Pelvic Inflammatory

Disease

PID: A Neglected Issue

Low disease awareness
Sub-optimal management
50% named correct antibiotic regimen
< 25% examined the sexual partners

Objectives
What is Pelvic Inflammatory
Disease?
Why is it important to treat timely?
Causative factors and transmission?
How does the patient present?
Treatment Plan?
- Drug therapies
- Surgical procedures
- Follow up

PID
Incidence acute PID 1-2% of young
sexually active women each year
85% of infection in sexually active
female of reproductive age
15% of infection occur after
procedures that break cervical
mucous barrier

What is PID ?
Acute/ Chronic clinical syndrome
Spectrum disease involve cx, uterus, tubes, and
ovaries
Ascending spread of infection from the
vagina and endocervix to the endometrium,
fallopian tubes, ovaries, &/ or adjoining structures
Upper genital tract infection, salpingitis
endometritis, parametritis, tubo-ovarian abscess
& pelvic peritonitis

Transmission
Sexual transmission via the vagina & cervix
Gynecological surgical procedures
Child birth/ Abortion
A foreign body inside uterus (IUCD)
Contamination from other inflamed structures in
abdominal cavity (appendix, gallbladder)
Blood-borne transmission (pelvic TB)

Pathogenesis

Predisposing Factors
Frequent sexual encounters, many partners
Young age, early age at first intercourse
Exposure immediately prior to menstruation.
Relative ill-health & poor nutritional status.
Previously infected tissues (STD/ PID)
Frequent vaginal douching

Predisposing Factors
Increase risk
IUD user (multifilament string
surgical procedure
previous acute PID
Reinfection untreated male partners
80%
Decrease risk

- barrier method

- OC
Risk factors

Infective Organisms
Sexually transmitted - Chlamydia trachomatis
Neisseria gonorrhoeae
Endogenous Aerobic Streptococci
Haemophilus
E. coli
Anaerobes - Bacteroides, Peptostrptococcus
- Bacterial Vaginosis
- Actinomyces israelii
Mycoplasma hominis, Ureaplasma
Mycobacterium tuberculosis & bovis

 slow
growth (48-72 hr)
C.
trachomatis

intracellular organism
insidious onset
remain in tubes for months/years after
initial colonization of upper genital
tract
more severe tubes involvement

N. gonorrhoeae
gram ve diplococcus
rapid growth (20-40 min)
rapid & intense inflammatory response
2 major squeals : infertility & ectopic
pregnancy, strong asso. with prior
Chlamydia infection

Why is it Important to Treat PID ?

Systemic upset / Tubo-ovarian abscess
Chronic Pain (15-20 %) Hysterectomy

Ectopic pregnancy (6-10 fold)

Infertility (Tubal): 20% ~ 2 episodes

40% ~ 3 episodes

Recurrence (25%)

Cancer

Cervix/ Ovarian Cancer ?

Presentation: Acute PID

Severe pain & tenderness lower abdomen
Fever, Malaise, vomiting, tachycardia
Offensive vaginal discharge
Irregular vaginal bleeding
B/L adnexal tenderness
cervical excitation
Tubo-ovarian mass
Fitz-Hugh-Curtis Syndrome
Poor sensitivity & specificity
Correct diagnosis : 45 70%

Presentation: Chronic PID

Chronic lower abdominal pain, Backache
General malaise & fatigue
Deep dyspareunia, Dysmenorrhea
Intermittent offensive vaginal discharge
Irregular menstrual periods
Lower abdominal/ pelvic tenderness
Infertility
Bulky, tender uterus

PID: Differential Diagnosis

Ectopic Pregnancy
Torsion/ Rupture adnexal mass
Appendicitis
Endometriosis
Cystitis/ pyelonephritis

Laboratory Studies
Pregnancy test
Complete blood count, ESR, CRP
Urinalysis
Gonorrhea, Chlamydia
stain/ Cultures / ELISA/ DNA )
Tests for TB, syphilis, HIV
Pelvic Ultrasound
Culdocentesis
Laparoscopy

detection (Gram

Treatment
Therapeutic goal
eliminate acute infection & symptoms
prevent long-term sequelae

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

Sequelae
Chronic pelvic pain

4 times higher after acute salpingitis

caused by hydrosalpinx, adhesion around
ovaries
should undergo laparoscope R/o other disease

TOA 10%
Mortality
acute PID 1%
rupture TOA 5-10%

Sequelae
Infertility
of pt have acute salpingitis
infertility rate increase direct with number of episodes of
acute pelvic infection

Endometritis (thickened heterogenous endometrium)

Hydrosalpinx (anechoic tubular structure)

Hydrosalpinx.

Pyosalpinx (tubular structure with debris in adnexa

Tuboovarian abscess resulting from tuberculosis

Right hydrosalpinx with an occluded left fallopian tube

Syndromic Diagnosis of PID

Minimum Criteria for Diagnosis

(CDC

2002)
Lower abdominal tenderness on palpation
Bilateral adnexal tenderness
Cervical motion tenderness
No other established cause
Negative pregnancy test

Additional Criteria (CDC 2002)

Oral temperature > 38.3C (101F)
Abnormal cervical / vaginal discharge
Elevated ESR
Elevated C-reactive protein
WBCs on saline micro. of vaginal sec.
Lab. documentation of cervical infection
N. gonorrhoeae/ C. trachomatis

with

Definitive Criteria (CDC 2002)

Endometrial biopsy with histopathology
evidence of endometritis
TVS/ MRI: Thickened fluid filled tubes/
free pelvic fluid / tubo-ovarian complex
Laparoscopic abnormalities consistent with PID

Management Issues
Inpatient vs. outpatient management ?
Broad-spectrum antibiotic therapy
without microbiological findings
vs.
Antibiotic treatment adapted to the
microbiological agent identified ?
Oral vs. Parenteral therapy?
Duration of the treatment ?
Associated treatment ?
Prevention of re-infection ?

Criteria for Hospitalization (CDC

2002)
Surgical emergencies can not be excluded
(appendicitis)
Severe illness/ nausea/ vomit/ high fever
Tubo-ovarian abscess
Clinical failure of oral anti-microbials
Inability to follow/ tolerate oral regimen
Pregnancy
Immunodeficient (HIV low CD4 counts,
immunosuppressive therapy)

Antibiotic Therapy
Gonorrhea : Cephalosporin , Quinolones
Chlamydia: Doxycycline, Erythromycin &
Quinolones (Not to cephalosporin)
Anaerobic organisms: Flagyl, Clindamycin and
in some cases to Doxycycline.
Beta hemolytic streptococcus and E. Coli
Penicillin derivatives, Tetracycline, and
Cephalosporin. E. Coli is most often treated with
the penicillin or gentamicin.

Antibiotic Regimens (CDC 2002)

Parenteral regimen A
Cefoxitin 2 g IV q 6h / cefotetan 2 g IV q 12h
+
Doxycycline 100 mg PO/IV q12h +
Metronidazole or Clindamycin (TO abscess)
Parenteral regimen B
Clindamycin 900 mg IV q 8h
+
Gentamicin Loading dose 2 mg/kg IV/IM,
maintenance 1.5 mg/kg IV/ IM q 8h

Other 2nd/ 3rd Generation

Cephalosporins
Ceftizoxime - Cefizox,
Cefotaxime - Omnatex,
Ceftriaxone - Monocef,
Cefoperazone - Magnamycin,
Ceftizidime - Fortum

Alternative Parenteral Regimens

(CDC 2002)
Ofloxacin 400 mg IV q 12 hours
or
Levofloxacin 500 mg IV once daily
WITH OR WITHOUT

Metronidazole 500 mg IV q 8 hours

or
Ampicillin/Sulbactam 3 g IV q 6 hrs
PLUS

Doxycycline 100 mg orally/ IV q 12 hrs

Outpatient Antibiotic Therapy

Regimen A (CDC 2002)
Ofloxacin 400 mg twice daily for 14 days
or
Levofloxacin 500 mg once daily for 14 days
WITH OR WITHOUT

Metronidazole 500 mg twice daily for 14 days

Outpatient Antibiotic Therapy

Regimen B (CDC 2002)
Ceftriaxone 250 mg IM once
OR

Cefoxitin 2 g IM probenecid 1 g PO once

+
Doxycycline 100 mg PO bid for 14
WITH OR WITHOUT

Metronidazole 500 mg BD x 14 d

Surgical treatment
Laparotomy for
surgical emergencies
definite Rx of failure medical treatment

Laparoscopy
consider in all pt with ddx of PID & without
contraindication
R/O surgical emergency

Evidence of current / previous abscess

Acute exacerbation of PID with bilateral
TOA

PID

CDC Recommendations
No efficacy data compare parenteral with oral

regimens
Clinical experience should guide

decisions reg. transition to oral therapy

When should treatment be stopped ?

Parenteral changed to oral therapy after 72 hrs, if
substantial clinical improvement
Continue Oral therapy until clinical & biological
signs (leukocytosis, ESR, CRP) disappear or for
at least 14 days
If no improvement, additional diagnostic tests/
surgical intervention for pelvic mass/ abscess
rupture

Fitz-Hugh-Curtis
syndrome :

1-10%
perihepatic inflammation & adhesion
s/s ; RUQ pain, pleuritic pain,
tenderness at RUQ on palpation of the
liver
mistaken dx ; acute cholecystitis,
pneumonia

Fitz-Hugh-Curtis

Associated treatment
Rest at the hospital or at home
Sexual abstinence until cure is achieved
Anti-inflammatory treatment
Dexamethasone 3 tablets of 0.5 mg a day or Non
steroidal anti-inflammatory drugs
Oestro-progestatives: contraceptive effect +
protection of the ovaries against a peritoneal
inflammatory reaction + cervical mucus induced
by OP has preventive effect against re-infection.

Conclusion

PID in women - Silent epidemic

Can have serious consequences.

Be aware of limitations of clinical diagnosis.
Adequate analgesia and antibiotics.
Proper follow up is essential.
Treatment of male partner
Educational campaigns for young women and
health professionals.
Prevention by appropriate screening for STD
and promotion of condom usage.

THANK YOU