Download Pelvic Inflammatory Disease

Pelvic Inflammatory Disease
Definition
Spread of primary lower genital tract infection to upper (inc. endometritis, salpingitis, tubo-ovarian
abscess, peritonitis)
Symptoms
Non-sexual: mixed pathogens from vaginal flora; anaerobes, facultative bacteria, mycoplasma,
ureaplasma, gut coliforms (E coli, H influenzae); PV discharge not usually STD (candida most common
cause of PV discharge, bacterial vaginosis)
Sexual: often polymicrobial
Chlamydia - most common cause of cervicitis; most common in hetero; usually asymptomatic in women
Intracellular parasite; incubation 1-3/52 or longer; More watery discharge, less painful than
gonorrhoea; can also cause proctitis / prostatitis; lymphogranuloma venereum (males get
vesicles/ulcers on genitals  inguinal buboe after 1-4/52  fuse, breakdown, discharge)
Gonorrohea – rates increasing; more common in homos / Maoris etc… / overseas sex; 50% have coexistant chlamydia; incr penicillin and quinolone resistance; G-ive intracellular diplococci; incubation
3-7/7; Urinary symptoms and penile discharge in men; 10-20% of untreated infections become PID;
disseminated in 3%
Septic arthritis (2x more common in women, occurs in 0.2%, onset 3-17/7 after infection, may be
preceded by migratory polyarthritis; 75% poly, 80% asymmetric)
Rash (in 2/3; petechiae / painful red papules on digits; may become vesicular / pustular  grey
necrotic centre, often on haemorrhagic base; usually <20 lesions)
Can also cause pharyngeal, anal, conjunctivitis, tenosynovitis, meningitis, myocarditis, pericarditits
Trichomonas: has fishy smell
Gardnerella = bacterial vaginosis: has clue cells
Aetiology
Direct; haematogenous (TB, mumps); iatrogenic (IUCD, RPOC); >50% have no cause detected for cervicitis
Risk Factors
 with sexual activity;  with progesterones and pregnancy (especially after 12/40)
Complications
Infertility (12-50%; 10% after first episode; risk doubles with each infection; 2 infections = 20%, 3
infections = >50%); chronic salpingitis (25%); chronic pain, adhesions, dysparaeunia (20%), ectopic (1215% higher incidence; incidence 1:120 normally, 1:16 with PID); tubo-ovarian abscess (5% mortality if
rupture; occurs in 1/3 hospitalised patients); Fitz-Hugh-Curtis syndrome (transcoelemic spread of
inflammatory peritoneal fluid to subphrenic and subdiaphragmatic spaces)
Assessment
History: 90% pelvic pain (usually bilateral); 75% vaginal discharge; >30% irregular PV bleeding; systemic
toxicity
Examination: poor sensitivity and specificity; low grade fever, adnexal mass
Investigation
Bloods: WBC >10 in 50%
Swab: gonorrhoea culture (urethral or endocervical) 97% sensitivityitivity, gram stain 50% sensitivity;
cheap; reasonable sensitivity and specificity; PCR 99% sensitivity and specificity on swab; chlamydia
culture 95% sensitivity, 99% specificity; self collected samples and urine samples as good
Urine: gonorrhoea PCR 90% sensitivity, 99% specificity; Chlamydia PCR in males
USS: if abscess suspected (ie. Toxic, asymmetrical findings)
Laparoscopy: will be +ive in 50% of those diagnosed with PID clinically
General
Management
Commence if: lower abdominal tenderness + uterine and bilateral adnexal tenderness + cervical motion
tenderness
Admit if: toxic; severe pain; unable to tolerate PO meds; pregnancy; pre-pubertal; HIV +; poor likelihood
of compliance; IUD or recent instrumentation
Other: Remove IUCD or RPOC; consider sexual abuse; treat sexual contacts (partner infected in 40%; not
needed in bacterial vaginosis; needed in trichomonas and candida); counselling; always follow up at
72 hours; refer to sexual health clinic; abstain from sex at least 2/52; candida prophylaxis; gonorrhoea
and chlamydia = reportable disease
Empirical Treatment:
Azithromycin 1g PO single dose (or doxycycline 100mg BD for 14/7)
+ metronidazole 400mg BD for 14/7
+ ceftriaxone 250mg IM/IV stat (if gonorrhoea suspected; always give if community
incidence high)
Sexually
Acquired
Mild
If gonorrhoea only, no PID:
Azithromycin 1g PO single dose (or doxycycline 100mg BD for 1/52)
+ ceftriaxone
If chlamydia only, no PID:
Azithromycin 1g PO single dose (or doxycycline 100mg BD for 1/52)
Severe
Pelvic
Inflammatory
Disease
Antibiotics
NonSexually
Acquired
Septicaemia
Puerpueral
Syphilis
Mild
Severe
Doxycycline + metronidazole + ceftriaxone as per empirical treatment
above; continue IV for 48 hours after symptoms improve  PO)
Augmentin + doxycycline
As per septicaemia or severe sexually acquired
Ampicillin 2g IV Q6h + metronidazole 500mg BD + gentamicin 4-6mg/kg OD
Mild
Severe
Augmentin BD 5-7/7 (add roxithromycin 300mg OD / clindamycin 300mg
TDS if ongoing >48 hours)
As per septicaemia
Pregnant
/ breastfeeding
Use roxithromycin instead of doxycycline
Penicillin
Allergy
IV gentamicin + clindamycin
Very uncommon ( in homosexual); usually
detected in latent phase
Treponema pallidum: spirochete; STD
Primary syphilis: 2-6/52 after contact 
1 firm, nontender, raised red lesion
(chancre) on penis, cervix, vagina, anus in
70% men, 50% women; up tos severeal
cm’s in diameter; erodes to create shallow
based ulcer; regional lymph nodes  heals
in 3-6/52 without treatment
Secondary syphilis: 2-10/52 after primary, in
75%  dissemination in skin and mucocutaneous tissues; lasts several weeks 
latent phase
Maculopapular / scaly / pustular lesions on
soles of feet / palms – discrete red/brown spots <5mm diameter
Condylomata lata on moist areas (eg. Anogenital / axilla / inner thigh) – broad based, elevated plaques,
painless, highly infectious
Silver/gray superficial erosions on mucous membranes (especially mouth / external genitalia /
oropharynx)  ulcerate – these are most infectious
Fever, malaise, weight loss, lymphandenopathy, arthralgia; maybe asceptic meningitis (1-2%), hepatitis,
nephrotic syndrome
Syphilis
(cntd)
Tertiary syphilis: in 1/3 untreated after >5yrs
CV syphilis: aortitis  dilatation of aortic root and arch  aortic valve
regurgitation, aneurysms; accounts for 80%
Neurosyphilis: may be asymptomatic (1/3); chronic meningovascular disease,
tabes dorsalis, general paresis; dementia, psychosis, cranial nerve palsy,
spinal cord syndrome; in 5-10%
Benign 3Y syphilis: gummas in various sites; white/gray, rubbery, single /
multiple, small/large nodular lesions due to delayed hypersensitivity;
mostly in bone ( pain, tenderness, swelling, pathological fracture), skin,
subcutaneous tissue; mucous membranes of upper respiratory tract and
mouth, testes; rarely causes destructive ulcerative lesions
Congenital syphiliis: during primary or secondary syphilis in
mother; 25% intrauterine / perinatal death
Infantile (early): first 2yrs; nasal discharge and congestion;
desquamating / bullous rash  sloughing of skin
(especially hands, feet, mouth, anus); hepatomegaly,
skeletal abnormalities (syphilitic osteochonritis and
periostitis – especially nose with saddle nose deformity
and lower leg  new bone growth on anterior tibia  sabre shin)
Tardive (late): later; occur in >50% untreated; Hutchinson triad: notched central
incisors (may be screwdriver shaped), interstital keratitis (or choroiditis) with
blindness, deafness due to VIII injury (and optic nerve atrophy); skeletal,
neurological and facial abnormalities
Investigation: identified on MC+S of 95% chancres; VDRL 80% sens (>95% in stage 2 and 3), 1-2% false
+ive  if +ive, need to confirm with treponeal antibody test (80% sensitivity in primary, 100% later)
Management: penicillin (doxycycline if allergy); give IM in secondary