Pelvic Inflammatory Disease

Pelvic Inflammatory Disease

1. PELVIC INFLAMMATORY DISEASE (PID) “WHAT MORE CAN WE DO ?? “

2. INTRODUCTION PID is a major co-morbidity in young sexually active women The prevalence of PID increased worldwide Usually results from sexually transmitted pathogens ascending from the lower to upper genital tract PID is important as it can have long term sequela

3. OOPHORITIS SALPINGITIS/ HYDROSALPINX ENDOMETRITIS PELVIC PERITONITIS/ ABSCESS TUBO-OVARIAN ABSCESS

4. LONG TERM SEQUELA OF PID… CHRONIC PELVIC PAIN INFERTILITY ECTOPIC PREGNANCY

5. CAUSATIVE ORGANISMS… PID is a polymicrobial infection Neisseria gonorrhea Chlamydia trachomatis Others- Gardnerella vaginalis , anaerobes ( Prevotella , Atopobium , Leptotrichia ) & Mycoplasma genitalium

6. WHO GETS PID?... Young age (<25) Multiple sexual partners Past history of STI Termination of pregnancy Procedure- Hysterosalpingography (HSG), IVF Smoker

7. SYMPTOMS…. Can be symptomatic or asymptomatic Lower abdominal pain which is typically bilateral Fever (> 38 degree) Deep dyspareunia Chronic pelvic pain Abnormal vaginal bleeding- post-coital bleed, inter-menstrual bleed, menorrhagia Abnormal vaginal or cervical discharge- which is often purulent

8. SIGNS Fever Lower abdominal tenderness Cervical motion tenderness on bimanual examination Abnormal vaginal or cervical discharge- which is often purulent *Clinical signs & symptoms lack sensitivity & specificity Gonorrhea Chlamydia

9. DIFFERENTIAL DIAGNOSIS NEED TO RULE OUT…. 1.ECTOPIC PREGNANCY 2.OVARIAN ACCIDENT 3.APPENDICITIS 4.IRRITABLE BOWEL SYNDROME 5.INFLAMMATORY BOWEL DISEASE 6.URINARY TRACT INFECTION 7.BOWEL TORSION 8.PSYCHOSOMATIC PAIN

10. DIAGNOSIS…. The investigations available to diagnose PID are lack of sensitivity 1. Blood tests Raised WCC ( neutrophilia suggestive of acute inflammatory process) Reduced WCC (neutropenia in severe infection) Raised CRP and ESR

11. 2. Microbiological tests… NEISSERIA GONORRHEA CHLAMYDIA TRACHOMATIS 1.Endocervical swab -should be placed in transport medium -must reached lab within 6H but less than 24H otherwise viability will be lost 1.Endocervical swab for chlamydia NAAT (nucleic acid amplification test) -More sensitive than culture -Can be used as diagnostic / screening test on non invasively collected specimens (urine and vaginal swabs)

12. What SGH Lab has to offer for Gonorrhea? SGH lab does not have NAATs yet. Current investigation that our lab has is Culture As long as the technique of sample collection is accurate, Culture offers a high sensitivity of getting a diagnosis.

13. What SGH Lab has to offer for Chlamydia? Immunofluorescence A special collection kit is available in SGH Lab Proper smear and fixing of sample is require in order to run the investigation. During office hour, lab technician can help us do the test

14. 3.Radiology investigations ULTRASOUND -may also be helpful - insufficent evidence to support their routine use -present of adnexa mass, hydrosalpinx or fluid collection in POD LAPAROSCOPY -may strongly support the dx -not routinely done due to cost & invasive -The Fitz Hugh Curtis syndrome  adhesion between liver and peritoneal surface (typical violin string appearance)

15. SCREENING FOR STIs… 1.Women who tested positive for gonorrhea and chlamydia 2.Women at higher risk of STIs – multiple sexual partner 3.Previous history of STI # REMEMBER to screen husband or partner HIV VDRL HEPATITIS B/C

16. AIMS of management…. 1.Start treatment as early as possible to prevent long term sequelae Long term sequelae Ectopic pregnancy Infertility Chronic pelvic pain 2.To investigate and treat sexual partner in order to prevent re-infection

17. General measures.. Rest is advised for those with severe disease UPT test should be performed Appropriate analgesia Avoid unprotected intercourse until completed treatment Contact tracing

18. TREATMENT… Low threshold for empirical treatment of PID is recommended depends on severity Broad spectrum antibiotic is required to cover 1.Neisseria Gonorrhea 2.Chlamydia trachomatis 3.Aerobic & anaerobic bacteria Outpatient – as effective as inpatient treatment with clinically mild to moderate PID

19. Antibiotic regimes OUTPATIENT REGIMES.. 1.IM ceftriaxone 500mg stat - followed by T.Doxycycline 100mg bd and T.Metronidazole 400mg bd for 2 weeks Or 2.T.Ofloxacin 400mg bd and T.Metronidazole 400mg bd for 2 weeks

20. ALTERNATIVE REGIMES 1.IM Ceftriaxone 500mg stat -followed by T.Azithromycin 1g/week for 2 weeks (# evidence is limited but may be used if previous treatment are not appropiate eg allergy/ intolerance) Or 2.T.Moxifloxacin 400mg od for 2 weeks

21. INPATIENT REGIMES Severe infection Adnexal mass suspicious of abscess Generalized sepsis Poor/ inadequate response to oral treatment Severe pelvic/ abdominal pain requiring strong analgesics Intravenous therapy should be continued until 24hours after clinical improvement and followed by oral therapy

22. REGIMES.. 1.IV Ceftriaxone 2g od & IV Doxycycline followed by T.Doxycycline 100 mg od & T.Metronidazole 400mg bd for 2 weeks Or 2.IV Clindamycin 900mg tds & IV Gentamicin (2mg/kg loading dose) then 1.5mg/kg tds followed by T.Clindamycin 450mg qid or T.Doxycycline 100mg bd & T.Metronidazole 400mg nd for 2 weeks

23. ALTERNATIVE REGIMES 1.IV Ofloxacin 400mg bd & IV Metronidazole 500mg tds for 2 weeks Or 2.IV Ciprofloxacin 200mg & IV Doxycycline 100mg bd & IV Metronidazole 500mg tds for 2 weeks

24. SURGICAL TREATMENT.. Should be considered in following situations -a surgical emergency cannot be excluded -lack of response to oral therapy -clinically severe disease -presence of a tubo -ovarian abscess -intolerance to oral therapy -pregnancy

25. LAPAROSCOPY -dividing adhessions and draining pelvic abscess LAPAROTOMY -digital divission of all adhessions and any loculated area of abscess formation ULTRASOUND GUIDED ASPIRATION -less invasive -can be done if small abscess or collection at POD

26. TREAT PARTNER… Current male partner of women with PID should be contacted Offered health advice Screening for gonorrhea and chlamydia TX: IM Ceftriaxone 500mg stat # Advice avoid SI until completed treatment

27. FOLLOW UP… Review in 2-4 weeks to ensure -adequate clinical response to treatment -compliance with oral antibiotics -screening and treatment of sexual contacts -awareness of long term sequale of PID -repeat UPT if indicated Repeat testing for gonorrhea and chlamydia after 2-4 weeks in those with persistent symptoms

28. WHAT MORE CAN WE DO??

29. 1.PREVENTION Monogamous relationship Early onset of sexual intercourse Avoidance of high risk behaviour

30. Health education & Sex education Our DILEMMA !! -Sex education should not be discussed in school -Limited or no access for education & information on reproductive sexual health care -Policies often restrict adolescent’s access to information & services ( eg contraception)

31. NATIONAL STRATEGIES 1.School based health, life, sex & relationship education 2.Campaigns & media 3.Availability of contraception Co-ordination- national, state, district

32. Barrier methods -consistent use of barrier methods has been shown to reduce the risk of recurrent episodes of pelvic infection & long term sequela by 30-60%

33. There is significant risk of introducing infection into the upper genital tract when instrumenting the uterus Ensure sterility during procedure (ERPOC, HSG, IVF) Avoid illegal termination

34. 2.SCREENING UNIVERSAL VS SELECTIVE To screen all women or high risk women? Cost effective or not? VS

35. 3.CONTACT TRACING Tracing contact within a 6 month period of onset of symptoms is recommended Must get proper sexual history from the patient Patient’s co-operation !!

36. 4 .NOTIFICATIONS Notification system those with STIs or PID? Where and how to notify? Does it break patient’s confidentiality?

37. Thank you….