Pelvic Inflammatory Disease

A Condition Requiring Closer Attention

Prof. Aruna Batra Obstetrics & Gynecology VMMC & SJH, N. Delhi

PID: A Neglected Issue

Low disease awareness
Sub-optimal management 50% named correct antibiotic regimen < 25% examined the sexual partners
A National Audit of PID Diagnosis & Management in GP: England and Wales
Int. J STD AIDS 2000 Jul;11(7):440-4

Objectives
What is Pelvic Inflammatory Disease? Why is it important to treat timely? Causative factors and transmission? How does the patient present? Treatment Plan?
- Drug therapies - Surgical procedures - Follow up

What is PID ?
Acute/ Chronic clinical syndrome

Inflammation of pelvic structures

Ascending spread of infection from the
vagina and endocervix to the endometrium, fallopian tubes, ovaries, &/ or adjoining structures

Upper genital tract infection, salpingitis endometritis, parametritis, tubo-ovarian abscess & pelvic peritonitis

Transmission

Sexual transmission
via the vagina & cervix

Gynecological
surgical procedures

Child birth/ Abortion A foreign body inside uterus (IUCD)

Transmission

Contamination from
other inflamed structures in abdominal cavity (appendix, gallbladder)

Blood-borne transmission
(pelvic TB)

Pathogenesis

Infective Organisms
Sexually transmitted - Chlamydia trachomatis
Neisseria gonorrhoeae Endogenous Aerobic - Streptococci Haemophilus E. coli Anaerobes - Bacteroides, Peptostrptococcus - Bacterial Vaginosis - Actinomyces israelii Mycoplasma hominis, Ureaplasma Mycobacterium tuberculosis & bovis

Predisposing Factors

Frequent sexual encounters, many partners Young age, early age at first intercourse Exposure immediately prior to menstruation. Relative ill-health & poor nutritional status. Previously infected tissues (STD/ PID) Frequent vaginal douching

Why is it Important to Treat PID ?

Systemic upset / Tubo-ovarian abscess Chronic Pain (15-20 %) Hysterectomy
Ectopic

pregnancy (6-10 fold)

Infertility (Tubal): 20% ~ 2 episodes

40% ~ 3 episodes Recurrence (25%)

Male genital disease (25%) Cervix/ Ovarian Cancer ?

Cancer

Presentation: Acute PID

Severe pain & tenderness lower abdomen Fever, Malaise, vomiting, tachycardia Offensive vaginal discharge Irregular vaginal bleeding B/L adnexal tenderness cervical excitation Tubo-ovarian mass Fitz-Hugh-Curtis Syndrome
Poor sensitivity & specificity Correct diagnosis : 45 70%

Presentation: Chronic PID

Chronic lower abdominal pain, Backache General malaise & fatigue Deep dyspareunia, Dysmennorhea Intermittent offensive vaginal discharge Irregular menstrual periods Lower abdominal/ pelvic tenderness Bulky, tender uterus
Infertility ( Silent epidemic )

PID: Differential Diagnosis

Ectopic Pregnancy Torsion/ Rupture adnexal mass Appendicitis Endometriosis Cystitis/ pyelonephritis

Laboratory Studies
Pregnancy test Complete blood count, ESR, CRP Urinalysis Gonorrhea, Chlamydia detection (Gram
stain/ Cultures / ELISA/ FA/ DNA )

Tests for TB, syphilis, HIV Pelvic Ultrasound Culdocentesis Laparoscopy

Endometritis (thickened heterogenous endometrium)

Hydrosalpinx (anechoic tubular structure)

Hydrosalpinx.

Pyosalpinx (tubular structure with debris in adnexa

Tuboovarian abscess resulting from tuberculosis

Right hydrosalpinx with an occluded left fallopian tube

Syndromic Diagnosis of PID Minimum Criteria for Diagnosis (CDC 2002)

Lower abdominal tenderness on palpation
Bilateral adnexal tenderness

Cervical motion tenderness

No other established cause

Negative pregnancy test

Additional Criteria (CDC 2002)

Oral temperature > 38.3C (101F)

Abnormal cervical / vaginal discharge

Elevated ESR

Elevated C-reactive protein

WBCs on saline micro. of vaginal sec. Lab. documentation of cervical infection
with N. gonorrhoeae/ C. trachomatis

Definitive Criteria (CDC 2002)

Endometrial biopsy with histopathology
evidence of endometritis

TVS/ MRI: Thickened fluid filled tubes/

free pelvic fluid / tubo-ovarian complex

Laparoscopic abnormalities consistent

with PID

Management Issues
Inpatient vs. outpatient management ?

Broad-spectrum antibiotic therapy

without microbiological findings vs. Antibiotic treatment adapted to the microbiological agent identified ?

Oral vs. Parenteral therapy?

Duration of the treatment ? Associated treatment ? Prevention of re-infection ?

Criteria for Hospitalization (CDC 2002)

Surgical emergencies not excluded Severe illness/ nausea/ vomit/ high fever Tubo-ovarian abscess Clinical failure of oral anti-microbials Inability to follow/ tolerate oral regimen Pregnancy Immunodeficient (HIV low CD4 counts,
immunosuppressive therapy)

Antibiotic Therapy
Gonorrhea : Cephalosporins, Quinolones

Chlamydia: Doxycycline, Erythro-mycin & Quinolones (Not to cephalosporins) Anaerobic organisms: Flagyl, Clindamycin and in some cases to Doxycycline.
Beta hemolytic streptococcus and E. Coli Penicillin derivatives, Tetracyclines, and Cephalosporins., E. Coli is most often treated with the penicillins or gentamicin.

Antibiotic Regimens (CDC 2002)

Parenteral regimen A
Cefoxitin 2 g IV q 6h / cefotetan 2 g IV q 12h + Doxycycline 100 mg PO/IV q12h + Metronidazole or Clindamycin (TO abscess)

Parenteral regimen B
Clindamycin 900 mg IV q 8h + Gentamicin Loading dose 2 mg/kg IV/IM, maintenance 1.5 mg/kg IV/ IM q 8h

Other 2nd/ 3rd Generation Cephalosporins

Ceftizoxime - Cefizox, Cefotaxime - Omnatex, Ceftriaxone - Monocef, Cefoperazone - Magnamycin, Ceftizidime - Fortum

Alternative Parenteral Regimens

(CDC 2002)

Ofloxacin 400 mg IV q 12 hours or Levofloxacin 500 mg IV once daily

WITH OR WITHOUT

Metronidazole 500 mg IV q 8 hours or Ampicillin/Sulbactam 3 g IV q 6 hrs

PLUS

Doxycycline 100 mg orally/ IV q 12 hrs

Outpatient Antibiotic Therapy Regimen A (CDC 2002)

Ofloxacin 400 mg twice daily for 14 days or Levofloxacin 500 mg once daily for 14 days
WITH OR WITHOUT

Metronidazole 500 mg twice daily for 14 days

Outpatient Antibiotic Therapy Regimen B (CDC 2002)

Ceftriaxone 250 mg IM once
OR

Cefoxitin 2 g IM probenecid 1 g PO once

+ Doxycycline 100 mg PO bid for 14
WITH OR WITHOUT

Metronidazole 500 mg BD x 14 d

CDC Recommendations
No efficacy data compare parenteral
with oral regimens

Clinical experience should guide

decisions reg. transition to oral therapy

Until regimens that do not adequately

cover anaerobes have been demonstrated to prevent sequelae as successfully as regimens active against these microbes, anaerobic coverage should be provided

When should treatment be stopped ?

Parenteral changed to oral therapy after
72 hrs, if substantial clinical improvement

Continue Oral therapy until clinical &

biological signs (leukocytosis, ESR, CRP) disappear or for at least 14 days

If no improvement, additional diagnostic

tests/ surgical intervention for pelvic mass/ abscess rupture

Associated treatment
Rest at the hospital or at home Sexual abstinence until cure is achieved Anti-inflammatory treatment Dexamethasone 3 tablets of 0.5 mg a day or Non steroidal anti-inflammatory drugs Oestro-progestatives: contraceptive effect + protection of the ovaries against a peritoneal inflammatory reaction + cervical mucus induced by OP has preventive effect against re-infection.

Special Situations
Pregnancy - Augmentin or Erythromycin - Hospitalization Concomitant HIV infection - Hospitalization and i.v. antimicrobials - More likely to have pelvic abscesses - Respond more slowly to antimicrobials - Require changes of antibiotics more often - Concomitant Candida and HPV infections

Surgery in PID
Indications Acute PID - Ruptured abscess - Failed response to medical treatment - Uncertain diagnosis

Chronic PID - Severe, progressive pelvic pain - Repeated exacerbations of PID - Bilateral abscesses / > 8 cm. diameter - Bilateral uretral obstruction

Surgery in PID

Timing of Surgery - No improvement within 24-72 hours - Quiescent (2-3 months after acute stage) Type of Surgery - Colpotomy - Percutaneus drainage/ aspiration - Exploratory Laparotomy Extent of Surgery - Conservation if fertility desired - U/L or B/L S.Ophrectomy / subtotal/ TAH - Drainage of abscess at laporortomy - Identification of ureters

Ruptured Pelvic Abscess

Generalized Septic Peritonitis

absorption of bacterial endotoxins fluid from inflamed peritoneal surfaces Fluid shift intravascular to interstitial spaces Hypovolemia, CO, VC, PR tissue perfusion, ARDS, hyoxemia Multi-organ system failure Prompt Diagnosis & Treatment

Ruptured Abscess- Management

Pre-Operative
Rapid/ adequate metabolic/hemodynamic preparation Blood chemistry, CVP monitoring, ABG X-match blood, IV fluids, aggressive antibiotics Technical difficulties Aggressive lavage of peritoneal cavity Exploration for sub-diaphragmatic collection Closed suction drain Shock, infection, ileus, fluid balance

Operative Management

Post- Operative

Follow Up

Re-screening for Chlamydia & Gonorrhea Patient counseling: - Risk of re- infection and sequel. - Sexual counseling - Avoid douching

Management of sex partners

Examination and treatment

if they had sexual contact with patients during the 60 days preceding the onset of symptoms in the patients.

Empirical treatment with regimens

effective against C. trachomatis and N. gonorrhoeae

Opportunities for Control

STD
STD

PID

Infertility

Influenced by Interaction of following Environments

Genital Microbial Environment Individual Behavioral Environment Socio-geographic Environment

Prevention
Primary Prevention: - Sexual counseling: practice safe sex,
limit the number of partners, avoid contact with high-risk partners, delay the onset of sexual activity until 16 years. - Barrier and Oral contraceptives reduce the risk for developing PID. Secondary Prevention: - Screening for infections in high- risk. - Rapid diagnosis and effective treatment of STD and lower urinary tract infections. Tertiary Prevention: - Early intervention & complete treatment.

Conclusion
PID in women - Silent epidemic Can have serious consequences. Be aware of limitations of clinical diagnosis. Adequate analgesia and antibiotics. Proper follow up is essential. Treatment of male partner Educational campaigns for young women and health professionals. Prevention by appropriate screening for STD and promotion of condom usage.