Gynaecology د.شيماءعبداألميرالجميلي Pelvic inflammatory disesase Pelvic inflammatory disease (PID) is usually the result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis and subsequently formation of tubo-ovarian and pelvic abscesses. Neisseria gonorrhoeae and Chlamydia trachomatis have been identified as causative agents whilst Mycoplasma genitalium and anaerobes can also be implicated. Micro-organisms from the vaginal flora including streptococci, staphylococci, E. coli and H. influenzae are also associated with upper genital tract inflammation. Pathophysiology Once the infection has ascended to the upper genital tract, the Fallopian tubes are commonly damaged. There is inflammation of the mucosal lining which, if progressive, will destroy the cilia within the Fallopian tube followed by scarring in the tubal lumen. This can cause pocketing within the lumen with partial obstruction and thus predispose to ectopic pregnancy. In severe infection, mucopurulent discharge exudes through the fimbrial end of the Fallopian tube causing peritoneal inflammation. This can lead to scarring and adhesion formation between the pelvic structures. It can affect the ovary and form a tubo-ovarian abscess with distortion of the anatomy. Infections are usually contained by the omentum and 1
frequently omental adhesions are seen in the areas affected. Chlamydia and gonorrhoea can also cause perihepatitis leading to adhesions between the liver and the peritoneal surface. This gives a typical violin string appearance at laparoscopy and is known as the Fitz Hugh Curtis syndrome. Risk factors A number of factors are associated with PID: Factors related to sexual behaviour young age multiple partners recent new partner (within previous 3 months) past history of sexually transmitted infections (STIs) in the patient or their partner Instrumentation of the uterus / interruption of the cervical barrier termination of pregnancy insertion of intrauterine device within the past 6 weeks hysterosalpingography in vitro fertilisation Signs and symptoms lower abdominal pain usually bilateral deep dyspareunia particularly of recent onset 2
abnormal bleeding intermenstrual bleeding, post coital bleeding and menorrhagia can occur secondary to associated cervicitis and endometritis. abnormal vaginal or cervical discharge as a result of associated cervicitis, endometritis or bacterial vaginosis. Signs These signs are associated with PID: lower abdominal tenderness adnexal tenderness or palpable pelvic mass on bimanual vaginal examination cervical motion tenderness on bimanual vaginal examination fever (>38 C) Heavy/intermenstrual bleeding Pelvic tenderness and cervical excitation during examination Generalized sepsis in severe and systemic infection Differential Diagnosis The differential diagnosis of lower abdominal pain in a young woman includes: ectopic pregnancy acute appendicitis endometriosis irritable bowel syndrome 3
complications of an ovarian cyst i.e. rupture, torsion Diagnosis Testing for gonorrhoea and chlamydia in the lower genital tract is recommended since a positive result supports the diagnosis of PID. However the absence of infection from the endocervix or urethra does not exclude PID. Cervical, high vaginal and urethral swabs microscopy, for NAATs (nucleic acid amplification tests) for Neisseria gonorrhoeae and Chlamydia trachomatis AND for culture & sensitivity And offer routine STI and HIV screening. The absence of endocervical or vaginal pus cells has a good negative predictive value (95%) for a diagnosis of PID but their presence is nonspecific An elevated ESR or C reactive protein supports the diagnosis but is non-specific and often normal in mild/moderate PID Elevation of the white cell count (WBC) supports the diagnosis but can be normal in mild cases. Laparoscopy may strongly support a diagnosis of PID but is not justified routinely on the basis of associated morbidity, cost and the potential difficulty in identifying mild intra-tubal inflammation or endometritis U/S scanning to detect free fluid and pelvic abscess. Endometrial biopsy may also be helpful when there is diagnostic difficulty but there is insufficient evidence to support their routine use. A pregnancy test should be performed to help exclude an ectopic pregnancy. 4
Complications 1-Tuboovarian abscesses and pelvic peritonitis. Pyosalpinx 2-The Fitz-Hugh-Curtis syndrome 3- In pregnancy PID is uncommon but has been associated with an increase in both maternal and fetal morbidity 4- Ectopic pregnancy 5- Chronic pelvic pain 6- Tubal factor infertility 7-Recurrent PID Treatment Information, explanation and advice for the patient. Patients should be advised to avoid unprotected intercourse until they, and their partners, have completed treatment and follow-up Depending on the severity of the infection, patients with mild/moderate disease can be managed on an outpatient basis with easy access to hospital admission if the infection becomes more severe. An intrauterine 5
contraceptive device, if present, should be removed and alternative emergency contraception or other modes of contraception (combined pill, progesterone) should be offered.apregnancy test should be done in all cases to rule out ectopic pregnancy. There are several differing antibiotic regimes that are used; however, the following is recommended : Mild/moderate infection (outpatient treatment) Oral ofloxacin 400 mg twice a day + oral metronidazole 400 mg twice a day 14 days Ceftriaxone 250 mg single intramuscular injection + oral doxycycline 100 mg twice a day + oral metronidazole 400 mg twice a day 14 days Single intramuscular dose of ceftriaxone 250 mg + azithromycin 1 g/week 2 weeks. This type of triple antibiotic therapy is important to provide a broad spectrum of cover as PID is caused by multiple organisms, in addition to chlamydia and gonococcus. Hospitalization and parenteral therapy: patients should be admitted to the hospital when there is evidence of: Severe infection Adnexal masses suspicious of abscess Generalized sepsis Poor/inadequate response to oral treatment Severe pelvic/abdominal pain requiring strong analgesics. 6
Principles of treatment Adequate supportive care Strict watch on fluid balance Parenteral antibiotics Ceftriaxone 2 g i.v. + i.v./oral doxycycline 100 mg twice daily + i.v. metronidazole 500 mg twice daily. This should be continued until the patient gets clinically better which is usually within 24 hours, following which the antibiotics should be changed to oral therapy for 14 days. Clindamycin 900 mg i.v. three times daily + gentamycin i.v. (loading dose 2 mg/kg followed by 1.5 mg/kg three times a day) followed by either clindamycin 450 mg four times daily or oral doxycycline twice daily + oral metronidazole 400 mg daily for 14 days. Ofloxacin i.v. 400 mg twice daily + metronidazole i.v. three times a day 14 days. In pregnancy, a combination of cefotaxime + azithromycin + metronidazole should be used. Doxycycline, gentamycin and ofloxacin should be avoided. Surgical treatment In patients with a pelvic abscess or patients not responding to therapy, a laparoscopy is warranted. This may also exclude other causes of pain, such as appendicitis, endometriosis or ovarian pathology. The usual treatment would involve drainage of the abscess and sometimes the affected tube/ovary may have to be removed. Patient counselling Partner and other sexual contacts should be screened. 7
There is a risk of reinfection if the partner is not treated. Use of barrier contraception will reduce the risk of further recurrences. Risks of tubal damage leading to subfertility, ectopic pregnancy and chronic pelvic pain which increases with further episodes of infection. Prompt and early treatment will reduce the risk of subfertility. Seek early medical advice if pregnant, due to the risk of an ectopic pregnancy. 8