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A Case of Pelvic Inflammatory Disease

Silliman University Medical

School
Submitted by: Pasuquin, Alvin
01/26/2016
Submitted to: Dr. Gem Austria
Gynecology Worksheet
REPRESENTATIVE CASE
This is a case of LHG, a 25-year-old female, single, Filipino, Roman Catholic, an Online Job
woker from Magbanua, Bantayan, Dumaguete City, Negros Oriental who came in at Silliman
University Medical Center on January 14, 2016 due to persistent hypogastric pain.
The source of information is the patient herself with 90%.
HISTORY OF PRESENT ILLNESS
The patient was apparently well until 6 hours prior to admission, the patient had
an onset of generalized abdominal pain described as cramping in character, rated
as 7/10 in a pain scale. No other symptoms were noted such as fever, nausea and
vomiting. No medications were taken. Pain resolved spontaneously, 2 hours after.
4 hours prior to admission, the patient felt another discomfort, localized at the
hypogastric area described as pulsating and cramping, rated at 10/10 in a pain
scale. No other symptoms were noted. Patient took Mefenamic acid which
afforded temporary relief. Persistence of hypogastric pain prompted consultation,
and was subsequently admitted.
OB-GYNE HISTORY
The patient had her menarche at 11 years old which lasted for 3-4 days,
consuming <3 pads a day, moderately soaked, associated with occasional
dysmenorrhea. Subsequent menstruations were of regular interval of 30-daycycle lasting for 3-4 days, consuming 3 pads a day, moderately soaked, associated
with occasional dysmenorrhea.
Coitarche at 18 years of age. Patient claims to be sexually active with currently 1
sexual partner but had multiple sexual partners in the past. No history of sexually
transmitted diseases, as claimed. No history of oral contraceptive use.
Her OB score is G0. Her LMP was on 12/12/15. Her PMP was on 11/16/15
PAST MEDICAL HISTORY
Her first hospitalization was in October 2013 due to Acute Sinusitis. No other
known conditions such as hypertension, diabetes mellitus, bronchial asthma,
tuberculosis and heart diseases. No previous hospitalizations. She has no known
food and drug sensitivities. No history of trauma, injury or accidents. No previous
surgeries.
FAMILY HISTORY

A Case of Pelvic Inflammatory Disease

Maternal side: (+) HPN, (-) DM, (-) BA, (-) Malignancy
Paternal side: (+) HPN, (-) DM, (-) BA, (-) Malignancy
PERSONAL and SOCIAL HISTORY
She is not a cigarette smoker but an alcoholic beverage drinker. She consumes to
bottles of beer per week. Her last alcohol intake was on January 1, 2016. No
history of illicit drug use.
REVIEW OF SYSTEMS
General: no weight loss, no fatigue, no fever, no weakness, no difficulty sleeping,
Skin: no rashes, no lumps, no itching, no dryness
HEENT: no headache, no head injury, no neck pain, no earache, no drainage, no
vision changes, no eye pain, no redness, no blurring of vision, no stuffiness, no
discharge, no itching, no nosebleed, no sinus tenderness, no bleeding, no dry
mouth, no sore throat, no hoarseness, no thrush, no sores
Neck: no pain, no stiffness
Respiratory: no cough, no sputum, no hemoptysis, no shortness of breath
Cardio: no chest pain, no chest discomfort, no chest tightness, no palpitations
Gastrointestinal: no swallowing difficulties, no heart burn, no change in appetite,
with occasional nausea, no change in bowel habits, no rectal bleeding, no
diarrhea, no constipation,
Urinary: no frequency, no urgency, no dysuria, no hematuria, no incontinence,
Vascular: no calf pain with walking, no leg cramping
Musculoskeletal: no muscle or joint pain, no stiffness, no back pain, no tingling,
no tremor
Hematologic: no easy bruisability, no easy bleeding
Endocrine: no heat or cold intolerance, no sweating, no frequent urination, no
thirst, no change in appetite.
PHYSICAL EXAMINATION
General: Examined awake, conscious, coherent, responsive to questions, not in
respiratory distress
Vital Signs: BP: 90/60 mmHg; RR: 24/min; HR = 88/min; Temp: 36.9 C ; O 2
saturation: 98%
Skin: no pallor, no jaundice, no pigmentation, no active lesions, warm, good skin
turgor and mobility, CRT < 2 seconds
HEENT: anicteric sclerae, pink palpebral conjunctivae, no eye discharge, no sinus
tenderness, moist lips and oral mucosae, no tonsillopharyngeal congestion
Neck: supple neck, no neck vein engorgement, no lymphadenopathies, no thyroid
enlargement
Chest and Lungs: Symmetric chest expansion, no retractions, resonant lungs,
clear breath sounds
Heart: adynamic precordium, distinct heart sounds, normal rate and regular
rhythm, no murmurs
Abdomen: flat, nondistended, normoactive bowel sounds, no organomegaly, direct
tenderness in the hypogastric area
BPE: closed cervix, (+) cervical motion tenderness upon lateral wiggling of
examining finger, minimal mucupurulent slightly malodorous discharge
GUT: Negative kidney punch sign, bilateral; no discharge;
Extremities: No gross deformities, pink nail beds, strong peripheral pulses, full
range of motion

A Case of Pelvic Inflammatory Disease

PRIMARY WORKING IMPRESSION: Acute Pelvic Inflammatory Disease (Tubo-ovarian

Complex), G0
Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital
tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually
transmitted organisms, especially Neisseria gonorrhoeae and Chlamydia trachomatis, are implicated in many
cases; however, microorganisms that comprise the vaginal flora (e.g., anaerobes, Gardnerella vaginalis,
Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also have been associated with
PID. In addition, cytomegalovirus (CMV), Mycoplasma hominis, and Ureaplasma urealyticum may be the etiologic
agents in some cases of PID.

CLINICAL DIAGNOSTIC CRITERIA FOR PID

One or more of the following minimum criteria must be present on pelvic
examination to diagnose PID:
Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
The following criteria can improve the specificity of the diagnosis:
Oral temperature > 101F (> 38.3C)
Abnormal cervical or vaginal mucopurulent discharge
Presence of abundant numbers of white blood cells on saline microscopy of vaginal
fluid
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein level
Laboratory documentation of cervical infection with gonorrhea or chlamydia
The following test results are the most specific criteria for diagnosing PID
Endometrial biopsy with histopathologic evidence of endometritis
Transvaginal sonography or magnetic resonance imaging techniques showing
thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex,
or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia)
Laparoscopic abnormalities consistent with PID
Risk Factors
Risk factors for PID which are present in this particular patient include age younger than 25
years; young age at first sexual encounter; new, multiple sex partners; Patients vaginal
overdouching may also be a risk factor.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of lower abdominal pain in a young woman includes:
1.
2.
3.
4.
5.
6.

ectopic pregnancy
acute appendicitis
endometriosis
irritable bowel syndrome
complications of an ovarian cyst i.e. rupture, torsion
functional pain (pain of unknown physical origin)

DIAGNOSTIC WORK-UP
1. 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
2. The absence of endocervical or vaginal pus cells has a good negative predictive value
(95%) for a diagnosis of PID but their presence is non-specific (poor positive
predictive value 17%)
3. Human immunodeficiency virus (HIV) testing (e.g., enzyme-linked immunosorbent

A Case of Pelvic Inflammatory Disease

assay [ELISA]
or Western blot) and counseling should be offered to all patients with suspected PID
or sexually
transmitted disease (STD)
4. An elevated ESR or C reactive protein supports the diagnosis 11 but is non-specific
and often normal in mild/moderate PID
5. CBC- Elevation of the white cell count (WBC) supports the diagnosis but can be
normal in mild cases.
6. Laparoscopy is the criterion standard for the diagnosis of PID. It is significantly more
specific and sensitive than are clinical criteria alone. The minimum criteria for
diagnosing PID laparoscopically include tubal wall edema, visible hyperemia of the
tubal surface, and the presence of exudate on the tubal surfaces and fimbriae.
However, it is not justified routinely on the basis of associated morbidity, cost and the
potential difficulty in identifying mild intra-tubal inflammation or endometritis
7. Endometrial biopsy may also be helpful when there is diagnostic difficulty
8. Urinalysis to rule out urinary tract infection (UTI)
9. A pregnancy test should be performed to help exclude an ectopic pregnancy
10. Transvaginal Sonography -Although ultrasonography is neither specific nor sensitive
in distinguishing the cause of a pelvic mass, findings of dilated and fluid-filled tubes,
free peritoneal fluid, and adnexal masses may be confirmatory of symptoms and
physical signs. Thus, vaginal ultrasound has a high positive predictive value when
used in a high-risk population.
Patients result
Uterus: 3.54 x 4.45 x 3.67 cm, retroverted
Endometrium: 1.43 cm, hyperechoic
Cervix: 2.17 x 2.06 without nabothian cyst
R Ovary: 3.03 x 2.58 CM, lateral
L Ovary: 3.04 x 1.99 cm, posterior
Findings:
Endometrial and myometrial echoes appear homogenous and intact
Endometrium thick and hypoechoic with intact subendometrial halo
Left ovary unremarkable
Within R Ovary is a thin walled, unilocular, cystic structure measuring 2.71 x
2.21 cm with homogenous low level echoes within
Medial to R Ovary is a biloculated, tubular cystic structure 5.33 x 2.64 cm
filled with homogenous low level echoes
Minimal free fluid at the posterior cul de sac, left adnexal area with thin
adhesions

PATHOPHYSIOLOGY DIAGRAM
Risk Factors
Younger age
Multiple sex
partners
No condom use
PELVIC
INFLAMMATORY
DISEASE

Vaginal Inflammation and

hormonal change during
ovulation or menstruation

Salphinx and Ovaries

Cervix
Salphingitis
Mucopurulent
Cervicitis
Sterilitty

A Case of Pelvic Inflammatory Disease

Efficacy of the
functional barrier
provided by the cervical

Acquisition of vaginal or cervical

infection through sexual contact
(infected exudates and secretions)

Gonococcus and other bacteria

adhering to the Epithelium may

Gonococcus
Pili- attach to mucosal surface and prevents ingestion by
neutrophils
OPA proteins- adherence between gonococcus and
phagocytes, promoting invasion into the host cell,

Microorganisms ascend from the lower genital tract

through rhythmic uterine contractions occurring during
orgasm or bacteria may also be carried along with sperm

Inflammation

Hyperthermia
Pain
Erythema
Heat and Burning sensation
Swelling

Retrograde spread of the organisms

Urethra
Unrethrit
is
Dysuria

Vagina
Vaginitis
Formation
of Small
and larger
Abscess

Tubo-Ovarian
Complex
Salphingooophoritis
PATHOPHYSIOLOGY
Bilateral
Abdominal
Acute PID is usually a polymicrobial infection caused by organisms
ascending
from the
vagina and cervix along the mucosa of the endometrium to infect the mucosa of the oviduct.
In many cases, no causative organism is found. The two classic sexually transmitted
organisms associated with PID, N. gonorrhoeae
and C. trachomatis, cause acute PID in many cases.

A Case of Pelvic Inflammatory Disease

Risk Factors
Adolescence is a risk factor because of increased age-related chlamydia and gonorrhea
rates and the presence of cervical ectopy, which allows for increased adherence of infectious
organisms.
History of PID: damaged fallopian tube mucosa may be more susceptible to recurrent
infection.
History of gonorrhea or chlamydia: increased likelihood of recurrent gonorrhea or
chlamydia.
Male partners with gonorrhea or chlamydia
Multiple sex partners
Current douching: contributes to vaginal flora changes, epithelial damage, and disruption
of cervical mucous barrier.
Insertion of IUD within the first 21 days of placement (this risk is greatly reduced if a
woman is tested and, if necessary, treated for STDs before an IUD is inserted); after 21 days,
risk returns to baseline.
Bacterial vaginosis has been associated with PID.
Oral contraceptive use: may increase the risk of cervical chlamydial infection because of
cervical ectopy, but decreases the risk of clinically apparent symptomatic PID (mechanisms
unclear). Oral contraceptives also cause thickening of cervical mucous which may be
protective against lower genital tract organisms ascending
into the upper genital tract.
Demographics (socioeconomic status): may be related to access to care.
INFORMATION, EXPLANATION AND ADVICE
1. Patients should be advised to avoid unprotected intercourse until they, and their
partner(s),
have completed treatment and follow-up
2. A detailed explanation of their condition with particular emphasis on the long-term
implications for the health of themselves and their partner(s) should be provided,
reinforced with clear and accurate written information. Appropriate information
should include:
a. fertility is usually well preserved in women with first episode PID who receive
prompt appropriate anti-microbial therapy
b. the risk of impaired fertility increases significantly with each subsequent
episode of PID
c. the risk of impaired fertility is increased in clinically more severe PID
d. chronic pelvic pain of varying severity affects around 30% of women following
PID
e. PID increases the relative risk of a subsequent pregnancy being an ectopic,
but the absolute risk of ectopic pregnancy remains low at around 1%
3. Partner Notification
a. Current male partners of women with PID should be contacted and offered
health advice and screening for gonorrhea and chlamydia. Other recent sexual
partners may also be offered screening - tracing of contacts within a 6 month
period of onset of symptoms is recommended but this time period is not
evidence based and may be influenced by the sexual history, available
resources or local practice.
b. Partners should be advised to avoid unprotected intercourse until they and
their partner have completed the treatment course.

A Case of Pelvic Inflammatory Disease

c. Gonorrhea diagnosed in the male partner should be treated appropriately
SUGGESTED CRITERIA FOR HOSPITALIZATION OF PATIENTS WITH PELVIC
INFLAMMATORY DISEASE
Inability to follow or tolerate an outpatient oral medication regimen
No clinical response to oral antimicrobial therapy
Pregnancy
Severe illness, nausea and vomiting, or high fever
Surgical emergencies (e.g., appendicitis) cannot be excluded
Tubo-ovarian abscess
IN-PATIENT REGIMEN
1. Patient should be admitted for parenteral antibiotic therapy
2. Start intravenous fluid of PNSS 1 L @ 30 gtts/min for fluid replacement
3. Monitor the intake and output of the patient.
4. Advise the patient to eat low fat-low protein diet due to its liver involvement.
5. Monitor the VS every four hours.
6. Patient should be nursed in a semi-fowler position with frequent monitoring of
general and pelvic signs
7. Medications:
Antibiotics : IV Cefoxitin 2g four times daily (or i.v. cefotetan 2g twice daily or i.v./i.m.
ceftriaxone 1g once daily) + IV Doxycycline 100mg twice daily followed by Oral
doxycycline 100mg twice daily + Oral metronidazole 400mg twice daily to complete
14 days
Pain Reliever: Demerol 25 mg + Promethazine (Phenergan) 25 mg cocktail slow IVTT
DRUG STUDY
Ceftriaxone
1g once daily

Oral
metronidazole
400mg twice
daily to
complete 14
days

IV Doxycycline
100mg twice
daily

Inhibits the mucopeptide synthesis

in the bacterial cell wall. The betalactam moiety of Ceftriaxone binds
to carboxypeptidases,
endopeptidases, and
transpeptidases in the bacterial
cytoplasmic membrane. These
enzymes are involved in cell-wall
synthesis and cell division. By
binding to these enzymes,
Ceftriaxone results in the formation
of of defective cell walls and cell
death.
Inhibits nucleic acid synthesis by
disrupting DNA and inhibits protein
synthesis causing cell death;
amebicidal, bactrericidal,
trichomonacidal.

Doxycycline reversibly binds to the

30 S ribosomal subunits and possibly
the 50S ribosomal subunit(s),
blocking the binding of

Contraindicated to patients with

hypersensitivity to cephalosporins;
neonates. Do not use calcium or
calcium-containing solutions or
products with or within 48 hours of
ceftriaxone administration due to
risk of calcium-ceftriaxone
precipitate formation in neonates.

Hypersensitivity to the drug is a

contraindication. Caution in patients
with CNS disease, severe hepatic
impairment, history with blood
dycrasias. Avoid alcohol while
taking medication. Adverse
reactions include appetite loss,
candidiasis, diarrhea, dizziness,
headache, nausea, and vomiting.
Contraindicated in pregnancy,
lactation; porphyria;
hypersensitivity to tetracyclines;
severe hepatic dysfunction;

A Case of Pelvic Inflammatory Disease

aminoacyltRNA to the mRNA and
inhibiting bacterial protein synthesis.
Doxycycline prevents the normal
function of the apicoplast of
Plasmodium falciparum, a malaria
causing organism.

prolonged exposure to sunlight or

tanning

FOLLOW-UP
1. Review at 72 hours is recommended, particularly for those with a moderate or severe
clinical presentation, and should show a substantial improvement in clinical
symptoms and signs. Failure to do so suggests the need for further investigation,
parenteral therapy and/or surgical intervention.
2. Further review 4 weeks after therapy may be useful to ensure:
a. adequate clinical response to treatment
b. compliance with oral antibiotics
c. screening and treatment of sexual contacts
d. advice on future use of condoms to prevent recurrent PID
3. Repeat testing for gonorrhoea or chlamydia is appropriate:
a. in those with persistent symptoms
b. where antibiotic sensitivities are unknown or resistance is present
(gonorrhoea only)
c. history of poor compliance with antibiotics
d. inadequate tracing of sexual contacts where there is a possibility of persisting
or recurrent infection.