Pelvic Inflammatory Disease (PID)

Upper female reproductive infection

Endometritis (infection of uterine endometrium) PID (fallopian tube ovaries peritoneum)
Tubo-ovarian abscess Toxic shock syndrome (TSS)

 Upper reproductive tract, pelvic and abdominal infection affected women > men because of the absence of a mucosal lining or epithelium between these spaces and external body.

Presence of open tract btwen vagina, the pelvis and abdomen leading to ascending infections of uterus, fallopian tube, adnexa, pelvis and abdomen.
Ascending tract may also lead to Toxic Shock Syndrome (TSS)* *TSS = colonization of staph. Aureus that
produce epidermal toxin toxic shock syndrome toxin

Definition of PID
Acute salphingitis. An infectious and inflammatory disorder of the upper female reproductive tract involving the fallopian tubes, uterus, ovaries and adjacent pelvic structures. Results from ascending infection by microorganism from vagina/cervix. Incidence closely related to STD.

Causative agent
Perdominantly by Chlamydia trachomatis & Neisseria gonorrhoeae (40%) Recenct study: polymicrobial in nature including Gardnerella vaginalis, Haemophilus influenzae and anaerobe such as Bacteroides species. (60%)

Anatomy
Pelvic inflammatory disease may extend from infection of the lower female reproductive tract, including the vagina and cervix. Pelvic inflammatory disease (PID) is an infectious and inflammatory disorder of the upper female reproductive tract, including the uterus and fallopian tubes. Infection and inflammation may spread to adjacent pelvic structures in the pelvis and abdomen, including perihepatic structures (Fitz-Hugh Curtis syndrome).

Pathophysiology
Exact mechanism of ascent of microorganism: unknown Cervical mucus should provide functional barrier against upward spread, but efficacy of this mechanism is decreased by hormonal changes occur during ovulation and menstruation.

 Alteration in cervicovaginal microenvironment from antibiotic treatment and sexually transmitted infections - disrupt balance of endogenous flora causing normally non pathogenic organism to overgrow and ascend. + facilitated by : opening of cervix during menstruation and retrograde menstrual flow Intercourse due to rhythmic mechanical uterine contractions.

Pregnancy-related factors
Pregnancy risk of PID: cervical os is protected by the mucos plug. Rarely occurs in pregnancy
However, can occur at first 12 weeks of gestation; before mucos plug solidifies and seals off the uterus from ascending bacteria fetal loss

Risk factors
Multiple sexual partners Sexual intercourse at a young age (<25 y/o) and doesnt not use contraception IUD Lives in an area with a high prevalence of sexually transmitted infections (STIs) Women who have multiple sexual partners and who use an intrauterine device (IUD) for birth control have a higher rate of PID. Monogamous women using an IUD have no increased incidence of PID.

CLINICAL PRESENTATION

 Depending of severity of the infection., ranging from clinically asymptomatic to present with toxic symptom. Minimum criteria for empiric treatment:
Pelvic or lower abdominal pain
Dull, aching or crampy bilateral and constant. Begins few days after onset of the LNMP Accentuated by motion and exercise

History

pain with sexual intercourse (dyspareunia)

Additional diagnosis critieria

foul-smelling mucopuralent vaginal discharge Fever Vaginal bleeding (post coital)

Gonococcal PID abrupt onset + more toxic symptoms than nongonococcal Gonorrhea and chlamydia associated infection more likely to cause symptoms toward the end of menses and in the first 10 days following menstruation.

Toxic symptoms
Fever Nausea vomiting Severe pelvic and abdominal pain.

Physical Examination
Minimal criteria: ( abdminal pain + >1 of the minimal criteria) *
Cervical motion tenderness Uterine tenderness Adnexal tenderness

The uterus, ovary, or fallopian tube can be enlarged or tender on bimanual pelvic examination. An oral temperature of greater than 38.3 C is indicative of infection, along with the other signs of lower abdominal tenderness and abnormal vaginal discharge. Guarding peritonitis Adnexal fullness/disproportiante unilateral adnexal tenderness may indicate the development of tubo-ovarian abscess. Right upper quadrant tenderness a/w jaundice indicate of Fitz-HughCurtis syndrome. * Due to poor specificity( no precise hx, PE, and Ix found to be highly specific /sensitive for the disease) of
clinical finding, CDC has establish minimal criteria for the Dx.

Differential Diagnosis
Appendicitis
Mainly right sided pain, and the menstrual cycle is undisturbed

Adnexal tumors Diverticulitis

Older women and left sided pain

Torsion of pedicle cyst

History of intermittent pain over several months. Cyst should be palpable.

Tubal pregnancy (ectopic pregnancy)

PID is the most common incorrect diagnosis in cases of ectopic pregnancy. Through history, but in young women in whom spaphingitis and tubal pregnancy may co-exist the distinction can be very difficult. B-hCG aids diagnosis.

Endometriosis

Investigation
Definitive procedures used to increase the specificity of the diagnosis:

1.

Laparoscopic confirmation
Thickened (>5cm), fluuid filled fallopian tube Indisctint endometrial borders Ovaries with multiple small cysts Moderate-to-large amount of free pelvic fluid in acure, severe PID.

2. 3.

Transvaginal ultrasonographic scanning or magnetic resonance imaging (MRI) showing thickened, fluid-filled tubes with/without free pelvic fluid or tuboovarian abscess (TOA) Endometrial biopsy (histological exam) showing endometritis
FBC elevated WBC in presence of infection (>10,000) High vaginal swab(HVS) and culture or DNA probe look for causative organism (N gonorrhoeae or C trachomatis) Saline microscopy of vaginal secretions abundant WBC in presence of infection ESR elevated ESR C-reactive protein elevated Pregnancy test if +ve ectopic pregnancy must be addressed Urinalysis to help exclude UTI however positive urinalysis does not exclude PID Hepatits and HIV screening Repid protein reagin (RPR) test for syphilis

Fig. 2.24-year-old woman with pelvic inflammatory disease and tuboovarian complex. A, Sagittal endovaginal sonogram reveals complex free fluid (FF). U = uterus. B, Coronal image of left adnexa reveals dilated fallopian tube (T) with echogenic fluid. Findings are consistent with those of pyosalpinx

Sonographic features of pelvic inflammatory disease with pyosalpinx and surrounding inflamed fat. Combination of hypoechoic (arrows) and hyperechoic (asterisks) fat surrounds pyosalpinx (pyosalpinx itself is not seen on this image). Degree of inflammation is usually indication of infection and is unusual in other causes of acute gynecologic distress, but may be seen with other inflammatory causes such as Crohn's disease, acute appendicitis, and diverticulitis.

Sonographic features of pelvic inflammatory disease with thickened fallopian tubes in 38-year-old woman. Axial (A) and sagittal (B) transvaginal sonograms of right adnexa show normal ovary (OV) relatively close to thickened fallopian tube (arrows). Note elongated nature of thickened tube on sagittal view (arrows and crosshairs, B). Similar findings were present in left adnexa.

Complication
Tubo-ovarian abscess (TOA)

Pelvic peritonitis
Fitz-Hugh-Curtis syndrome Perihepatitis from ascending infection resulting right upper quadrant pain and tenderness and liver function test elevations violin-string adhesions

Tubo-ovarian abscess complicating colonic diverticulitis-the left ovary and tube have been transformed into a multicystic mass with a yellow lining (AFIP)

Management
Objective: relief of acute symptoms, eradication of current infection and minimization the risk of long-term complication.

Laparoscopy Remove any IUD Broad spectrum cephalosporin antibiotics due to polymicrobial nature
Doxycycline, cefoxitin, azithromycin or ampicillin

Laparotomy if signs and symptoms persist Clindamycin and gentamicin treatment of choice during pregnancy because tetracyclines and fluoroquinolones are avoided in pregnancy. Removal of the uterus and fallopian tubes and perhaps the ovaries as well

Admission criteria
Most patients with PID are managed as outpatient but hospitalization should be considered for:
Uncertain diagnosis Pelvic abscess on ultrasonographic scanning Pregnancy Failure to respond to outpatient management Inability to tolerate outpatient oral antibiotic regimen Severe illness or nausea and vomiting precluding outpatient treatment Immunodeficiency (eg, patients with HIV infection who have a low CD4 count, or patients using immunosuppressive medications) Failure to improve clinically after 72 hours of outpatient therapy

In patient Broad spectrum cephalosporin IV (cefoxitin) + doxycycline IV

Outpatient Ceftriaxone IM or cefoxitin IM +oral deoxycline