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Download Pelvic Inflammatory Disease
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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