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PELVIC INFLAMMATORY DISEASE

Huda A.K. Hamouda

INTRODUCTION
An upper genital tract infection that causes :
Uterus ( Endometritis) Fallopian tubes (Salpingitis) Ovaries (oophoritis), Pelvic peritonitis Tubo-ovarian abscess

A common and serious complication of STDs . Due to : ascending spread of microorganisms from vagina & endocervix to endometrium, tubes, contiguous structures Incidence acute PID 1-2% of young sexually active women each year

MOST COMMON BACTERIA


Chlamydia trachomatis Neisseria gonorrhoea
tends to sudden and severe symptoms, high fever and abdominal pain (acute PID)

Anaerobic bacterial species found in the vagina, particularly Bacteroides spp., Anaerobic gram-positive cocci, (Peptostreptococci), E. coli Mycoplasma hominis

RISK FACTORS
Age < 25 are more likely to develop PID than those older (Age of 1st intercourse)
Multiple sex partners Frequency of sex intercourse MS 33% nulliparous Douching regularly IUD (Dec in : barrier and OC methods )

Previous acute PID


Consumption of alcohol

SYMPTOMS
lower abdomen pain, usually bilateral lower back pain Dyspareunia pain during or after sex bleeding between periods or after sex Menometrorrhagia sense of pressure or swelling in the lower abdomen fever (often with chills) feeling tired or unwell abnormal vaginal discharge nausea, vomiting and dizziness leg pain increased period pain increased pain at ovulation dysuria, frequently urination

INVESTIGATION
- Laboratory studies : CBC ,ESR , CRP
Laboratory may be entirely normal An elevated leukocyte count does not distinguish PID from other diagnoses - Vaginal & cervical swab : Cervical cultures for gonorrhea or Chlamydia require 3-7 days for results -ve gram smear not R/O PID - Imaging studies : U/S, CT, MRI Pelvic ultrasonography can detect pelvic abscesses - HIV and syphilis testing should be recommended

- Laparoscopy
most accurate method for confirm PID all pt. with uncertain dx, not response to Rx

CLINICAL CRITERIA
Major criteria Minor criteria

cervical motion tenderness uterine motion tenderness adnexal tenderness


Definitive criteria histopathologic evidence of endometritis on endometrial biopsy transvaginal sonography or other imaging techniques showing thickened fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex laparoscopic abnormalities consistent with PID

Temperature >38 C Abnormal cervical discharge Pelvic abscess or inflammatory


complex on bimanual examination

Gram stain of the endocervix



showing gram negative intracellular diplococci Positive chlamydia test Leucocytosis Elevated ESR Elevated C-reactive protein

Gram stain of Neisseria gonorrhoeae, The bacteria are diplococci association with host pmn's (polymorphonuclear leukocytes).

DIFFERENTIAL DIAGNOSIS
Appendicitis Gastroenteritis Cholecystitis Irritable bowel syndrome Ectopic pregnancy Hemorrhagic ovarian cyst Ovarian torsion Endometriosis Nephrolithiasis Somatization

COMPLICATIONS AND LONG-TERM PROBLEMS


Recurrent PID
Ruptured abscess ( 5-10%) Chronic pain Ectopic pregnancy (50% of previous salpingitis ) Infertility ( 20% of pt with acute salpingitis) Perihepatic adhesions 1-10%

s/s ; RUQ pain, pleuritic pain, tenderness at RUQ on palpation of the liver mistaken dx ; acute cholecystitis, pneumonia

( Fitz-Hugh-Curtis syndrome)

Perihepatic adhesions (arrow) usually associated with pelvic gonorrhoeal or chlamydial infection (Fitz-Hugh-Curtis syndrome).

OUT PATIENT TRATMENT


Regimen A
1.

REGIMEN B
Ceftriaxone 250 mg IM in a single dose + Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days 2. Cefoxitin 2 g IM single dose and Probenecid, 1 g orally administered concurrently single dose + Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days 3. Third-generation cephalosporin + Doxycycline 100 mg orally twice a day for 14 day WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Levofloxacin 500 mg once daily for 14 days OR Ofloxacin 400 mg twice daily for 14 days

Metronidazole 500 mg twice a day for 14 days

CRITERIA FOR HOSPITALIZATION


surgical emergencies (e.g., appendicitis) cannot be excluded is pregnant does not respond to oral antimicrobial therapy unable to tolerate an outpatient oral regimen has severe illness, nausea and vomiting, or high fever
has a tubo-ovarian abscess.

INPATIENT TREATMENT
Regimen A
Doxycycline 100 mg
Cefoxitin 2 g IV every 6 hours + orally or IV every 12 hours

REGIMEN B
Clindamycin 900 mg IV every 8 hours

Gentamicin loading dose (2 mg/kg ) IV or IM followed by a maintenance 14 days dose (1.5 mg/kg) every 8 hours

SURGERY
Laparoscopy

consider in all pt with ddx of PID & without contraindication R/O surgical emergency surgical emergencies failure medical treatment

Laparotomy for

Evidence of current / previous abscess Acute exacerbation of PID with bilateral TOA

MANAGEMENT OF SEX PARTNERS


Male sex partners of women with PID should be examined and treated
Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic. regimens for uncomplicated gonorrhoeae & chlamydial infection
Ceftriaxone 125 mg im follow by
doxycycline (100) 1x2 pc x7days or azithromycin 1gm or ofloxacin (300) 1x2 pc x7days

THANK YOU