PELVIC INFLAMMATORY DISEASE (PID)

PELVIC INFLAMMATORY DISEASE (PID)

Seminar Prepared by Mohammed Musa

Gynecology
College of Medicine - University of Kirkuk

1. PELVIC INFLAMMATORY DISEASE (PID) Done by Mohammed Musa

2. ‹#› 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, etc. ) B. According to clinical picture: - Acute - Chronic

3. ‹#› CLASSIFICATION OF GENITAL TRACT INFECTIONS C. According to localization: - Lower genital tract infections ( vulvo-vaginitis, cervicitis ) - Upper genital tract infections ( salpingitis, endometritis, pelvioperitonitis ) D. Accordi ng to history of recent delivery: - Puerperial - Nonpuerperial

4. Definition PID is a spectrum of infection and inflammation of the upper genital tract organs typically involving the uterus (endometrium), fallopian tubes, ovaries, pelvic peritoneum and surrounding structures . It is attributed to the ascending spread of microorganisms from the cervicovaginal canal to the contiguous pelvic structures causing endometritis, salpingitis, pelvic peritonitis or tubo-ovarian abscess. The cervicitis is not included in the list. The clinical syndrome is not related to pregnancy and surgery. ‹#›

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6. Epidemiology The incidence of pelvic infection is on the rise due to the rise in sexually transmitted diseases. The incidence varies from 1–2 percent per year among sexually active women. ‹#›

7. Epidemiology ‹#› 85 % 15 % Following procedures Spontaneous infection in sexually active females About 85% are spontaneous infection in sexually active females of reproductive age. The remaining 15% follow procedures (include endometrial biopsy, uterine curettage, insertion of IUD and hysterosalpingography.

8. Two-thirds are restricted to young women of less than 25 years and the remaining one-third limited among 30 years or older. Epidemiology ‹#› 66 % 33 % 30 years or older less than 25 years

9. Risk factors Menstruating teenagers. Multiple sexual partners. Absence of contraceptive pill use. Previous history of acute PID. IUD users. Area with high prevalence of sexually transmitted diseases. ‹#›

10. Protective factors Contraceptive practice Barrier methods , specially condom, diaphragm with spermicides. Oral steroidal contraceptives have got two preventive aspects. Produce thick mucus plug preventing ascent of sperm and bacterial penetration. Decrease in duration of menstruation, creates a shorter interval of bacterial colo- nization of the upper tract. Monogamy or having a partner who had vasectomy. Others Pregnancy Menopause Vaccines : hepatitis B, HPV ‹#›

11. Microbiology Acute PID is usually a polymicrobial infection caused by organisms ascending upstairs from downstairs. The primary organisms are sexually transmitted and limited approximately to: N. gonorrhoeae in 30% Chlamydia trachomatis in 30% Mycoplasma hominis in 10%. ‹#›

12. Microbiology The secondary organisms normally found in the vagina are almost always associated sooner or later. These are: ‹#› Aerobic organisms —non-hemolytic streptococcus. E. coli, group B streptococcus and staphylococcus. Anaerobic organisms —Bacteroides species – fragilis and bivius, peptostreptococcus and peptococcus.

13. Mode of affection The classic concept is that the gonococcus ascends up to affect the tubes through mucosal continuity and contiguity . This ascent is facilitated by the sexually transmitted vectors such as sperm and trichomonads. Reflux of menstrual blood along with gonococci into the fallopian tubes is the other possibility. Mycoplasma hominis probably spreads across the parametrium to affect the tube. The secondary organisms probably affect the tube through lymphatics . Rarely, organisms from the gut may affect the tube directly . ‹#›

14. Pathology The involvement of the tube is almost always bilateral and usually following menses due to loss of genital defence. The pathological process is initiated primarily in the endosalpinx. There is gross destruction of the epithelial cells, cilia and microvilli and may becomes edematous and hyperemic (in severe infection). The exfoliated cells along with the exudate pour into the lumen of the tube and agglutinate the mucosal folds. The abdominal ostium is closed by the indrawing of the edematous fimbriae and by inflammatory adhesions. The uterine end is closed by congestion. The closure of both the ostia results in pent up of the exudate inside the tube. ‹#›

15. Pathology Depending upon the virulence, the exudate may be watery producing hydrosalpinx or purulent producing pyosalpinx. The purulent exudate then changes the microenvironment and favors growth of other organisms resulting in deeper penetration and more tissue destruction. There will be adhesions of the tube with the surrounding structures. On occasions, the exudate pours through the abdominal ostium to produce pelvic peritonitis and pelvic abscess or may affect the ovary producing ovarian abscess . ‹#›

16. CLINICAL FEATURES ‹#› Symptoms Patients with acute PID present with a wide range of non-specific clinical symptoms. Symptoms usually appear at the time and immediately after the menstruation. Bilateral lower abdominal and pelvic pain which is dull in nature. The onset of pain is more rapid and acute in gonococcal infection (3 days) than in chlamydial infection (5–7 days). There is fever , lassitude and headache . Irregular and excessive vaginal bleeding is usually due to associated endometritis. Abnormal vaginal discharge which becomes purulent and or copious.

17. CLINICAL FEATURES Symptoms Nausea and vomiting . Dyspareunia. Pain and discomfort in the right hypochondrium due to concomitant perihepatitis ( Fitz-Hugh-Curtis syndrome ) may occur in 5–10% of cases of acute salpingitis. The liver is involved due to transperitoneal or vascular dissemination of either gonococcal or chlamydial infection. ‹#›

18. CLINICAL FEATURES ‹#› Signs The temperature is elevated to beyond 38.3°C . Abdominal palpation reveals tenderness on both the quadrants of lower abdomen. The liver may be enlarged and tender . Vaginal examination reveals: (1) Abnormal vaginal discharge which may be of purulent . (2) Congested external urethral meatus or openings of Bartholin’s ducts through which pus may be seen escaping out on pressure. (3) Speculum examination shows congested cervix with purulent discharge from the canal. (4) Bimanual examination reveals bilateral tenderness on fornix palpation, which increases more with movement of the cervix. There may be thickening or a definite mass felt through the fornices.

19. CLINICAL FEATURES ‹#›

20. ‹#› Clinical diagnostic criteria of PID (CDC 2015) Minimum Criteria Adnexal tenderness. Cervical motion tenderness. Uterine tenderness Definitive Criteria Endometrial biopsy with histopathologic evidence of endometritis; Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or Doppler studies suggesting pelvic infection (e.g., tubal hyperemia); Laparoscopic findings consistent with PID. Additional Criteria Oral temperature >101°F (>38.3°C); Abnormal cervical mucopurulent discharge or cervical friability; Presence of abundant numbers of WBC on saline microscopy of vaginal fluid; Elevated ESR; Elevated CRP; laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.

21. ‹#› CLASSIFICATION

22. Investigations A pregnancy test should always be performed to exclude the important differential diagnosis of ectopic pregnancy. High vaginal and endocervical swabs (high vaginal for Trichomonas vaginalis, Candida and bacterial vaginosis, endocervical for gonorrhoea and endocervical for Chlamydia) should be taken, paying attention to using the correct technique. Midstream specimen of urine should be sent for microscopy and culture. Full blood count and C-reactive protein are important if the woman is systemically unwell, and urea and electrolytes should be analysed if she is vomiting. Serological test for syphilis should be carried out for both the partners in all cases. ‹#›

23. Investigations Ultrasound scan will exclude a large tubo-ovarian collection, but is usually normal with PID except for possible free peritoneal fluid, which is a non-specific finding. Culdocentesis : Aspiration of peritoneal fluid and its white cell count, if exceeds 30,000 per mL. is significant in acute PID. Bacterial culture from the fluid is not informative because of vaginal contamination. Investigations are also to be extended to male partner and smear and culture are made from urethral secretion. Laparoscopy is indicated if the diagnosis is unclear or there is no response to treatment after 48 hours. ‹#›

24. Laparoscopy ‹#› Laparoscopy is considered the " gold standard ". While it is the most reliable aid to support the clinical diagnosis but it may not be feasible to do in all cases. It is reserved only in those cases in which differential diagnosis includes salpingitis, appendicitis or ectopic pregnancy. Laparoscopy helps to aspirate fluid or pus for microbiological study from the fallopian tube, ovary or pouch of Douglas. Nonresponding pelvic mass needs laparoscopic clarification .

25. Laparoscopy ‹#› Mild : Tubes: edema, erythema, no purulent exudates and mobile. Mod : Purulent exudates from the fimbrial ends, tubes not freely movable. Severe : Pyosalpinx, inflammatory complex, abscess. ‘ Violin string’ like adhesions in the pelvis and around the liver suggests chlamydial infection. Laparoscopic findings and severity of PID:

26. Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome

27. Differential diagnosis The clinical condition may be confused with: (1) Appendicitis (2) Disturbed ectopic pregnancy (3) Torsion of ovarian pedicle, haemorrhage or rupture of ovarian cyst (4) Endometriosis (5) Diverticulitis (6) Urinary tract infection The two conditions—acute appendicitis and disturbed ectopic pregnancy must be ruled out , because both the conditions require urgent laparotomy whereas acute salpingitis is to be treated conservatively. ‹#›

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29. Complications of PID IMMEDIATE: (1) Pelvic peritonitis or even generalized peritonitis. (2) Septicemia — producing arthritis or myocarditis. ‹#› LATE : (1) Dyspareunia . (2) Infertility rate is 12%, after two episodes increases to 25% and after three raises to 50%. It is due to tubal damage or tubo-ovarian mass. (3) Chronic pelvic inflammation is due to recurrent or associated pyogenic infection. (4) Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian abscess. (5) Chronic pelvic pain and ill health (24–75%). (6) Increased risk of ectopic pregnancy (6-10 fold).

30. Treatment To prevent reinfection. 03 To prevent infertility and late sequelae. 02 To control the infection energetically. 01 THE PRINCIPLES OF THERAPY ARE:

31. ‹#› Treatment Outpatient therapy : Apart from adequate rest and analgesic, antibiotics are to be prescribed even before the microbiological report is available. As because the infection is polymicrobial in nature, instead of single, combination of antibiotics should be prescribed. Out-patients antibiotic therapy for acute PID is given in the next Table.

32. ‹#› Treatment All patients treated in the outpatients are evaluated after 48 hours and if no response, are to be hospitalised.

33. ‹#› Treatment In patient therapy: The patients are to be hospitalized for antibiotic therapy in these conditions:

34. Treatment Inpatient therapy: Bed rest is imposed. Oral feeding is restricted. Dehydration and acidosis are to be corrected by intravenous fluid. Intravenous antibiotic therapy is recommended for at least 48 hours but may be extended to 4 days, if necessary. Improvement of the patient is evidenced by remission of temperature, improvement of pelvic tenderness, normal white blood cell count and negative report on bacteriological study. ‹#›

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36. ‹#› Treatment Indications of surgery : The indications of surgery are comparatively less. The unequivocal indications are: Generalized peritonitis. Pelvic abscess. Tubo-ovarian abscess which does not respond (48–72 hours) to antimicrobial therapy.

37. Prevention The following formalities are to be rigidly followed to prevent reinfection: Educating the patient to avoid reinfection and the potential hazards of it. The patient should be warned against multiple sexual partners. To use condom. The sexual partner or partners are to be traced and properly investigated to find out the organism(s) and treated effectively. If they have got non-gonococcal urethritis, they should be treated with tetracycline 500 mg 6 hourly or doxycycline 100 mg twice daily for 7 days. ‹#›

38. ‹#› Pregnancy PID is extremely uncommon in pregnancy, probably due to the mucous cervical plug and the pregnancy itself impeding passage of organisms into the fallopian tubes. In pregnancy or breastfeeding, penicillin or ceftriaxone can be used instead of ciprofloxacin. Erythromycin should be used instead of doxycycline or azithromycin, although azithromycin is not known to be harmful.

39. Follow-up Repeat smears and cultures from the discharge are to be done after 7 days following the full course of treatment. The tests are to be repeated following each menstrual period until it becomes negative for three consecutive reports when the patient is declared cured. Until she is cured and her sexual partner have been treated and cured, the patient must be prohibited from intercourse. The only unequivocal proof of successful treatment after salpingitis is an intrauterine pregnancy. ‹#›

40. REFERENCES SALLY COLLINS, SABARATNAM ARULKUMARAN, KEVIN HAYES, SIMON JACKSON, LAWRENCE IMPEY. Pelvic inflammatory disease. Oxford Handbook of Obstetrics and Gynaecology, 2013, 3rd edition, P.561-563. HIRALAR KONAR. Pelvic inflammatory disease. Dc dutta’s textbook of gynecology, 2013, 6th edition. P.127-133. BARRY O’REILLY, CECILIA BOTTOMLEY, JANICE RYMER. Pelvic Inflammatory Disease. Essentials of Obstetrics and Gynaecology, 2012, 2nd edition, P.130-133. Pelvic Inflammatory Disease. Centers for Disease Control and Prevention, June 4, 2015 [Viewed on 27 January 2018]. Available from : https://www.cdc.gov/std/tg2015/pid.htm ‹#›

41. Thank You