2 Pelvic Inflammatory Disease (PID).pdf pid

Pelvic Inflammatory Disease

1. KURSK STATE MEDICAL
UNIVERSITY
DEPARMENT OF OBSTETRICS AND
GYNECOLOGY


Pelvic Inflammatory Disease
(PID)




KURSK 2017

2. Pelvic inflammatory disease (PID) is an
infection of the reproductive organs in
women. The pelvis is in the lower abdomen
and includes the fallopian tubes, the ovaries,
the cervix, and the uterus. According to
the U.S. Department of Health and Human
Services, this condition is common and
affects about 1 million women each year in
the United States.

3. Several different types of bacteria can cause PID,
including the same bacteria that cause the sexually
transmitted infections (STIs) gonorrhea and
chlamydia. What commonly occurs is that bacteria
first enter the vagina and cause an infection. As time
passes, this infection can move into the pelvic
organs.
PID can become extremely dangerous, even life-
threatening, if the infection spreads to your blood. If
you suspect that you may have an infection, see your
doctor as soon as possible.

4. RISK FACTORS FOR PELVIC INFLAMMATORY
DISEASE

Your risk of pelvic inflammatory disease increases if
you have gonorrhea or chlamydia. However, you can
develop PID without ever having an STI. Other factors that
can cause pelvic inflammatory disease include:
having sex and being under the age of 25
having sex with more than one person
having sex without a condom
using an intrauterine device (IUD) to prevent a pregnancy
douching
a history of pelvic inflammatory disease

5. RISK FACTORS FOR PELVIC INFLAMMATORY
DISEASE

A sexual history should include:
Time since last intercourse
Type of intercourse (vaginal, oral, anal)
Contraception used
Number of previous partners
Menstrual history
Previous pregnancies
Previous treatment for STD in patient or her
partner
History of IV drug use by patient or her partners.

6. CLASSIFICATION OF GENITAL TRACT
INFECTIONS
A. According to etiology:
- specific (caused by N.gonorrhoeae and TB)
- nonspecific (caused by Staphyloccocus, Streptococus,
E.Coli, Proteus, Chlamydia trachomatis, Mycoplasma
hominis, viruses)

B. According to clinical picture:
- acute
- chronic
C. According to localization:
- infections of lower genital tract (vulvo-vaginitis,
cervicitis)
- infections of upper genital tract (salpingitis,
endometritis, pelvioperitonitis)
D. According to history of recent delivery:
- puerperial
- nonpuerperial

7. SYMPTOMS OF PELVIC INFLAMMATORY DISEASE

Some women with pelvic inflammatory disease don’t
have symptoms. For the women who do have symptoms,
these can include:
pain in the lower abdomen (the most common symptom)
pain in the upper abdomen
fever
painful sex
painful urination
irregular bleeding
increased or foul-smelling vaginal discharge
tiredness

8. SYMPTOMS OF PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease can cause mild or
moderate pain. However, some women have severe pain
and symptoms, such as:
sharp pain in the abdomen
vomiting
fainting
a high fever (greater than 101 degrees Fahrenheit)
If you have severe symptoms, call your doctor immediately
or go to the emergency room. The infection may have
spread to your bloodstream or other parts of your body.
Once again, this can be a life-threatening condition.

9. VAGINITIS

Vaginitis, also known as vaginal
infection and vulvovaginitis, is an
inflammation of the vagina and possible vulva.
It can result in discharge, itching and pain, and
is often associated with an irritation or
infection of the vulva. Infected women may
also be asymptomatic.

10. CAUSES VULVOVAGINITIS

Many triggers can cause an infection in the
vagina and vulval areas. The most common cause
is bacteria. The following can also cause
vulvoganitis:
yeast
viruses
parasites
environmental factors
sexually transmitted infections
exposure to allergens
chemical irritants

11. SYMPTOMS OF VULVOVAGINITIS
The symptoms of vulvovaginitis vary and depend
on their cause. In general, symptoms can include:
irritation of the genital area
itching
inflammation around the labia and perineal areas
an increased, strong-smelling vaginal discharge
discomfort while urinating

14. TREATMENT
This could include:
oral antibiotics
antibiotic creams applied directly to the skin
antifungal creams applied directly to the skin
antibacterial creams applied directly to the skin
oral antihistamines, if an allergic reaction is a
possibility
estrogen creams
oral antifungal pills

15. TREATMENTS AND DRUGS
Treatment for pelvic inflammatory disease may include:

Antibiotics. Your doctor may prescribe a combination of
antibiotics to start taking right away. After receiving your lab
test results, your doctor may adjust the medications you're
taking to better match what's causing the infection.
Usually, your doctor will request a follow-up visit in three
days to make sure the treatment is working. Be sure to take
all of your medication, even if you start to feel better after a
few days. Antibiotic treatment can help prevent serious
complications but can't reverse any damage that's already
been done.

16. TREATMENTS AND DRUGS
Treatment for your partner. To prevent reinfection
with an STI, advise your sexual partner or partners to
be examined and treated. Partners can be infected
and not have any noticeable symptoms.
Temporary abstinence. Avoid sexual intercourse
until treatment is completed and tests indicate that
the infection has cleared in all partners.

17. Topically applied azole drugs are the most commonly available
treatment for VVC.
●An oral antifungal agent, fluconazole, used in a single 150-mg
dose, has been approved for the treatment of VVC. It appears to
have equal efficacy when compared with topical azoles in the
treatment of mild to moderate VVC.
●Women with complicated VVC benefit from an additional 150-mg
dose of fluconazole given 72 hours after the first dose.
Topical Treatment Regimens
Butoconazole
2% cream, 5 g intravaginally for 3 days
2% cream, 5 g BI-BSR, single intravaginal application
Clotrimazole
1% cream, 5 g intravaginally for 7–14 days
100-mg vaginal tablet for 7 days
100-mg vaginal tablet, two tablets for 3 day
500-mg vaginal tablet, single dose

18. Miconazole
2% cream, 5 g intravaginally for 7 days
200-mg vaginal suppository for 3 days
100-mg vaginal suppository for 7 days

Nystatin
100,000-Units vaginal tablet, one tablet for 14 days

Ticonazole
6.5% ointment, 5 g intravaginally, single dose

Terconazole
0.4% cream, 5 g intravaginally for 7 days
0.8% cream, 5 g intravaginally for 3 days
80-mg suppository for 3 days

19. CERVICITIS
The cervix is made up of two different types of epithelial
cells: squamous epithelium and glandular epithelium.
The cause of cervical inflammation depends on the
epithelium affected.

The ectocervical epithelium can become inflamed by the
same micro-organisms that are responsible for vaginitis. In
fact, the ectocervical squamous epithelium is an extension
of and is continuous with the vaginal epithelium.
Trichomonas, candida, and HSV can cause inflammation of
the ectocervix.

Conversely, N. gonorrhoeae and C. trachomatis infect only
the glandular epithelium

20. Diagnosis

The diagnosis of cervicitis is based on the finding
of a purulent endocervical discharge, generally
yellow or green in color and referred to as
―mucopus‖.

Microscopy of the mucopus

Tests for both gonorrhea and chlamydia should be
performed. The microbial etiology of
endocervicitis is unknown in about 50% of cases
in which neither gonococci nor chlamydia is
detected.

21. Treatment of cervicitis consists of an antibiotic
regimen recommended for the treatment of uncomplicated
lower genital tract infection with both chlamydia and
gonorrhea. All sexual partners be treated with a similar
antibiotic regimen.

Neisseria gonorrhoeae endocervicitis
Cefixime, 400 mg orally (single dose), or
Ceftriaxone, 125 mg intramuscularly (single dose), or
Ciprofloxacin, 500 mg orally (single dose)a, or
Ofloxacin, 400 mg orally (single dose)a, or
Levofloxacin 250 mg orally (single dose)

Chlamydia trachomatis endocervicitis
Azithromycin, 1 g orally (single dose), or
Doxycycline, 100 mg orally twice daily for 7 days, or
Ofloxacin, 300 mg orally twice daily for 7 days, or
Levofloxacin, 500 mg orally for 7 days

22. ADNEXITIS

Unfortunately, increasingly more women,
especially young women, have this pathology.
Adnexitis is a inflammatory diseases that is
generally affecting the fallopian tubes and ovaries,
but can also affect the uterus. It is called metro-
adnexitis (the uterus is affected). Inflammatory
lesions occur most commonly in the fallopian tubes
and ovaries and uterus are less damaged.
Statistical studies show that one in four women
suffers from adnexistis and in 60% of cases the
infection becomes chronic.

23. CAUSES OF ADNEXITIS


The main cause of adnexitis can be an infection which is
transmitted during unprotected intercourse, and in this case,
treatment should be followed by both sexual partners. Other
causes are vaginal infections (vaginitis) or uterus infectionsthat
are transmitted to the fallopian tubes.

Abdominal infections: appendicitis infection can be
transmitted through the ligament which is connecting the
appendix to the ovary, resulting in adnexitis which is secondary
to appendicitis (this infection is unilateral).
Other abdominal infections, which can be transmitted to the
genital organs, causing secondary infections.

Exposure to cold or alternating hot-cold, the settlement on
cold surfaces (concrete, stairs, etc..) can favor the occurrence of
adnexitis.

24. DIAGNOSIS AND SYMPTOMS OF ADNEXITIS


Adnexitis is generally affecting both of the fallopian
tubes, but the inflammation is more pronounced in one
fallopian tube, which becomes symptomatic. Symptoms
of acute forms of adnexitis are characterized by:
Pain in lower abdomen, unilaterally or bilaterally.
Pain may be deaf and sometimes may become
intense, exaggerated by the urination or defecation
efforts.
Fever.
Modified and more abundant vaginal discharge.
Menstrual disorders, especially manifested by heavy
bleeding and prolonged menses.
Nausea and vomiting, headaches and frequent
urination in small amounts.
Malaise.

25. COMPLICATIONS OF ADNEXITIS

Unfortunately the worst and also
most common complication of adnexitis
is infertility. For a woman to become
pregnant, during the ovulation the egg
must be fertilized by a sperm, and this
thing happens in the fallopian tubes. If a
woman has adnexitis, the fallopian tube
is narrowed and it is possible that the
egg not to be released, and for this
reason the woman can not get pregnant
naturally.

26. TREATMENT OF ADNEXITIS


Treatment is using antibiotics and should be
initiated quickly.

Because adnexitis is an infection, the
treatment consists of antibiotics administration.
The doctor may suggest to the patient, before
the antibiogram results (test used to determine
germ sesitivity to certain antibiotics) , to use
broad-spectrum antibiotics or antibiotics which
proved by medical practice that are the most
effective in treating adnexitis.

27. SALPINGITIS
Clinical findings:

Acute onset of lower abdominal and pelvic pain
(usually bilateral)
In most cases, symptoms appear shortly after
menses.
Purulent vaginal discharge
Nausea may occur, with or without vomiting
Some times T above 38*C
Lower abd.tenderness
On bimanual examination: periadnexal tenderness
or inflammatory masses

28. SALPINGITIS
Laboratory findings:

Leukocytosis with a shift to the left
Smear of vaginal discharge may demonstrate
diplococci
Endocervical smear for C/S

USG findings: free fluid in cul-de-sac,
inflammatory masses

Laparoscopy visually confirming salpingitis

29. SALPHINGITIS
Differential diagnosis:

acute appendicitis,
ectopic pregnancy,
 ruptured ovarian cyst,
 infected septic abortion,
torsion of adnexal masses,
leiomyoma,
endometriosis,
UTI,
diverticulitis,
enteritis.

30. SALPHINGITIS
Complications:

peritonitis,
pelvic thrombophlebitis,
formation of pelvic abscess,
infertility,
ectopic pregnancy,
chronic infection,
intestinal adhesions and obstruction,
sepsis.

32. ENDOMETRITIS

Lower abdominal pain
Fever with shivering
Purulent vaginal discharge
Lower abdominal tenderness
PV: enlarged tender uterus, tenderness on
movement of the cervix and uterus
Lab. Findings
USG picture of endometritis
History f termination of pregnancy, intrauterine
procedure, using IUCD

35. TREATMENT OF ENDOMETRITIS
Outpatient Treatment
Regimen A
Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally
concurrently, or
Ceftriaxone, 250 mg intramuscularly, or
Equivalent cephalosporin
Plus:
Doxycycline, 100 mg orally 2 times daily for 14 days
With or without:
Metronidazole, 500 mg orally 2 times daily for 14 days
Regimen B
Ofloxacin, 400 mg orally 2 times daily for 14 days, or
Levofloxacin, 500 mg orally once daily for 14 days
With or without:
Metronidazole, 500 mg orally 2 times daily for 14 days

36. TREATMENT OF ENDOMETRITIS
Criteria for hospitalization:

Suspected pelvic or tubo-ovarian abscess
Pregnancy
T above 38
Inability to tolerate PO intake
Peritoneal sings
Failure to respond to oral antibiotics within 48 hrs
Adolescent patient
Nulliparous patient
Uncertain diagnosis

37. Inpatient Treatment

Regimen A
Cefoxitin, 2 g intravenously every 6 hours, or
Cefotetan, 2 g intravenously every 12 hours,
Plus:
Doxycycline, 100 mg orally or intravenously every 12
hours
Regimen B
Clindamycin, 900 mg intravenously every 8 hours
Plus:
Gentamicin, loading dose intravenously or
intramuscularly (2 mg/kg of body weight) followed by
a maintenance dose (1.5 mg/kg) every 8 hours

Active management by laparoscopical repeated drainage

38. MORE-SERIOUS CASES

Outpatient treatment is adequate for treating
most women with pelvic inflammatory disease.
However, if you're seriously ill, pregnant or
haven't responded to oral medications, you may
need hospitalization. At the hospital, you may
receive intravenous (IV) antibiotics, followed by
antibiotics you take by mouth.
Surgery is rarely necessary. However, if an
abscess ruptures or threatens to rupture, your
doctor may drain it.
In addition, surgery may be performed on women
who don't respond to antibiotic treatment or who
have a questionable diagnosis, such as when one
or more of the signs or symptoms of PID are
absent.

39. COMPLICATIONS

Untreated pelvic inflammatory disease may
cause scar tissue and collections of infected fluid
(abscesses) to develop in your fallopian tubes and
damage your reproductive organs. Complications
may include:
Ectopic pregnancy. PID is a major cause of tubal
(ectopic) pregnancy. In an ectopic pregnancy, the
fertilized egg can't make its way through the
fallopian tube to implant in the uterus. Ectopic
pregnancies can cause massive, life-threatening
bleeding and require emergency surgery.

40. COMPLICATIONS
Infertility. PID may damage your reproductive
organs and cause infertility — the inability to
become pregnant. The more times you've had PID,
the greater your risk of infertility. Delaying
treatment for PID also dramatically increases your
risk of infertility.
Chronic pelvic pain. Pelvic inflammatory disease
can cause pelvic pain that may last for months or
years. Scarring in your fallopian tubes and other
pelvic organs can cause pain during intercourse
and ovulation.

41. PREVENTION
To reduce your risk of pelvic inflammatory disease:

Practice safe sex. Use condoms every time you have sex,
limit your number of partners and ask about a potential
partner's sexual history.
Talk to your doctor about contraception. Some forms of
contraception may affect your risk of developing pelvic
inflammatory disease. A contraceptive intrauterine device
(IUD) may increase your risk of PID temporarily for the
first few weeks after insertion, but a barrier method, such
as a condom, reduces your risk.

42. PREVENTION

Use of a birth control pill alone offers no protection
against acquiring STIs. But the pill may offer
some protection against the development of PID by
causing your body to create thicker cervical mucus,
making it more difficult for bacteria to reach your
uterus, fallopian tubes or ovaries. It's still
important to use a condom every time you have
sex, however.
Get tested. If you're at risk of an STI, such as
chlamydia, make an appointment with your doctor
for testing. Set up a regular screening schedule
with your doctor, if you need to. Early treatment of
an STI gives you the best chance of avoiding pelvic
inflammatory disease.

43. PREVENTION

Request that your partner be tested. If you have pelvic
inflammatory disease or an STI, advise your partner to be
tested and, if necessary, treated. This can prevent the
spread of STIs and possible recurrence of PID.
Don't douche. Douching upsets the balance of bacteria in
your vagina.
Pay attention to hygiene habits. Wipe from front to back
after urinating or having a bowel movement to avoid
introducing bacteria from your colon into the vagina.