PID and Inflammation.pptx OBS and gynaei

OBS and gynaei

1. PELVIC INFECTION AND INFLAMMATION BY MBELI MBELI JEDIDIAH REG: 2019-01-04939 SUPERVISED BY DR. SHARIFAH NAMUTEBI

2. OUTLINE Defence of the genital tract Pelvic inflammatory disease Clinical diagnostic criteria Investigation Complications Treatment Late sequele of PID Chronic pelvic infection Genital tuberculosis Actinomyces infection

3. DEFENSE OF THE GENITAL TRACT Vulvar defense : labia, Bartholin’s glands, natural resistance of vulvar and peritoneal skin Vaginal defense : transverse rugae, stratified epithelium, estrogen Cervical defense : mucus plug and its bactericidal effect. Uterine defense : cyclic shedding of the endometrium, closure of the uterine ostium of the fallopian tube with inflammation in the endometrium Tubal defense : integrated mucus plicae, epithelial cilia, peristalsis of the tubule and also movement of Cilia are towards the uterus.

4. ETIOLOGY Bacterial Pyogenic (50%): commonest causative organisms Aerobes Gram positive: Staphylococcus, Lactobacillus, Diphtheroids Gram negative: E.coli, Pseudomonas, Klebsiella, N. gonorrhoeae Anaerobes Gram positive: Streptococcus, Clostridium welchii, C. tetani, Peptostreptococcus Gram negative: mainly bacteroides commonly Bacteroides fragilis

5. ETIOLOGY STDs : N.gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, Herpes simplex virus type II, Human papilloma virus, Gardnerella vaginalis, Haemophilus ducreyi, HIV etc. Parasitic : Trichomonas vaginalis Fungal : Candida albicans Viral : HSV II, HPV, HIV Tubercular : Mycobacterium tuberculosis

6. MODES OF SPREAD OF INFECTION Through continuity(repeated) and contiguity(share boundaries)-gonococcal infection Through lymphatic and pelvic veins (postpartum or abortion infections)-pyogenic organisms other than gonococcal Through bloodstream-tubercular From adjacent infected extra genital organs like intestines

7. ACUTE PELVIC INFECTION Pelvic Inflammatory Disease (PID) Following delivery and abortion Following gynecological procedure Following intrauterine devices (IUD) Secondary to other infections

8. PELVIC INFLAMMATORY DISEASE It 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 (parametrium) It is attributed to the ascending spread of microorganisms from the cervicovaginal canal to the contiguous pelvic structures.

9. The infection may include any or all of the following anatomical sites and it is described as Endometritis Salpingitis Pelvic peritonitis Tubo -ovarian abscess Parametritis . Cervicitis is not included in the list..

10. Epidemiology A health hazard both in developed and more so in the developing countries. The incidence of pelvic infections on the rise due to the rise in STDs. The incidence varies from 1-2% per year among sexually active women. About 85% are spontaneous infection in sexually active females of reproductive age and the remaining 15% are due to procedures (endometrial biopsy, uterine curettage, insertion of IUD, hysterosalpingography) that favor the ascension of organisms. 2/3 are restricted for women <25yrs and remaining 1/3 among >30yrs

11. Risk factors Sexually active teenagers Younger age <19 years Multiple sexual partners Absence of contraceptive pill use Previous history of acute PID IUD users Lower socioeconomic status Husband/sexual partner with urethritis or STI Genetic predisposition

12. Protective factors Contraceptive use Barrier methods especially condoms, diaphragm with spermicides Oral steroidal contraceptives Others Pregnancy Menopause Vaccines: hepatitis B, HPV Postcoital washing

13. Microbiology PID is usually a polymicrobial infection caused by ascension of organisms The primary organisms are sexually transmitted and limited approximately to N.gonorrhoeae in 30%, Chlamydia trachomatis in 30% and Mycoplasma hominis in 10% The secondary organisms normally found in the vagina include nonhemolytic Streptococcus, GBS, Staphylococcus, Bacteroides, Peptococcus and Peptostreptococcus

14. Pathogenesis The involvement of the tubes is almost always bilateral and usually following menses due to loss of genital defense. The pathology is initially in the endosalpinx where there is gross destruction of the epithelial cells, cilia and microvilli. In severe infection, it invades all layers of the tube and produces acute inflammatory reaction, becomes edematous and hyperemic.

15. Depending on the virulence, the exudate may be watery producing hydrosalpinx (fallopian tube is blocked and filled with clear fluid) or purulent producing pyrosalpinx .(pus accumulation in the fallopian tube) . The accumulated purulent exudate then changes the microenvironment of the tube which favours the growth of other pyogenic and anaerobic organisms resulting in deeper penetration and more tissue destruction. On occasion the exudate pours through the abdominal ostium to produce pelvic peritonitis and pelvic abscess or may affect the ovary causing ovarian abscess. A tubo -ovarian abscess is formed.

16. Clinical features Symptoms These usually appear at the time and immediately after menstruation and are nonspecific. They include; Bilateral lower abdominal and pelvic pain which is dull in nature and radiating to the legs. The onset of pain is more acute and rapid in gonoccocal infection (3 days) than in chlamydial infection (5-7 days) Fever, lassitude and headache

17. Irregular and excessive vaginal bleeding( associated endometritis) Abnormal vaginal discharge which becomes purulent and copious Nausea and vomiting Dyspareunia(painful coitus) Pain and discomfort in the right hypochondrium (5-10%) of patients.

18. Clinical Diagnostic Criteria of Acute PID (CDC 2015) Minimum criteria Lower abdominal tenderness Adnexal tenderness Cervical motion tenderness Additional criteria Oral temperature >38C Mucopurulent cervical or vaginal discharge Abundant WBCs on saline microscopy of cervical secretions Raised C-reactive protein Elevated ESR Laboratory documentation of positive cervical infection with Gonorrhoea or C.trachomatis

19. Clinical Diagnostic Criteria of Acute PID Definitive criteria Histopathological evidence of endometritis on biopsy Imaging study (MRI) showing evidence of thickened fluid filled tubes and /or free pelvic fluid of tubo-ovarian complex Laparoscopic evidence of PID

20. Investigations Gram stain and culture Blood studies: leukocytosis (10,000 per cu mm) and elevated ESR value more than 15mm per hour Laparoscopy-gold standard Sonography- Fluid in the pouch of Douglas or adnexal mass are suggestive of PID Culdocentesis: aspiration of peritoneal fluid and its white cell count (30,000/mL)

21. Differential diagnosis Appendicitis Ruptured ectopic pregnancy Torsion of ovarian pedicle, haemorrhage or rupture of ovarian cyst Endometriosis Diverticulitis Urinary Tract Infection

22. Treatment The principles of therapy are; To control infection To prevent infertility and late sequelae To prevent reinfection Follow up examination of women within 48 to 72 hours for evaluation of response

23. Treatment Outpatient therapy Antibiotics: Ceftriaxone 250mg IM single dose or Cefoxitin 2g IM single dose and probenecid 1g PO single dose or injection Cefotaxime IV plus Doxycycline 100mg PO BD for 14 days with or without Metronidazole 500mg PO BD for 14 days Analgesics Adequate rest

24. Treatment Inpatient therapy Bed rest Restricted oral therapy IV fluids IV antibiotic therapy for at least 48 hours

25. Indications for hospitalization Suspected tubo-ovarian abscess Severe illness, vomiting, temperature >38C Uncertain diagnosis – where surgical emergencies cannot be excluded e.g. appendicitis Unresponsive to outpatient treatment for 48 hours Intolerance to outpatient oral antibiotics Coexisting pregnancy Patient is known to have HIV infection

26. Indications for surgery Generalized peritonitis Pelvic abscess Tubo-ovarian abscess which does not respond to antimicrobial therapy in 48-72 hours or there is rupture Life-threatening infections

27. Prevention Community-based approach to increase public health awareness Prevention of sexually transmitted infections with the knowledge of healthy and safer sex Liberal use of contraceptives Routines screening of high-risk population

28. PELVIC INFECTION FOLLOWING DELIVERY AND ABORTION Common causative organisms include anaerobic Streptococcus, Staphylococcus pyogenes, nonhemolytic streptococcus, E.coli and Bacteroides group. Usually polymicrobial hence cause difficult to pinpoint. The infection is either localized to the cervix, producing acute cervicitis or may affect the placental site producing endometritis. It may then spread to the myometrium, parametrium or tubal openings resulting in endomyometritis, parametritis or endosalpingitis .

29. Chief complaints include fever lower abdominal and pelvic pain and offensive vaginal discharge following abortion or delivery.

30. Continuation On admission, triple swabs – from high vagina, from the endocervix and from the urethra are taken and taken for culture, drug sensitivity test and Gram stain, prior to bimanual examination. Routine investigations such as blood and urine studies can also be done as well as ultrasonography. Definitive treatment pending sensitivity report include gentamycin 2mg/kg and clindamycin IV 600mg daily with IV metronidazole 500mg every 6-8 hours interval. Alterations are made if temperature does not subside after 48 hours according to the sensitivity and microbiology report.

31. These infections can be prevented by Aseptic birth measures. Avoiding traumatic vaginal birth, use of prophylactic antibiotics in delayed labour And encouraging family planning to avoid unwanted pregnancies.

32. PELVIC INFECTION FOLLOWING GYNAECOLOGICAL PROCEDURES Infection of residual pelvic organs or cellular tissues following hysterectomy is uncommon and is more vaginal than abdominal. Predominant causative organisms are E.coli and Bacteroides fragilis. Fever and lower abdominal or pelvic pain of varying degrees may appear 3-4 days after surgery. Offensive and purulent discharge may be observed on vaginal examination. Preoperative cleaning of the vagina with antiseptic lotion, perfect hemostasis during surgery could reduce postoperative infection.

33. IUCD AND PELVIC INFECTION One of the iatrogenic causes of pelvic infection in gynecology. All types of IUCD except hormone producing ones are responsible. Incidence ranges from 2-10% but the risk is more in nulliparous women. It may flare up preexisting pelvic infection. Bacteria may be carried from the cervix into the endometrium during insertion. Risk of PID is high during first month of insertion and in a patient with multiple sexual partners. It is better not to insert IUCD in cases of patients with recent history of PID and strict aseptic procedure should be followed during insertion.

34. CHRONIC PELVIC INFECTION A distressing clinical entity not only to patients but also to physicians. It results: Following delayed or inadequate initial treatment of acute pelvic infection. Following low grade recurrent infection. Tubercular infection

35. The pathology in the uterus is usually spared due to periodic shedding of the endometrium . The tubal changes are due to previous acute salpingitis resulting in loss of the epithelium especially in gonococcal infection and the walls are thickened with plasma cell infiltration and blocking of openings causing hydrosalpingitis .

36. Clinical features May remain asymptomatic Previous history of acute pelvic infection following child birth or abortion. Recurrent episodes of reinfection is often present. History of use of IUCD highly confirms the diagnosis.

37. Symptoms include chronic pelvic pain aggravated prior to menstruation, dyspareunia , congestive dysmenorrhea , lower abdominal pain, menorrhagia and polymenorrhagia , mucopurulent vaginal discharge, infertility. Tenderness on one or both iliac fossae and an irregular pelvic mass may be felt on abdominal examination.

38. Management Investigations Blood studies for ESR, WBC count, Hb estimation Urine examination Culture and sensitivity Laparoscopy to confirm the diagnosis General Improvement of general health and anemia. Analgesics as required.

39. Continuation Specific Removal of IUCD Antibiotic therapy for recent acute exacerbation Surgery : Laparoscopy or laparotomy indications include; Persistence of symptoms Recurrence of acute attacks Increase in size of pelvic mass Infertility

40. Examples of chronic pelvic infections Genital tuberculosis Caused by Mycobacterium tuberculosis of the human type. Secondary to primary infection elsewhere in the extra genital sites such as lungs (50%), lymph nodes, bones and joints. Fallopian tubes are the primary sites of infection affecting both tubes simultaneously and spread can be hematogenous (90%), lymphatic, ascending (rare) or direct to other organ.

41. Symptoms include low grade fever, weakness, anorexia, anemia, night sweats, menstrual abnormality (20-30%), chronic pelvic pain, postcoital bleeding. Major manifestations are Infertility, Menorrhagia, Chronic pelvic pain often associated with tubulo -ovarian mass, Blood stained vaginal discharge.

42. Investigations are done to confirm genital lesions and identify primary lesions such as blood studies, Mantoux test ( test sensitivity to tuberculoprotein ) PCR (85-95% sensitive) Gene Expert ( to detect M-TB and Rifampicin resistance. Biopsy ( from lymph nodes, cervix, vagina and vulva. Imaging : chest x-ray, hysterosalpingography ( for infertility), laparoscopy, MRI, abdominal and pelvic ultrasound, hysteroscopy.

43. Continuation Treatment includes admission, antitubercular chemotherapy (first choice) and surgery may be indicated when there is drug unresponsiveness. Vulvar tuberculosis Painful tender ulcer in the vulva. Confirmation is done by biopsy and treatment is the same as genital tuberculosis. Cervical tuberculosis Presenting complaints are mucopurulent discharge and postcoital bleeding. On speculum examination appears as an ulcerated growth that bleeds on touch.

44. Continuation Actinomyces infection A rare cause of upper genital tract infection caused by Actinomyces israelii, gram positive anaerobe. May be associated with IUCD users and more with noncopper devices Causes chronic endometritis and there may be foul smelling vaginal discharge. Symptoms include fever, abdominal pain, abnormal uterine bleeding may necessitate removal of the IUCD It is sensitive to penicillin, doxycycline or fluoroquinolones. Treatment should be continued for 12 weeks and a pap smear is repeated after 3 months following antibiotic therapy.

45. References DC Dutta’s Textbook of Gynecology 8 th Edition Williams Gynecology 3 rd Edition