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Pelvic Inflammatory Disease
DR. EBTIHAG HASHIM
CONSULTANT OBS & GYNE
MINIMAL ACCESS ENDOPELVIC SURGERY
Pelvic Inflammatory Disease (PID)
Infection of the upper female genital tract.
Refers to the clinical syndrome among
women resulting from infection.
Includes endometritis (infection of the
uterine cavity).
Salpingitis (infection of the fallopian tubes)
Mucopurulent Cervicitis (infection of the
cervix).
Oophoritis (infection of the ovaries).
Pathologic Processes of PID
PID has a broad clinical spectrum that includes
A. acute PID
B. silent PID
C. chronic PID
D. postpartum/postabortal PID
Relevance to Women’s Health:
Commonly occurs in women <35 years.
Rarely occurs before menarche, after menopause or
during pregnancy.
About 1.2 million women are treated for PID.
Over 100,000 women with PID are hospitalized each
year.
About 15% are acutely ill that require intensive inpatient
treatment.
Approximately 85,000 women with mild or moderate
PID who currently are being hospitalized, treating them
as outpatients may save around $500 million each year.
Causative Agents of PID
Neiserria Gonorrhoeae and Chlamydia trachomatis are the
2 major causative organisms.
Chlamydia trachomatis is the predominant STD organism
causing PID.
In the U.S., the role of Neisseria Gonorrhoeae as the
primary cause of PID has decreased.
Other agents: Mixed infection caused by both aerobic and
anaerobic organisms
Recent studies demonstrate the presence of Bacterial
Vaginosis and trichomoniasis in cases of confirmed PID
Causative Agents of PID
Cytomegalovirus (CMV) has been found in the upper
genital tracts of women with PID.
Enteric gram-negative organisms (E-coli)
Peptococcus species
Streptococcus agalactiae
Bacteroides fragilis
Mycoplasma hominis
Gardnerella vaginalis
Haemophilus influenzae
Signs & Symptoms of PID
The patient presents with lower abdominal pain, fever,
vaginal discharge, and/or abnormal uterine bleeding.
Symptoms frequently occur during or after menses.
Peritoneal irritation produces marked abdominal pain
with or without rebound tenderness.
The abdomen should be palpated gently to prevent
abscess rupture.
Relevance to Women’s Health
Is one of the major causes of gynecologic
morbidity.
Infertility.
Ectopic pregnancy
Chronic pelvic pain
Diagnosis and treatment must be prompt
to avoid these conditions.
Chlamydial Pyosalpinx
Pelvic inflammatory disease, proven Chlamydial Pyosalpinx.
Right tube is swollen and tortuous (arrow)
Cervicitis
The cervix appears red
and bleeds easily when
touched with a spatula or
cotton swab.
Mucopurulent discharge
is yellow-green.
Contains >10
polymorphonuclear WBCs
per oil immersion field
(using Gram stain).
Acute Salpingitis
Onset is usually shortly after menses.
Lower abdominal pain becomes progressively
more severe, with guarding, rebound
tenderness, and cervical motion tenderness.
Involvement is usually bilateral.
Nausea and vomiting occur with severe
infection.
In the early stages, acute abdominal signs are
often absent
Acute Salpingitis (PID)
Bowel sounds are
present unless
peritonitis with ileus
has developed.
Fever, leukocytosis,
and mucopurulent
cervical discharge are
common
Irregular bleeding and
bacterial vaginosis often
accompany the pelvic
infection.
Complications of PID
Tubo-ovarian abscess develops in about 15% of women
with salpingitis.
It can accompany acute or chronic infection
The tube and ovary can become completely matted
together.
May require prolonged hospitalization, sometimes with
surgical percutaneous drainage.
Rupture of the abscess is a surgical emergency
Rapidly progressing from severe lower abdominal pain to
N & V, generalized peritonitis, and septic shock
Tubo-ovarian abscess
Pyosalpinx, in which one or both fallopian tubes
are filled with pus, may also be present.
Hydrosalpinx (fimbrial obstruction and tubal distention
with nonpurulent fluid) develops if treatment is late or
incomplete.
The consequent mucosal destruction leads to infertility.
Hydrosalpinx is generally asymptomatic but can cause
pelvic pressure, chronic pelvic pain, or dyspareunia.
Women with HIV infection are more likely to have tuboovarian abscess
Tubo-ovarian abscess
Here at least the ovaries, tubes and uterus can still be
recognized as separate structures
Fitz-Hugh-Curtis syndrome
Can be a complication of
gonococcal or chlamydial
salpingitis.
Characterized by right
upper quadrant pain in
association with acute
salpingitis, indicating
perihepatitis.
Acute cholecystitis may be
suspected, but signs and
symptoms of PID are
present or develop rapidly.
Diagnostic Studies:
CBC with differential
Erythrocyte Sedimentation Rate
Cervical cultures
Blood Cultures
Urine Pregnancy Test
Rapid Plasma Reagin (RPR)
Cervical infection due to N. Gonorrhoeae can also
be diagnosed by Gram stain showing intracellular
gram-negative diplococci
Diagnostic studies
Leukocytosis is typical.
Pelvic ultrasonography may be used when a patient
cannot be adequately examined because of
tenderness or pain.
When a pelvic mass may be present, or when no
response to antibiotic therapy occurs within 48 to 72
h.
Laparoscopy should be performed only if the
diagnosis is uncertain or if the patient does not
promptly improve with medical therapy.
CDC’s Minimum Criteria for
Empiric Treatment of PID
Lower Abdominal
Tenderness.
Adnexal Tenderness.
Cervical Motion
Tenderness.
Diagnosis
And one or more minor criteria
Temperature over 100.9F or 38.3 C
White Blood Cell count > 10,000
Elevated ESR
Elevated C-reactive protein
Pus in cul-de-sac
Pelvic abscess or inflammatory complex
Cervical Mucus findings
Gram Stain: Gram Positive diplococci
Intracellular parasites
Diagnosis
ESR and C-reactive protein are elevated in
many disorders and are therefore not specific
for PID.
All three major criteria and at least one minor
criterion must be present to diagnose PID.
Differential Diagnosis
Condition
Characteristic Signs/Symptoms
Acute Appendicitis
Anorexia, N & V, decreased or absent bowel signs,
unilateral pain limited to right or left lower
quadrant
Ectopic Pregnancy
Unilateral pain; missed menstrual period usually
warrants hCG test
Ruptured Ovarian Cyst
Unilateral pain
Endometriosis
Constant pain begins 2-7 days before menses
Urinary Tract Infection
Dysuria, abnormal urinalysis. No cervical motion
tenderness
Renal calculus
Severe unilateral pain, hematuria
Adnexal torsion
Unilateral pain
Proctocolitis
Anorectal pain, tenesmus, rectal discharge or
bleeding
Hemorrhaging corpus
luteum
Unilateral pain
Treatment Goals & Benefits
Therapeutic goals include complete
resolution of the infection and prevention
of infertility and ectopic pregnancy.
Management Outpatient
Regimen A:
Initial Treatment at Diagnosis
Ofloxacin 400 mg orally BID for 14 days
(95% cure)
Or
Levofloxacin 500 mg orally once daily for 14 days
With or without:
Metronidazole 500 mg orally twice a day for 14
days.
Management Outpatient: Regimen B
Ceftriaxone 500 mg IM in a single dose
Or
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g
orally administered concurrently in a single dose
Or
Other parenteral third-generation cephalosporin
(ceftizoxime or cefotaxime)
Plus
Doxycycline 100 mg PO BID for 14 days (75% cure)
With or without
Metronidazole 500 mg PO BID for 14 days
Management Inpatient
Toxic appearance
Unable to take oral
fluids
Unclear DX
Appendicitis
Ectopic Pregnancy
Ovarian torsion
Pelvic abscess
Pregnancy
HIV positive
Outpatient TX
failure
Inpatient Treatment Regimens:
General: Treat for at least 48 hours IV
Regimen A
Cefotetan 2g IV q12 hours
OR
Cefoxitin 2g IV q6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours
Inpatient Treatment
Regimen B
Clindamycin 900 mg IV q8 hours
Plus
Gentamicin 2 mg/kg IV loading dose, then 1.5
mg/kg IV q8h
Discharge Regimen (after IV antibiotics)
Doxycycline 100mg PO BID for 10 days
or
Clindamycin 450mg PO QID for 14 days
Alternative Parenteral Regimens
Ofloxacin 400 mg IV q 12 hours
Or
Levofloxacin 500 mg IV once daily
With or without
Metronidazole 500 mg IV every 8 hours
Or
Ampicillin/Sulbactam 3 g IV every 6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours
Prognosis
Therapy using antibiotics alone is successful in
33-75% of cases.
If surgical therapy is warranted, the current
trend in therapy is conservation of
reproductive potential with simple drainage
and copious irrigation or unilateral
adnexectomy, if possible.
Further surgical therapy is needed in 15-20% of
cases so managed.
Prognosis
Chronic pelvic pain occurs in approximately 25% of
patients with a history of PID.
This pain is thought to be related to cyclic menstrual
changes, but it also may be the result of adhesions or
Hydrosalpinx.
Impaired fertility is a major concern in women with a
history of PID.
The rate of infertility increases with the number of
episodes of infection.
The risk of ectopic pregnancy is increased in women
with a history of PID.
Ectopic pregnancy is a direct result of damage to the
fallopian tube.
Prevention
Randomized controlled trials suggest that preventing
chlamydial infection reduces the incidence of PID.
Other methods of preventing PID and STD include
reducing the number of sexual partners, avoiding unsafe
sexual practices, and using condoms with spermicide.
Use of mechanical barriers with spermicide also
decreases the risk of acquiring STDs.
Notification of the female sex partners of men infected
with Chlamydia trachomatis is recommended
Surveillance
At all levels, PID surveillance is affected by four main
constraints:
PID is difficult to diagnose accurately.
PID is diagnosed in a wide variety of clinical settings.
Microbiology test results are needed to determine the
etiology of PID.
Patient Education
When medical-care messages are clear, explicit,
relevant, and rigorously delivered by providers,
patients are likely to comply.
Reinforcement of these messages can be achieved by
providing written information.
Information on written materials for patient
distribution can be obtained from CDC or local and
state health departments
Controversies Surrounding PID
The exact incidence of PID is unknown
The disease cannot be diagnosed reliably from clinical signs
and symptoms.
Laparoscopy exam of the pelvic organs continues to be the
"gold standard" approach to diagnosis of PID.
But, because this is a surgical procedure which requires an
incision in the abdomen, the high priority is to design and
development of non-invasive techniques, with smaller costs
and fewer risks.
OC may reduce the risk of PID that is not attributable to C.
trachomatis.
Questions 1:
Pelvic inflammatory disease (PID) in
women is most commonly caused by:
A. Leptotrichia buccalis
B. Treponema pallidum
C. Chlamydia trachomatis
D. Bacillus anthracis
E. Borelia burgdorferi
Answer
The correct answer is #C. Chlamydia
Trachomatis
Question 2:
IUD use has been linked with:
A. pelvic inflammatory disease
B. tubal infections
C. uterine infections
D. all of the above
E. none of the above
Answer
The correct answer is #D. All of the above
Question 3:
Which of the following conditions is not a
risk factor for pelvic inflammatory disease
(PID)?
A. Smoking
B. Multiple sexual partners
C. Young age at first intercourse
D. Hepatitis B
E. Intrauterine device (IUD)insertion
Answer
The correct answer is D:
Hepatitis B is not a known risk factor for PID.
Question 4:
Which of the following is not used to
treat symptoms associated with pelvic
inflammatory disease (PID)?
A: Nitrofurantoin
B: Ceftriaxone
C: Ampicillin
D: Ofloxacin
E: Cefoxitin
Answer
The correct answer is A:
No data suggest that Nitrofurantoin is an appropriate
oral regimen for the tx of PID.
Most patients are now managed as outpatients.
One outpatient regimen is Cefoxitin and probenecid
taken orally in a single dose.
Alternatively, ceftriaxone (less active against anaerobic
bacteria compared to Cefoxitin) can be taken once IM
with doxycycline orally twice daily for 14 days.
Another regimen is ofloxacin taken orally for 14 days
with either clindamycin or metronidazole, which also are
taken orally for 14 days.
Question 5:
(T/F): The major criteria for the diagnosis
of pelvic inflammatory disease (PID)
include
Leukocytosis
elevated C-reactive protein (CRP)
elevated erythrocyte sedimentation rate
(ESR)
fever.
Answer
The correct answer is False:
The major criteria for the diagnosis of PID include:
Cervical motion tenderness
Adnexal tenderness
Lower abdominal tenderness.
ESR, CRP, and laboratory documentation of
Neisseria gonorrhea or Chlamydia trachomatis
cervical infection, among others, can aid in
increasing the specificity of diagnosis
Question 6:
(T/F): All of the following are indications
for hospitalization for treatment of pelvic
inflammatory disease (PID):
failed outpatient therapy
Inability to tolerate oral therapy
Pregnancy
pelvic abscess.
Answer
The correct answer is True:
These are circumstances in which women should
be hospitalized for treatment of PID.
Other conditions that may require hospitalization
are:
uncertain diagnosis
severe illness
Severe N & V
Immunodeficiency (HIV, immunosuppressive
medications).
Question 7:
(T/F): In the initial workup, laparoscopy
should be used to confirm the diagnosis
of pelvic inflammatory disease (PID).
Answer
The correct answer is False:
Laparoscopy is costly and not always
available.
It should be used if the diagnosis is in
doubt.
Question 8:
(T/F): Consider hospitalizing patients who
do not improve clinically after 72 hours
with outpatient therapy for pelvic
inflammatory disease (PID).
Answer
The correct answer is True:
While most patients are now treated on
an outpatient basis, these patients should
be admitted to the hospital and treated
appropriately.