PELVIC INFECTIONS:EMPHASIS ON

PELVIC INFLAMMATORY DISEASE

BY
PROF IKECHEBELU/DR EZEAMA’S
UNIT
OUTLINE
• INTRODUCTION
• CLASSIFICATION
• EPIDEMIOLOGY
• AETIOLOGY
• RISK FACTORS
• PATHOGENESIS
• CLINICAL FEATURES
• INVESTIGATIONS
• TREATMENT
• COMPLICATIONS
• PREVENTION
• CONCLUSION
INTRODUCTION
• Pelvic Infections are among the most important
problems encountered in gynaecological
practice.

• It account for 2% of consultations made by

young women to their doctor.

• It refers to any infection of the pelvic region.

CLASIFICATION
• Pelvic infections can be classified as follows:

• Pelvic inflammatory disease

• Puerperal infections
• Postoperative pelvic infection
• Abortion-associated infections
• Pelvic Tuberculosis
• Secondary to other infections
Classification
• Some authorities use the word pelvic infection
and PID interchangeably.

• Others refer to PID as ascending infection from

STI while Pelvic infections are those from other
sources.

• Here, PID refers to those from STI.

PELVIC INFLAMMATORY DISEASE
• Pelvic inflammatory disease comprises a
spectrum of inflammatory disorders of the upper
genital tract
•.
• This includes any combination of endometritis ,
salpingitis, tubo-ovarian abscess, and pelvic
peritonitis.

• PID has been described as a ‘silent epidemic’.

EPIDEMIOLOGY
• PID is one of the common causes of morbidity in
young women in both developing and developed
world.

• About 10-15% of women of reproductive age

have at least one episode of PID.

• The peak age incidence is 15-25yrs.

• More among women of low socioeconomic
status.
AETIOLOGY
• Polymicrobial

• STI, particularly
▫ Neisseria gonorrhoea
▫ Chlamydia trachomatis

• Other organisms
• Vaginal flora
▫ Gardnerella vaginalis
▫ Haemophilus influenza
AETIOLOGY
• More uncommonly:

• Mycoplasma hominis
• Mycoplasma genitalium
• Ureaplasma urealyticum
• Streptococcus agalactiae

• Anaeorobes.
RISK FACTORS
• Multiple sexual partners
• Young age
• Past history of STI
• Recent new partners
• Douching
• Single status
• Substance abuse
Pathogenesis
• PID is caused by bacteria from lower genital
tract that ascend to the upper .

• The ascension of bacteria is enhanced during

menstruation due to loss of endocervical barrier.

• The gonococcus can cause direct inflammatory

response in the lumen of
endocervix,endometrium and fallopian tube.
Pathogenesis
• In Chlamydia trachomatis,cell mediated
immune response is responsible for the resulting
tissue injury.

• When the bacteria has breached the cervical

barrier,there is ascension,inflammation and
scarring of the upper genital tract
Pathogenesis
• These lead to endometritis, salpigitis, salpingo-
oophoritis,tubo-ovarian abscess, and pelvic
peritonitis.

• These will eventually give rise to pelvic

adhesions and tubal blockage.
Classification of PID
• PID is classified into:

Acute PID
Chronic PID
CLINICAL FEATURES
• ACUTE PID:

• PID may be symptomatic or asymptomatic.

• Even when present,clinical symptoms and signs
lack sensitivity or specificity

• The positive predictive value of clinical diagnosis

is65 - 90%.
ACUTE PID
• SYMPTOMS:
• Lower abdominal pain- usually bilateral
• Deep dysparaeunia
• Abnormal vaginal bleeding( intermenstrual,
postcoital, menorrhagia)
• Abnormal vaginal/cervical discharge
ACUTE PID
• SIGNS:
• Lower abdominal tenderness
• Adnexal tenderness
• Cervical motion tenderness
• Fever(>38.3*C)
CHRONIC PID
• This diagnosis is given to women who describe a
history of PID and who have pelvic pain.

• Clinical features are usually less in magnitude

than for acute PID.

• A hydrosalpinx might qualify as a criterion for

diagnosis.
CHRONIC PID
• It is actually a histologic diagnosis.

• So,clinical utility of this diagnosis is limited.

INVESTIGATIONS
• FBC + ESR
• C-reactive protein
• High vaginal swab m/c/s
• Endocervical swab m/c/s
• Endometrial biopsy – more specific
• Transvaginal Ultrasound
• Laparoscopy
Diagnostic considerations
• Acute PID is difficult to diagnose.
• Delay in diagnosis and treatment contributes to
the inflammatory sequelae

• Laparoscopy will not detect endometritis.

• Consequently, diagnosis of PID is usually based

on clinical finding.
Diagnosis
• CDC in 2010, recommended that empiric
treatment for PID be initiated in a sexually
active young woman or other women at risk who
are experiencing

• Pelvic or Lower abdominal pain,

• If no other cause and
Diagnosis
• if one or more of the following minimum
criteria are present on pelvic examination:

• Cervical motion tenderness

• or
• Uterine tenderness
• or
• Adnexal tenderness
Diagnosis
• Also,one or more of the following additional
criteria can be used to enhance the specificity of
the minimum criteria.
Additional criteria
• Oral temperature >101*F (38.3*C)
• Abnormal cervical or vaginal discharge.
• Presence of abundant number of WBC on saline
microscopy of vaginal fluid.
• Elevated ESR.
• Elevated C-reactive protein.
• Laboratory documentation of cervical infection
with N. gonorrhoeae or C. trachomatis.
DIFFERENTIAL DIAGNOSIS
• Ectopic preagnacy
• Acute appendicites
• Endometriosis
• Complication of ovarian cyst(rupture, torsion)
• Diverticulitis
• Degeneration of a leiomyoma
• Acute urinary tract infection
• Functional pain
TREATMENT
• To commence once presumptive diagnosis is made.

• All regimens used to treat PID should also be

effective against N. gonorrhoeae and C. trachomatis
.

• Most respond on out patient basis.

• Hospitalization usually reserved for women who are

severely ill,or patients with the following cases.
Conditions for admission
• Surgical emergencies (e.g., appendicitis) cannot
be excluded;

• The patient is pregnant;

• The patient does not respond clinically to oral

antimicrobial therapy;
Conditions for admission
• The patient is unable to follow or tolerate an
outpatient oral regimen;

• The patient has severe illness, nausea and

vomiting, or high fever; or

• The patient has a tubo-ovarian abscess

Outpatient therapy
• Ceftriaxone 1g IM in a single dose
PLUS
•
Doxycycline 100 mg orally twice a day for 14
days
WITH or WITHOUT
•
Metronidazole 400 mg orally thrice a day for
14 days
Outpatient treatment
• OR
• Cefoxitin 2 g IM in a single dose and
Probenecid, 1 g orally administered concurrently
in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14
days
WITH or WITHOUT
Metronidazole 400 mg orally 3x a day for 14
days
Inpatient treatment
• Recommended Parenteral Regimen A

• Cefotetan 2 g IV every 12 hours

OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Inpatient treatment
• Recommended Parenteral Regimen B

• Clindamycin 900 mg IV every 8 hours

PLUS
Gentamicin loading dose IV or IM (2 mg/kg of
body weight), followed by a maintenance dose
(1.5 mg/kg) every 8 hours. Single daily dosing
(3–5 mg/kg) can be substituted.
Treatment
• ALTERNATIVE REGIMENS

• Ampicillin/sulbactam 3g IV every 6hours,plus

• Doxycycline 100mg orally or IV every 12hours.

• Parenteral agents can be discontinued 24hours

after clinical improvement, but oral doxycycline
should be continued for 14days.
treatment
• Treatment with quinolone is no longer
recommended because of quinolone-resistant
N. gonorrhoea (QRNG).

• If parenteral cephalosporin is not feasible,

• Tab Levofloxacin 500mg dly for 14days or
• Tab Ofloxacin 400mg bd for 14days
Treatment
• TREATMENT OF PARTNERS
• Male sex partners of women with PID should be
examined and treated if they had sexual contact
with the patient during the 60 days preceding
the patient’s onset of symptoms.

• If a patient’s last sexual intercourse was >60

days before onset of symptoms,the most recent
partner should be treated.
Treatment
• Patients should be instructed to abstain from
sexual intercourse until therapy is completed,
• And till they and their partners no longer have
symptoms.
Complications
• Ectopic pregnancy
• Infertility
• Tubal blockage
• Tubo-ovarian abscess
• Chronic pelvic pain
• Fitz-Hugh- Curtis Syndrome
• Frozen pelvis
• Septicaemia
Complication
• One episode of PID doubles the risk of tubal
infertility.
• Three or more episodes increases the risk by
75%.
• One episode of PID increases the risk of ectopic
pregnancy sevenfold
• Chlamydia causes 50% of sexually acquired PID,
gonorrhoea causes 25%

• Tubal blockage is more with gonorrhoea.

Tubo-ovarian abscess(TOA)
• This is part of the spectrum of PID.
• Usually seen with recurrent infection leading to
fallopian tube necrosis and epithelial damage.
• With anaerobic invasion and growth.
• The adjacent ovary may become involved
• Ovulation site serving as portal of entry for
infection and subsequent abscess formation.
 TOA
• Pressure on the purulent exudate may cause
rupture of the abscess causing peritonitis
• Ruptured TOA is a surgical emergency
• The disease can be bilateral
• Though unilateral disease is more common
• Abscesses are usually polymicrobial
Clinical findings
• Patients with TOA are often young and of low
parity
• With history of pelvic infection
• They report pelvic and abdominal pain, fever,
nausea and vomiting
• May be moribund with acute abdomen
Clinical findings
• Examination may reveal l abdominal tenderness
and guarding.
• Adnexal mass may be palpated
• In rupture TOA, she presents with signs of acute
abdomen and may develop signs of septic shock.
investigations
• Wbc may vary fom leucopenia to leucocytosis
• Urinalysis may show pyuria with bacteriuria
• Elevated ESR and C-reactive protein

• Ultrasonography is the radiologic modality of

choice
• It will demonstrate complex multiloculated
adnexal masses ,which may contain internal
echoes consistent with inflammatory debris.
investigations
• Computed tomography may be preferable in
patients in whom other abdominal pathology
cannot be excluded eg. appendicites
Treatment
• UNRUPTURED TOA
• Treatment is similar to inpatient management of
PID
• Though duration of therapy may be longer,
depending on the size of the abscess (up to 4-
6wks)
• Patient should be monitored on inpatient basis
for 48-72hrs
treatment
• UNRUPTURED TOA contd
• Patients with large abscess or who are not improving
with medical treatment,surgical management is
adopted:

• Exploratory laparotomy
• Minimally invasive radiologic-guided drainage of
abscess
• Total abdominal hysterectomy and bilateral
salpingo-oophorectomy—for patients who have
completed their family
treatment
• RUPTURED TOA
• This requires immediate surgery with antibiotic
therapy
• Total abdominal hysterectomy and bilatertal
salpingo-oophorectomy is the procedure of
choice
• Intensive care unit admission is needed
PREVENTION
• Abstinence from sexual intercourse
• Avoiding multiple sexual partners
• Avoiding sexual contact with people at risk of
infection
• Getting early treatment which may prevent the
development of Pelvic Inflammatory Disease (PID)
• Using latex condoms and other barrier
contraception can usually protect against infections
associated with Pelvic Inflammatory Disease (PID)
and prevent transmission of the bacteria from one
person to the next
CONCLUSION
• PID is a highly preventable and treatable
disease.

• It can however, have devastating effect if not

detected early.

• Early diagnosis and prompt treatment is

therefore key to its management.
• THANK

• YOU

• FOR

• LISTENING
References
1. ^ "STD Facts — Pelvic inflammatory disease (PID)". Retrieved 2007-11-
23.
1. ^ Sutton MY, Sternberg M, Zaidi A, St Louis ME, Markowitz LE (December
2005). "Trends in pelvic inflammatory disease hospital discharges and
ambulatory visits, United States, 1985–2001". Sex Transm Dis 32 (12): 778–
84. doi:10.1097/01.olq.0000175375.60973.cb. PMID 16314776.

2. ^ a b c Lauren Nathan; DeCherney, Alan H.; Pernoll, Martin L. (2003).

Current obstetric & gynecologic diagnosis & treatment. New York: Lange
Medical Books/McGraw-Hill. ISBN 0-8385-1401-4. OCLC 150148652.

3. ^ a b Loscalzo, Joseph; Andreoli, Thomas E.; Cecil, Russell L.; Carpenter,

Charles A.; Griggs, Robert C. (2001). Cecil essentials of medicine.
Philadelphia: W.B. Saunders. ISBN 0-7216-8179-4. OCLC 43051599.

1. ^ Tuboovarian complex by Emily C. Wasco and Gillian Lieberman MD. Beth

Israel Deaconess Medical Center. October 17, 2003
References
▫ ^ Walker CK, Wiesenfeld HC (2007). "Antibiotic therapy
for acute pelvic inflammatory disease: the 2006 Centers for
Disease Control and Prevention sexually transmitted
diseases treatment guidelines". Clin. Infect. Dis. 44 (Suppl
3): S111–22. doi:10.1086/511424. PMID 17342664.
▫ ^ Pelvic Inflammatory Disease~treatment at eMedicine
• ^ Smith KJ, Cook RL, Roberts MS (2007). "Time from
sexually transmitted infection acquisition to pelvic
inflammatory disease development: influence on the
cost-effectiveness of different screening intervals". Value
Health 10 (5): 358–66. doi:10.1111/j.1524-
4733.2007.00189.x. PMID