Pelvic inflamatory disease(PID)

Pelvic inflammatory disease (PID) is a nonspecific term for a spectrum of upper genital tract conditions ranging from acute bacterial infection to massive adhesions from old inflammatory scarring.

The most common initial organisms are chlamydia and gonorrhea. With persistent infection, secondary bacterial invaders include anaerobes and gram-negative organisms.
PID is an ascending infection that starts within the cervix and moves up to involve the oviducts and ovaries.
Cervicitis: The initial infection starts with invasion of endocervical glands with chlamydia and gonorrhea. A mucopurulent cervical discharge or friable cervix may be noted. Cervical cultures will be positive, but symptoms are usually absent.
Acute salpingo-oophoritis: Usually after a menstrual period with breakdown of the cervical mucus barrier, the pathogenic organisms ascend through the uterus causing an endometritis; then the bacteria enter the oviduct where acute salpingo-oophoritis develope.
Chronic PID: If the salpingo-oophoritis is not appropriately treated, the body’s immune defenses will often overcome the infection but at the expense of persistent adhesions and scarring.
Tubo-ovarian abscess (TOA): If the body’s immune defenses cannot overcome the infection, the process worsens, producing an inflammatory mass involving the oviducts, ovaries, uterus, bowel, and omentum.

Risk Factors

The most common risk factor is female sexual activity in adolescence,with multiple partners.
PID is increased in the month after insertion of an IUD, but this is probably exacerbation of preexisting subclinical infection.

Cervicitis:

Often there are no symptoms except vaginal discharge.
The most common finding is mucopurulent cervical discharge or a friable cervix.
No pelvic tenderness is noted.
The patient is afebrile.

Investigative findings can be a lab diagnosis or a clinical diagnosis. Diagnosis section for chlamydia. WBC and ESR are normal.
Management: Single dose orally of cefixime and azithromycin.

Acute Salpingo-Oophoritis

Bilateral lower abdominal-pelvic pain may be variable, ranging from minimal to severe.
Onset may be gradual to sudden, often after menses.
Nausea and vomiting may be found if abdominal involvement is present.

On examination

mucopurulent cervical discharge, cervical-motion tenderness, and bilateral adnexal tenderness are present.
Fever, tachycardia, abdominal tenderness, peritoneal signs, and guarding may be found depending on the extent of infection progression.

Investigative findings include

Elevated WBC and ESR.

Pelvic sonography is usually unremarkable.

Laparoscopy will show erythematous, edematous, purulent oviducts.

Cervical cultures will come back positive for chlamydia or gonorrhea.

Differential diagnosis includes

adnexal torsion

ectopic pregnancy

endometriosis

appendicitis

diverticulitis

Crohn disease, and ulcerative colitis.

Diagnosis: This is a made on clinical grounds using the following:

Minimal criteria:

-Sexually active young woman

-Pelvic or lower abdominal pain

-Tenderness: cervical motion or uterine or adnexal

Supportive criteria (but not necessary for diagnosis):

-Oral temperature >38.3 C (>101 F)

-Abnormal cervical or vaginal mucopurulent discharge

-Presence of abundant WBC on vaginal fluid saline microscopy

-Elevated erythrocyte sedimentation rate

-Positive lab findings of cervical N. gonorrhoeae or C. trachomatis

Most specific criteria for diagnosis:

-Endometrial biopsy showing endometritis

-Vaginal sono or MRI imaging showing abnormal adnexa

-Laparoscopic abnormalities consistent with PID

Managemen

t:is often based on a presumptive diagnosis. Empiric broad spectrum

coverage need to include N. gonorrhoeae or C. trachomatis as well as anaerobes (e.g.,

B. fragilis)

Outpatient treatment is equivalent to inpatient in mild to moderate cases.

–Criteria: absence of inpatient criteria

–Antibiotics: ceftriaxone IM x 1 plus doxycycline po bid for 14 days with/without metronidazole po bid for 14 days

Inpatient treatment is essential with severe cases.

–Criteria: cannot rule out; failed outpatient therapy; unable to tolerate oral medications; severe illness, high fever, nausea/vomiting; tubo-ovarian abscess or pregnancy

–Antibiotics: (1) cefotetan IV 12 h plus doxycycline po or IV q 12 h or (2)clindamycin plus gentamicin IV q 8 h

obestetric triad of Acute Salpingo-Oophoritis:

Bilateral abdominal/pelvic pain

Mucopurulent cervical discharge

Cervical motion tenderness

Tubo-ovarian abscess:

Tubo-ovarian abscess (TOA) is the accumulation of pus in the adnexa forming an inflammatory mass involving the oviducts, ovaries, uterus, or omentum.

The typical clinical presentation is similar to severe acute PID with acute pain, fever, chills, and vaginal discharge; some patients present with chronic pain and are afebrile.

The patient will look septic. Lower abdominal-pelvic pain is severe. Often there is severe back pain, rectal pain, and pain with bowel movements. Nausea and vomiting are present.

On examination

She has high fever with tachycardia.

She may be in septic shock with hypotension.

Abdominal examination shows peritoneal signs, guarding, and rigidity.

Pelvic examination may show such severe pain that a rectal examination must be performed.

Bilateral adnexal masses may be palpated.

Investigative findings include

positive cervical cultures for chlamydia or gonorrhea.

Blood cultures may be positive for gram-negative bacteria and anaerobic organisms such as Bacteroides fragilis.

Culdocentesis may yield pus.

WBC and ESR are markedly elevated.

Sonography or CT scan will show bilateral complex pelvic masses.

Differential diagnosis includes

septic abortion

diverticular or appendiceal abscess

adnexal torsion.

Management:

Inpatient IV clindamycin and gentamicin should result in fever defervescence within 72 hours.

If there is no response or there is rupture of the abscess exposing free pus into the peritoneal cavity, significant mortality can occur.

Exploratory laparotomy with possible TAH and BSO or percutaneous drainage through a colpotomy incision may be required.

Chronic pelvic inflamatory disease

Chronic bilateral lower abdominal-pelvic pain is present, varying from minimal to severe. Other symptoms may include history of infertility, dyspareunia, ectopic pregnancy, and abnormal vaginal bleeding. Nausea and vomiting are absent.

On examination, bilateral adnexal tenderness and cervical-motion tenderness is present, but mucopurulent cervical discharge is absent. Fever and tachycardia are absent.

Investigative findings include

negative cervical cultures with normal WBC and ESR.

Sonography may show bilateral cystic pelvic masses consistent with hydrosalpinges.

Diagnosis: Diagnosis is based on laparoscopic visualization of pelvic adhesions.

Management:

Outpatient mild analgesics for pain.

Lysis of tubal adhesions may be helpful for infertility.

Severe unremitting pelvic pain may require a pelvic clean-out (TAH, BSO). If the ovaries are removed, estrogen replacement therapy is indicated.

Pelvic inflamatory disease(PID)