop PID. In USA 40-80% of PID is attributed to STDs.
Incidence and Prevalence
Occurs in approximately 1 million U.S. women annually. Women 15 – 44 yrs of age get infected.
Annual cost exceeds $4.2 billion.
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Risk Factors
Adolescence History of PID A history of gonorrhea or chlamydia infection Male partners with gonorrhea or chlamydia Multiple partners Current douching Insertion of IUD- risk in first few months of placement Bacterial vaginosis Demographics (socioeconomic status) Oral contraceptive use (in some cases) Decrease the risk of Chlamydial but not gonococcal PID Reflux of infected blood during menstrual uterine contraction can also provide a route of entry into the fallopian tubes
Pathogenesis:
Prior infection with N. gonococci or C. trachomatis is essential
Results in damage of ciliary lining of the fallopian tubes
Non specific inflammatory responses to bacterial invasion Results in tissue damage Break down the endocervical canal mucus plug Allowing the pathogens and endogenous organisms to ascend to upper genital tract
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Pathogenesis:
In many cases of PID, STD organisms initiate the inflammation of tubal mucosa and this process facilitates the invasion of the mucosa by organisms endogenous to the lower genital tract. The organisms have more predilection to Larger zone of ectopy ( extension of columnar epithelium from the endocervical canal to the ectocervix)
This zone is highly susceptible to Gonococcal and Chlamydial infections- preferential sites of microbial attachment and invasion
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Pathway of Ascendant Infection
Salpingitis/ oophoritis/ tubo-ovarian abscess
Endometritis Cervicitis
Signs and symptoms
Moderate fever Tenderness on cervical motion Bilateral lower abdominal pain in the region of fallopian tubes Increased vaginal discharge Irregular bleeding Purulent endocervical discharge Nausea and vomiting It is important to note that PID can occur and cause serious harm without causing any noticeable symptoms.
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Sequelae
Infertility in women Dissemination to liver resulting in Perihepatitis Unilateral and bilateral ovarian abscesses Tubular occlusion, scarring and adhesions Fitz-Hugh-Curtis syndrome: “Violin Strings” from between the abdominal wall & liver capsule Death due to rupture of ovarian abscesses
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Diagnosis
Definitive diagnosis consists of direct visualization of inflamed fallopian tube on laparoscopy, laparotomy, or biopsy evidence of Salpingitis
Only a confirmed culture of a biopsy of the fallopian tube positively identifies the etiology of Salpingitis. A presumptive diagnosis can be made on clinical grounds alone.
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Definitive criteria include:
Histopathologic evidence of endometritis
Thickened filled fallopian tubes Laparoscopic findings
Gram-stain/smear becomes important in identification of rare and possibly more serious organisms
Differential Diagnosis
Appendicitis Ectopic pregnancy Septic abortion Hemorrhagic or ruptured ovarian cysts or tumors Twisted ovarian cyst Degeneration of a myoma (A benign tumor of smooth muscle in the wall of the uterus.) Acute enteritis must be considered.
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PID is more likely to occur when there is a history of PID Recent sexual contact Recent onset of menses IUD in place If the partner has a STD.
Acute pelvic inflammatory disease is highly unlikely when recent intercourse has not taken place or an IUD is not being used. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix).
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Pelvic and vaginal ultrasound are helpful in the differential diagnosis of ectopic pregnancy of over 6 weeks. Laparoscopy is often utilized to diagnose PID, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hrs.
No single test has adequate sensitivity and specificity to diagnose PID
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Complications
PID can cause scarring inside the reproductive organs, which can later cause serious complications, including Chronic pelvic pain Infertility Ectopic pregnancy (the leading cause of pregnancyrelated deaths in adult females) Other dangerous complications of pregnancy. Multiple infections and infections that are treated later are more likely to result in complications.
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Laboratory findings:
Positive culture for Gonococci, and Chlamydia
PCR test is available
Positive gram stain for intracellular gonococci form endocervical swab Elevated white blood cell count Elevated ESR
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Treatment:
Can be treated on an out patient only if the temperature is<38°C, WBC <11,000/mm3 and there is minimum evidence of peritonitis, active bowel sounds Hospitalize the patient in case of diagnosis is uncertain surgical emergencies such as appendicitis and ectopic pregnancy are suspected a pelvic abscesses is suspected No single antibiotic will be active against all possible pathogens
Hosptitalized patients:
Cefotetan IV every 12 hours Cefoxitin IV every 6 hours
PLUS
Doxycycline orally or IV every 12 hours. Out patient treatment: Switching to oral therapy can include: Ofloxacin orally twice a day for 14 days OR Levofloxacin orally once daily for 14 days
WITH or WITHOUT
Metronidazole orally twice a day for 14 days.
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Pelvic inflammatory disease a. Usually arises from haematogenous spread from another site b. Is most commonly a chlamydial infection T c. Untreated can progress to a pyosalpinx T d. Reduces the risk of ectopic pregnancy e. 20% of patients develop chronic pain T
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REFERENCES: MIMS: 2ND edition-Chapter No.- 19
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