Pelvic Inflammatory Disease with YouTube Video

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1. Pelvic Inflammatory Disease

2. Introduction Acute & subclinical infection of the upper female genital tract Uterus, fallopian tubes and ovaries ( endometritis, salphingitis , oophoritis , peritonitis, perihepatitis , or tubo -ovarian abscess) Disease of sexually active females

3. Etiology Neisseria gonorrhoeae & chlamydia trachomatis account for majority of the cases Others - Mycoplasma genitalium, anaerobes , Gardnerella vaginalis, Haemophilus influenzae , enteric gram-negative organisms, and Streptococcus agalactiae Mycobacterium tuberculosis and actinomycosis Other causes -cytomegalovirus (CMV), Mycoplasma hominis, and Ureaplasma urealyticum poly microbial infection

4. Pathogenesis Ascending lower genital tract infections Epithelial damage by the primary pathogens- opportunistic entry of others Inflammation  injury  late complications like adhesion and abscess Modalities that disrupt the barrier – promotes PID Initiated by a single microbe- later it becomes poly microbial

5. Clinical spectrum Ranges from acute, sub clinical to chronic Acute - mild, moderate and severe disease Sub clinical- exact proportion of sub clinical cases not known( 13% -30% or more) Chronic low grade fever, weight loss, mild to moderate abdominal pain M. tuberculosis and actinomycosis

6. Factors associated with increased risk Young age at first sexual encounter Multiple sexual partners Recent new partner (within previous 3 months) Past history of STIs in the patient or the partner Instrumentation of the uterus/ interruption of cervical barrier Termination of pregnancy Insertion of intrauterine devices recently Hysterosalpingography Hysteroscopy Saline infusion sonography In vitro fertilization

7. Approach to a patient with PID When to suspect ? All sexually active young women complaining of acute abdominal pain which is bilateral – suspect PID Other causes of acute abdominal pain to be ruled out Maintaining low threshold for diagnosis

8. Minimum clinical criteria CDC- 2015 Cervical motion tenderness Uterine tenderness Adnexal tenderness Any ONE of the 3

9. Imaging and invasive tests Transvaginal ultrasound- also rules out other mimickers Tubal wall thickness > 5 mm Fluid in the cul-de-sac Cogwheel sign on cross section of the tubal view Pelvic CT Thickened uterosacral ligaments Inflammatory changes of the tubes or ovaries Abnormal fluid collection Pelvic MRI More sensitive

10. Laparoscopy Gold standard for diagnosing PID Edematous, erythematous tubes Purulent exudate emanating from the fimbrial end Peritubal adhesions Intra-operative view of hydrosalpinx Image source: Revzin MV et al, Radiographics . 2106;36:1579-96

11. Endometrial biopsy Showing endometritis Confirming doubtful cases Plenty of plasma cells High sensitivity – subtle cases Image source: Wikimedia commons

12. Differential diagnosis Ectopic pregnancy Acute appendicitis Ovarian cysts- ruptured/ torsion/ hemorrhage Endometriosis Any other acute abdomen

13. Treatment- oral/out patient Oral regimens for mild to moderate disease in out patient basis N. gonorrhoeae and C. trachomatis to be targeted Also to consider anaerobes , enteric gram negative rods in special situations

14. Recommended oral regimen, CDC 2015   Recommended intramuscular/ oral regimen 1 Ceftriaxone 250mg IM single dose plus doxycycline 100mg orally BD x 14 days with/without metronidazole 500mg orally BD x 14 days 2 Cefoxitin 2g IM in single dose and probenecid, 1g orally administered concurrently single dose Plus doxycycline 100mg orally BD x 14 days with/ without metronidazole 500mg BD x 14 days 3 Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime ) PLUS Doxycycline 100 mg orally BD x 14 days with/ without Metronidazole 500 mg orally BD x 14 days

15. NACO Guideline

16. Parenteral treatment Severe disease Hospitalized patients Who fail to show clinical improvement at 72 hours treatment with oral regimens H/o severe allergic reactions to penicillin

17. Recommended IV Regimens, CDC 2015   Recommended parenteral regimen 1 Cefotetan 2g IV BD PLUS Doxycycline 100mg orally OR IV BD x 14 days 2 Cefoxitin 2g IV every 6 hours PLUS Doxycycline 100mg orally OR IV BD x 14 days 3 Clindamycin 900mg IV TDS PLUS Gentamicin loading dose IV or IM(2mg/kg), followed by maintenance dose (1.5mg/kg) every 8 hours. Single daily dosing (3-5mg/kg) can be substituted. 4 Tubo ovarian abscess - clindamycin (450mg QID) or metronidazole (500mg BD) should be used to complete at least 14 days of therapy with doxycycline - for anaerobic coverage

18. Azithromycin based regimens Azithromycin as monotherapy (7 days)or in combination with metronidazole also has equal cure rate as (metronidazole with doxycycline, and cefoxitin) and ( doxycycline with amoxicillin/clavulanate) Ceftriaxone IM combined with Azithromycin 1 g weekly X 2weeks equivalent to ceftriaxone IM combined with 14 days of 100mg BD doxycycline Savaris RF, Obstet Gynecol. 2007 Jul;110:53-60 Bevan CD et al, J Int Med Res. 2003 Jan;31:45-54

19. When to hospitalise? Other surgical emergencies cannot be ruled out Tubo ovarian abscess Pregnancy Severe illness Lack of clinical response/ unable to follow out-patient regimens No significant differences in outcome between out and inpatients in mild and moderate diseases Ness RB et al, Am J Obstet Gynecol. 2002 May;186:929-37

20. Complications Tubo ovarian abscess Infertility Chronic pelvic pain Ectopic pregnancy Ovarian cancer Fitz – Hugh – Curtiz syndrome

21. Fitz-Hugh-Curtis syndrome Peri -hepatic inflammation Adhesions on the surface of the liver- violin string appearance Image source: Revzin MV et al, Radiographics . 2106;36:1579-96

22. Special situations - HIV Differences among sero -negative and positive individuals not well established Respond equally well to antibiotic regimens Microbial profile similar No recommendation for aggressive treatment/ hospitalization Irwin KL et al, Obstet Gynecol. 2000 Apr;95:525-34

23. Special Situation - Pregnancy Extremely rare in pregnancy Requires hospitalization – for closer monitoring of pregnancy outcomes No studies to support increased risk to fetus

24. PID and intra uterine devices (IUD) Increased risk in the first 3 weeks of IUD insertion Removal of IUD not recommended routinely Recommended in case of lack of clinical response after 72 hours of initiation of treatment Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. 2015 Jun 5;64(RR-03):1-137 Ross J et al. 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-14