W3-18 Pelvic Inflammatory Disease, Sexually Transmitted Disease - Lecture-2.pdf

Obgynae

1. Module: Women’s Health
TOPIC:
Sexually Transmitted
Infection and Pelvic
Inflammatory Disease

2. Objectives
1.To discuss the different lower and
upper genital tract infections
2.To discuss the treatment of choice of
the different genital tract infections
3.To discuss the complications of the
different genital tract infections

3. Sources
Comprehensive Gynecology 7
th
edition
Chapter 23
https://www.cdc.gov/std/tg2015/tg-2015-
print.pdf
https://www.cdc.gov/std/prevention/std-
clinic-guidance-during-covid-19-webinar-
5-12-2020.pdf

4. LECTURE OUTLINE
•InfectionsoftheVulva
•Bartholin’s glandabscess
•Ectoparasites
•DiseasescharacterizedbyUlcers
•HPV andAnogenitalWarts
•InfectionsoftheVagina
•DiseasesCharacterizedbyVaginal Discharge
•InfectionsoftheCervix
•DiseasesCharacterizedbyCervicitis

5. LECTURE OUTLINE
•InfectionsoftheUpperGenital Tract
•Pelvic InflammatoryDisease
•SexualAssault&STDs

6. TheFiveP’s
1.Partners
2.Practices
3.Preventionof
Pregnancy
4.Protectionfrom
STDs
5.Pasthistory of
STDs

7. VULVA
•Stratifiedsquamousepitheliumwithhair
folliclesandsweat,sebaceousand
apocrineglands
•AlsocontainsBartholin’sandSkene’s
glands
•Vulvarskinissensitivetohormonal,
metabolicandallergic influences
•Sensorynerveendingsaremore
numerousinthevulvarskinthaninthe
vagina

8. MostPrevalentPrimary
Infections
•Herpesgenitalis
•Condylomaacuminatum
•Molluscumcontangiosum

9. Signs &Symptoms of
VulvarInfection
•Vulvaritchingandburning
•Erythema
•Edema
•Superficialskinulcersofthevulva
•Skinfissures
•Excoriation

10. BARTHOLIN’S
GLANDS
•Locatedatentranceof
thevaginaat5o’clock
and7o’clock
•mostcommoncause:
cystic dilationof the
Bartholin’sduct
secondaryto
nonspecific
inflammationor
trauma.
•womenareusually
asymptomatic.

11. Infectionsofthe
Bartholin’sGlands
•Cystic dilationofBartholin’sduct
•Abscessof Bartholin’sgland
•Adenocarcinoma of Bartholin’sgland

12. INFECTIONSOFTHE
BARTHOLIN’SGLANDS
•thecystsmayvary from1to8cmin
diameter
•they areusuallyunilateral,tense,and
nonpainful.
•Signs of classic abscess:
•erythema,acutetenderness,
edema and occassionally
cellulitisofthesurrounding
subcutaneoustissue.

13. Treatment:
•asymptomatic cystsinwomenunderthe
ageof40donotneedtreatment.
•fora symptomatic cystorabscess→
developmentofa fistuloustractfrom
thedilatedducttothevestibule.
•Classicalsurgicaltreatment–developa
fistuloustractto“marsupialize” theduct

14. Marsupialization

15. Ectoparasites
•Pediculosispubis
•Scabies
•Molluscumcontangiosum

16. PediculosisPubis
•Pediculosispedisisaninfestationof the
crablouse,Phthiruspubis
•transmittedby closecontact,towelsor
beddings
•liceinpubic hairisthemostcontagiousof
allSTDs:90%singleexposure
•Confinedtohairyareasofthevulva
•Majornourishmentishumanblood

17. PediculosisPubis
•Lifecycle:egg(nit),nymph,adult
•Diagnosis:microscopic slidebyscratch
technique,placecrustunderdropof
mineral oil

18. TreatmentofPediculosis
Pubis
•permethrin(NixCrème)1%creamrinse,applied
toaffectedareasandwashedoffafter10
minutes
•Lindane(Kwell)1%asshampoo,appliedfor4
minutesthenthoroughlywashedoff
•Side effect:Seizureswhenappliedimmediately aftera
bath
•Notrecommendedforpregnant orlactatingwomen
orchildrenlessthanage2
•pyrethrins withpiperonylbutoxide appliedto
affectedareasandwashedoffafter10minutes

19. @hel
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20. Scabies
•Scabiesisaparasitic infectionof theitch
mite,Sarcoptesscabiei,transmittedby
closecontact,widespreadoverthebody
withoutapredilectionforhairyareas
•Itchmitetravelsrapidlyover skin,ableto
surviveonlyewhafoursawayfrom
warmthof skin
•Severebutintermittentitching,
predominantlyatnightwhenskinis
warmerandmitesaremoreactive

21. Scabies
•Scabiespresentaspapules,vesicles,or
burrows(pathognomonic),termedthe
“greatdermatologicimitator”
•Mostcommonlyinfectedareas:hands,
wrists,breasts,vulva,buttocks,examine
underhandheldmagnifyinglens
•Microscopicslides:scratchtechnique,
undermineraloil

22. Scabies

23. TreatmentofScabies
•Permethrin5%appliedtoallareasof the
bodyfromneckdownandwashedoff
after8to14hours
•Ivermectin0.2mg/kgorally,repeatedin
twoweeksif necessary
•Lindane1%1oz of lotionor30gofcream
appliedthinlytoallareasof thebody
fromneckdownandthoroughlywashed
offafter 8hours.
•Antihistamineforpruritus

24. CDC2015STDGuidelines

25. PediculosisPubisand
Scabies
•Treatmentprescribedforsexual
contactswithinprevious6weeksand
otherhouseholdcontacts
•Clothingandbeddingshouldbe
decontaminated
•Permethrin1%creamrinseforpubic lice
•Permethrin5%creamforscabies

26. Molluscum
contagiosum
•Asymptomaticviraldiseaseprimarilyof
thevulvarskin
•Causedbythepoxvirusandisspreadby
closecontact.Poxvirusdoesnotgrowon
mucousmembranes.
•Commongeneralizedskindiseasein
adultswithimmunodeficiency,
especiallyHIVinfection.

27. Molluscum contagiosum
•Characteristic skinlesion–
umbilicatedpapule.
•Smallnodulesordomed
papules-1to5mmin
diameter.
•“Waterwart”
•Incubationperiodis2to7
weeks

28. Molluscum contagiosum
•Infectedwomen=1to20solitary
lesionsrandomlydistributedoverthe
vulvarskin.
•Diagnosis
•simpleinspection
•whitewaxymaterial frominsidethenodule
shouldbeexpressedinamicroscopic slide
•Findings: intracytoplasmic molluscum
bodies(Wright’sorGiemsastain)

30. Molluscumcontagiosum
•Majorcomplication:bacterial
superinfection
•Aselflimitinginfection
•Treatmentofindividualpapules:
•Decreasetransmission
•Autoinoculationof thevirus

31. Molluscumcontagiosum
•InjectionofLA–subdermalwheal,
evacuationofcaseousmaterial andthe
noduleexcisedwithasharpdermal
curet.
•Chemicallytreatedwitheitherferric
subsulfate(Monsel’ssolution)or85%
trichloroacetic acid–baseofpapule.
•Alternative:cryosurgeryor
electrocautery

32. HumanPapillomavirus
•Anogenitalwarts

33. Condyloma
Acuminatum
•MostcommonviralSTD duetoHuman
Papillomavirus(HPV)infection
•Non-oncogenic,orlow-riskHPVtypes6
and11arethecauseofgenital warts
andrecurrentrespiratory
papillomatosis.
•Morethan50%of sexuallyactive
personsbecomeinfectedatleastonce
intheirlifetime.

36. Prevention
•TwoHPVvaccines:
•abivalentvaccine(Cervarix)
containingHPVtypes16and18
•aquadrivalentvaccine(Gardasil)
containingHPVtypes6,11,16
and18.

37. Prevention
•Bothvaccinesofferprotection
againstHPVtypesthatcause70%
ofcervicalcancers.
•QHPVprotectsagainstHPVtypes
thatcause90%ofgenitalwarts
(approvedforusein malesand
females9-26years)

40. CDC2015STDGuidelines

41. CDC2015STDGuidelines

42. CDC2015STDGuidelines

43. CDC2015STDGuidelines

44. Counseling
•AdiagnosisofHPVinonesexpartneris
notindicativeofsexualinfidelityinthe
otherpartner.
•Sexuallyactivepersonscanlowertheir
chancesofgettingHPVbylimitingtheir
numberofpartners.
•Genitalwartscommonlyrecurafter
treatment,especiallyinthefirst3
months.
CDC2010STDTreatmentGuidelines

45. Counseling
•WomenshouldgetregularPaptestsas
recommended,regardlessofvaccination
orgenitalwarthistory.
•If onesex partnerhas genitalwarts,
bothsexpartnersbenefitfromgetting
screenedforotherSTDs.
•Refrainfromsexualactivity untilthe
wartsaregoneorremoved.
CDC2010STDTreatmentGuidelines

46. Cervicalcancer
screening
•CurrentguidelinesfromUSPSTFand
ACOGrecommendthatcervical
screeningbeginatage21years.
•ACSrecommendsthatwomenstart
cervical screeningafter3yearsof
initiatingsexualactivitybutbynolater
thanage21years.

47. Hayden, a 23-year-old videographer is the next patient you see in the
clinic. Under the chief complaint, the nurse has written, “Wants a general
checkup.”You enter the room and greet a generally healthy-appearing
young, Filipino man, who seems anxious. He appears to have difficulty in
maintaining eye-to-eye contact with you.
Hayden tells you, “I have an ulcer…but not in my stomach.”He finally
admits that he has been worried about a lesion on his penis. He denies
pain or dysuria. He has never had any sexually transmitted diseases (STDs)
and has an otherwise unremarkable medical history.
Hayden is afebrile, and his examination is notable for a shallow clean ulcer
without exudates or erythema on the shaft of his penis, which is nontender
to palpation, and has a cartilaginous consistency. There are some small,
nontender, inguinal lymph nodes bilaterally.

48. Diseases
Characterizedby
GenitalUlcers
•Genitalherpes
•Granulomainguinale(Donovanosis)
•Lymphogranulomavenereum(LGV)
•Chancroid
•Syphilis

50. Chancroid
•Painfulgenitalulcer
•Tendersuppurativeinguinal
adenopathy
•Diagnosis:identificationofH.ducreyi

51. •Probablediagnosis
•Patient hasoneormorepainfulgenital
ulcers
•NoevidenceofT.palliduminfectionby
darkfieldexam
•Clinicalpresentation,appearanceofgenital
ulcerand+/-regionallymphadenopathy
•TestforHSVonulcerisnegative

52. CDC2015STDGuidelines

54. GenitalHSVInfection
•MostarecausedbyHSV-2
•Painfulmultiplevesicular/ulcerative
lesions
•Absent inmanyinfectedpatients

56. Diagnosis
•Cellculture
•PCR
•Typespecific serologic test

57. •Typespecificserologic test
•Recurrent genital symptomsoratypical
symptomswithnegativeHSVculture
•Clinicaldiagnosisof genitalherpeswithout
laboratoryconfirmation
•Apartnerwithgenitalherpes

58. MANAGEMENTOF
GENITALHERPES
•Antiviralchemotherapyoffersclinicalbenefits
tomostsymptomatic patientsandisthe
mainstayofmanagement.

59. SuppressiveTherapy
forRecurrentGenitalHerpes
•Suppressivetherapyreducesthefrequencyof genitalherpes
recurrencesby70%–80%
•manypersonsreceivingsuchtherapyreporthavingexperienced
no symptomaticoutbreaks

60. EpisodicTherapy
forRecurrentGenitalHerpes
Effectiveepisodictreatmentofrecurrentherpes requires
initiationoftherapywithin1dayoflesiononsetorduring
theprodromethatprecedes someoutbreaks.

61. CDC2015STDGuidelines

62. •SevereHSVdisease
•Acyclovir5-10mg/kgIVevery8hoursfor2-
7daysuntilwithclinicalimprovementthen
POantiviraltherapytocompleteatleast10
days

64. GranulomaInguinale
•Klebsiella granulomatis
(Calymmatobacteriumgranulomatis)
•Painless,slowlyprogressiveulcerative
lesionsongenitalsorperineum
•Noregionallymphadenopathy

65. •Diagnosis:
•Visualizationof darkstainingDonovan
bodiesontissuecrushpreparationor
biopsy

66. CDC2015STDGuidelines

68. Lymphogranuloma
Venereum
•C.trachomatisserovarsL1, L2orL3
•tenderinguinaland/orfemoral
lymphadenopathy
•unilateral

69. MANAGEMENT
CDC2015STDGuidelines

70. @helenvmadamba CDUCM 2016

71. Syphilis
•Treponemapallidum
•Primary,secondary,neurologic,tertiary
infection

72. PrimarySyphilis:
Chancre

73. SecondarySyphilis:
Palmar/PlantarRash

74. SecondarySyphilis:
Condylomalata

75. SecondarySyphilis:
Nickel/DimeLesions

76. TertiarySyphilis:
GummatousLesions

77. •Diagnostic:
•Nontreponemal tests
•VenerealDiseaseResearchLaboratory
•RPR
•Treponemal tests
•Fluorescenttreponemalantibodyabsorbed(FTA-
ABS)tests
•T. pallidumpassiveparticleagglutination(TP-PA)
assay

78. TreatmentforPrimaryandSecondary
Syphilis
CDC2015STDGuidelines

79. Treatment forLatentSyphilis
CDC2015STDGuidelines

81. CDC2015STDGuidelines

82. CDC2015STDGuidelines

83. Diseases Characterizedby
VaginalDischarge
•Bacterial vaginosis
•Trichomoniasis
•Vulvovaginal Candidiasis

84. VAGINA
•Normal vaginal pHapprox 4.0in pre-
menopausal women
•Estrogen stimulatesglycogencontentof
vaginal epithelial cells.
•Lactobacillus
•aerobic grampositiverod
•foundin62%to88%of asymptomaticwomen
•regulatorofnormalvaginalflora
•60%vaginallactobacillistrainsmake hydrogen
peroxide whichinhibitsthe growthofbacteria
•destroysHIVinvitro

85. VAGINA
•Lactic acid,pH3.8–4.5
•maintainsnormalvaginal
•inhibit adherenceofbacteriatovaginal
epithelial cells
•Normalphysiologic vaginaldischarge
•Epithelialcells
•Normalbacterial flora
•Water
•Electrolytes
•Otherchemicals

87. Symptomsofvaginal
infection
•Vaginaldischarge
•Superficialdyspareunia
•Dysuria
•Odor
•Vulvarburning
•Pruritus

88. DISEASESCAUSING
VAGINITIS
•Fungus
(Candidiasis)
25%
Protozoan
(Trichomoniasis) 25%
Bacterialinfection(Bacterial
vaginosis) 50%
•
•

89. •Vaginaldischargeisthemostcommon
symptomingynecology
•Theclinicaldiagnosisoftheetiologyof
vaginitisdependson:
•MeasurementofthevaginalpH
•KOHtest
•Examinationofthevaginalsecretionunder
themicroscope

90. Common VaginalInfections
Symptomssigns Examination
Findings
dishargepresentin
dependentportions
ofvagina
pH Wetmount
Normal Whitefloccularor
curdy,odorless
3.8–4.5
Bacterial
vaginosis
Increasedwhitethin
discharge,increased
odor
Thinwhitishgray
homogenous
dischargesometimes
frothy
Thickcurdy
discharge,vaginal
erythema
Yellowfrothy
dischargewith or
withoutvaginalor
cervicalerythema
>4.5
basic
Cluecells>20%
shiftinflora,
amineodorafter
KOHsmear
Hyphae or
spores
CandidiasisIncreasedwhitethick
discharge,pruritus,
dysuria,burning
Increasedyellow
frothydischarge,
increasedodor,
pruritus,dysuria
<4.5
Acidic
Trichomonas >4.5
Basic
Motile
trichomonads
Increasedwhite
cells

91. BACTERIAL VAGINOSIS
(BV)
•polymicrobial clinicalsyndrome
resultingfromreplacementof the
normalH
20
2-producingLactobacillussp
inthevaginawithhighconcentrations
ofanaerobicbacteria (e.g.,Prevotella
sp.and Mobiluncussp.),G.vaginalis,
andMycoplasmahominis.
•mostprevalentcauseof vaginal
dischargeormalodor.

92. BACTERIAL VAGINOSIS
(BV)
•Associatedwith:
•multiple maleorfemalepartners
•Anewsexpartner
•Douching
•Lackofcondomuse
•Lackofvaginal lactobacilli
•Womenwho haveneverbeensexuallyactivecan
also beaffected
•WomenwithBVareat increasedriskforthe
acquisitionofsomeSTDs(HIV,Ngonorrhoeae,
C trachomatisandHSV-2)

94. Amsel’sCriteria:
3of thefollowingsymptomsorsigns
•Homogeneous,thin,whitedischargethat
smoothlycoatsthevaginalwalls;
•Presenceofcluecellsonmicroscopic
examination;
•pHofvaginalfluid>4.5; and
•Afishyodorofvaginaldischargebeforeor
afteradditionof10%KOH(i.e.,whifftest).

95. Nugentcriteria
•Gramstainmorphologyscore(1-10)basedon
lactobacilli andothermorphotypes
•Ascoreof 1-2indicatesnormalflora
•Ascoreof 7-10bacterialvaginosis
•Highinterobserverreproducibility

96. Acceptablediagnostic testsfor
BV
•DNAprobe-basedtestforhighconcentrationsofG.
vaginalis(AffirmVPIII,BectonDickinson,Sparks,
Maryland)
•Aprolineaminopeptidasetestcard(PipActivity
TestCard,Quidel,SanDiego,California)
•OSOMBVBluetest
•PCR(forresearchpurposes)

97. @helenvmadambaCDUCM 2016

99. CDC2015STDGuidelines

100. CDC2015STDGuidelines

101. TRICHOMONIASIS
•causedbyTrichomonasvaginalis
•aunicellularprotozoonthatinhabitsthe
vaginaandlowerurinarytract,specially
theSkene’sglandinfemales.
•ahighlycontagioussexuallytransmitted
disease.
•Incubationperiod:4-28days

102. TRICHOMONIASIS
•Itisahardyorganismandwillsurvivefor
upto24hoursonawettowelandupto
6hoursonmoistsurface.
•Primarysymptom:
•profusefrothyvaginaldischargewithan
unpleasantodor
•diffuse,malodorous,yellow-greenvaginal
dischargewithvulvarirritation

104. HighRiskforinfection
•Womenwhohavenewormultiple
partners
•Haveahistory of STDs
•Exchangesex forpayment
•Useinjectiondrugs

105. Diagnosis
•Microscopyofvaginalsecretions,
withsensitivityof60%to70%
requiresimmediateevaluationof
wetpreparationslideforoptimal
results
•OSOMTrichomonasRapid Test(GenzymeDiagnostics,
Cambridge, Massachusetts)
AffirmVPIII (BectonDickenson,San Jose, California)
APTIMAT.vaginalisAnalyteSpecific Reagents(ASR,Gen-
Probe, Inc)
Cultureof vaginalsecretions
Liquid-based Paptest
•
•
•
•

106. CDC2015STDGuidelines
Sexpartnersof patientswithT. vaginalisshould be
treated.

107. VULVOVAGINAL
CANDIDIASIS
•causedbyCandidaalbicansand
occasionallybyotherCandidaspeciesor
yeasts
•associatedwithnormalvaginalph(<4.5)
•Atleast75%of womenwillhaveatleast
oneepisodeof VVCand40-45%willhave
twoormoreepisodeswithintheir
lifetime.

108. VULVOVAGINAL
CANDIDIASIS
•Symptoms:pruritus,vaginalsoreness,
dyspareunia,externaldysuriaand
abnormalvaginaldischarges
•Signs :vulvaredema,fissures,
excoriationsorthickcurdyvaginal
discharges
•Onthebasisof clinicalpresentation,
microbiology,hostfactors,responseto
therapy:uncomplicatedorcomplicated.

110. @helenvmadamba CDUCM2016

111. Miconazole1,2000mgvaginal
suppository,onesuppositoryfor
1day
Fluconazole150mgoral tablet,
onetabletinsingledose
@helenvmadamba CDUCM2016

112. CDC2015STDGuidelines

113. CDC2015STDGuidelines

114. Diseases
Characterizedby
Urethritisand
Cervicitis
•Gonococcalinfections
•Chlamydialinfections

115. CERVIX
•Thecervixactsasa barrierbetweenthe
abundantbacterialflora of thevagina
andthebacteriologicallysterile
endometrialcavityandoviducts

116. Cervicitis
•Vaginaldischarge,deepdyspareunia,
postcoital bleeding
•Cervix thatishypertrophicand
edematous
•Chlamydiatrachomatisisthemost
commonetiologic agent

117. Cervicitis
•Vaginaldischarge,deepdyspareunia,
postcoitalbleeding
•Cervix thatishypertrophic and
edematous
•Majorityofwomenwho have
mucopurulentcervicitisareinfectedby
C.trachomatisorN.gonorrhoeae
•Manywomenharboringsexually
transmittedpathogensinthecervix are
asymptomatic.

118. Mucopurulent Cervicitis
•Grossvisualizationof yellow
mucopurulentmaterial onawhite
cottonswab

119. Mucopurulent Cervicitis
•Presenceof 10ormorePMN
leukocytespermicroscopicfieldon
Gram-stainedsmearsobtainedfrom
theendocervix
•Erythemaandedemainanareaofcervical
ectopy
•Associatedwithbleedingsecondaryto
endocervicalulceration
•Friabilitywhenendocervicalsmearis
obtained

121. Chlamydia trachomatis
•mostfrequentlyreported
infectiousdisease
•prevalenceishigh among
personsaged25yearsorless
•mostserioussequelae:
•PID
•ectopicpregnancy
•infertility

122. Chlamydia trachomatis
•Diagnostics:urineorswab
specimenscollectedfrom
endocervixorvagina
•Others:
•culture
•directimmunofluorescence
•EIA

123. Chlamydia
trachomatis
Thiswoman’scervixhasmanifestedsigns
ofanerosionanderythemadueto
chlamydialinfection.
•Anuntreatedchlamydiainfectioncan
causesevere,costlyreproductiveand
otherhealthproblemsincludingboth
short-andlong-termconsequences

124. CHLAMYDIALCERVICITIS

125. Treatmentfornonpregnant
women
RecommendedRegimens
•Azithromycin1gorallyinasingledoseOR
•Doxycycline100mgorallytwiceadayfor7days
AlternativeRegimens
•Erythromycinbase500mgorallyfourtimesaday
for7daysOR
•Erythromycinethylsuccinate800mgorallyfour
timesadayfor7daysOR
•Ofloxacin300mgorallytwiceadayfor7daysOR
•Levofloxacin500mgorallyoncedailyfor7days

126. Treatmentforpregnant
women
RecommendedRegimens
•Azithromycin1g orally inasingle doseOR
•Amoxicillin500mg orallythrice adayfor 7days
AlternativeRegimens
•Erythromycinbase500mg orallyfour timesaday
for7daysOR
•Erythromycinbase250mg orallyfour timesaday
for14 daysOR
•Erythromycinethylsuccinate800mg orallyfour
timesaday for7daysOR
•Erythromycinethylsuccinate400mg orallyfour
timesaday for14days

127. CDC2015STDGuidelines

128. Neisseriagonorrhoeae
•secondmostcommonlyreported
bacterial STD.
•majorityofurethralinfectionscausedby
N.gonorrhoeae
•amongwomen,severalinfectionsdonot
producerecognizable symptomsuntil
complications(PID)haveoccurred.
•womenaged25yearsorlessareat
highestriskforgonorrheainfection.

129. Neisseriagonorrhoeae
•Riskfactorsincludepreviousgonorrhea
infection,othersexuallytransmitted
infections,newormultiplesex partners,
inconsistentcondomuse,commercial
sex work,anddruguse.
•Diagnostics:aGramstainof amale
urethralspecimenthatdemonstrates
polymorphonuclearleukocyteswith
intracellularGram-negativediplococci

130. Treatment
Ceftriaxone250mgIMinasingledose
OR
Cefixime400mgorallyina singledose
OR
Singledoseinjectablecephalosporin
regimens
PLUS
Treatmentforchlamydiaif chlamydial
infection isnotruledout

131. CDC2015STDGuidelines

132. CDC2015STDGuidelines

133. PelvicInflammatory
Disease
•Aninfectionintheuppergenital tract
notassociatedwithpregnancyor
intraperitonealpelvicoperations.
•Salpingitis–infectionof theoviductsis
themostcharacteristicandcommon
componentof PID.
Katzetal.2007. ComprehensiveGynecology.

134. PelvicInflammatory
Disease
•Aspectrumof inflammatory disorders
oftheupperfemalegenitaltract,
includinganycombinationof
endometritis,salpingitis,tubo-ovarian
abscessandpelvicperitonitis.
CDC.2010STDTreatmentGuidelines.

135. Fitz-Hugh-Curtis

136. AcutePID
•ascendinginfectionfromthebacterial
floraofthevaginaandcervixin>99%
ofcases
•<1%of cases,fromtransperitoneal
spreadofinfectiousmaterial from
perforatedappendix orintraabdominal
abscess
•Hematogenousandlymphatic spread
tothetubesorovaries

137. Riskfactors
●Menstruatingteenagers.
●Multiplesexualpartners.
●Absenceofcontraceptivepilluse.
●Previoushistory ofacutePID.
●IUDusers.
●Areawithhighprevalence of sexuallytransmitteddiseas

138. Protectivefactors
Contraceptivepractice
●Barriermethods,speciallycondom,diaphragm
withspermicides.
●Oralsteroidalcontraceptiveshavegottwo
preventiveaspects.
○Producethickmucus plugpreventing
ascent of sperm andbacterialpenetration.
○Decreaseindurationof menstruation,
creates ashorterintervalofbacterialcolo-
nizationof theuppertract.
●Monogamyor havinga partner whohad
vasectomy.
Others
●Pregnancy
●Menopause
●Vaccines:hepatitisB,
HPV

139. MajorSequelae ofPID
•Ectopic pregnancies:↑6to10-fold
•Chronic pain:↑4-fold
•Infertility:6%to60%dependingon
severity of theinfection,thenumber of
episodesandtheageofthepatient

140. ReductionofImpactofacute
PID
•AggressivetherapyforLGTI
•EarlydiagnosisandtreatmentofUGTI
•Primaryprevention:safesexual
practices
•Secondaryprevention:screeningfor
gonorrhea,chlamydia andactive
cervicitis,treatmentof partners,
educationtopreventrecurrent
infection

141. Silentorasymptomatic PID
•CDC emphasized:aggressivelytreat
womenif thereisanysuspicionof the
disease,becausethesequelaeareso
devastatingandtheclinicaldiagnosis
madefromthesymptoms,signsand
laboratory dataisoftenincorrect.

142. Microbiology
Acute PID is usuallya polymicrobialinfectioncausedby
organismsascending upstairsfromdownstairs.
➔Theprimary organismsaresexually
transmittedandlimited approximatelyto:
◆N. gonorrhoeaein30%
◆Chlamydiatrachomatisin30%
◆Mycoplasmahominisin10%.

143. Microbiology
➔Thesecondaryorganismsnormallyfoundinthe
vaginaarealmostalways associatedsooneror later.
Theseare:
◆Aerobicorganisms—non-hemolyticstreptococcus.
E.coli,groupBstreptococcusandstaphylococcus.
◆Anaerobicorganisms—
Bacteroidesspecies–
fragilisandbivius,
peptostreptococcusand
peptococcus.

144. Modeofinfection
●Theclassicconceptisthatthegonococcusascendsup
toaffectthe tubesthroughmucosalcontinuityand
contiguity.Thisascentisfacilitatedbythesexually
transmittedvectorssuchasspermandtrichomonads.
●Refluxofmenstrualbloodalongwith gonococci into
thefallopian
tubes istheotherpossibility.
●Mycoplasmahominisprobablyspreadsacross the
parametriumto affectthetube.
●Thesecondaryorganismsprobably affectthetube
through
lymphatics.
●Rarely,organismsfromthegutmayaffectthetube directly.
13

145. Pathology
theostiaresultsinpent up oftheexudateinsidethetube.
14
●Theinvolvementofthe tubeis almostalways bilateral
andusually
followingmensesduetolossofgenitaldefence.
●The pathological processisinitiatedprimarilyin the
endosalpinx.
●Thereisgrossdestructionof theepithelialcells,cilia
andmicrovilliand maybecomesedematousand
hyperemic(in severeinfection).
●Theexfoliatedcellsalong withthe exudatepour intothe
lumenofthe tubeandagglutinatethemucosal folds.
The abdominalostiumisclosedbytheindrawingofthe
edematousfimbriaeandby inflammatoryadhesions.
Theuterineendis closedbycongestion.Theclosureof
both

146. Pathology
producingovarianabscess.
15
●Dependinguponthevirulence,theexudatemaybe
wateryproducinghydrosalpinxorpurulent
producingpyosalpinx.
●The purulent exudatethenchangesthemicroenvironment
andfavors growthofotherorganismsresultingindeeper
penetrationandmoretissuedestruction.
●Therewill beadhesions ofthetubewiththe surrounding
structures.
●Onoccasions,the exudatepoursthroughtheabdominal
ostiumto
producepelvicperitonitisandpelvicabscessormayaffectthe
ovary

147. Differentialdiagnosis
Theclinicalconditionmaybeconfusedwith:
(1)Appendicitis
(2)) Disturbed ectopicpregnancy
(3)Torsionofovarianpedicle,
haemorrhageor ruptureofovarian
cyst
(4)) Endometriosis
(5)Diverticulitis
(6)Urinarytract infection
Thetwoconditions—acuteappendicitisanddisturbed
ectopicpregnancy
must be ruledout, becauseboth theconditionsrequireurgent
laparotomywhereasacutesalpingitisis tobetreatedconservatively.
27

148. 28

149. Investigations
●Apregnancytest shouldalwaysbeperformedto
excludetheimportant differentialdiagnosisof ectopic
pregnancy.
●Highvaginalandendocervicalswabs(highvaginalfor
Trichomonas vaginalis,Candidaand bacterialvaginosis,
endocervicalfor gonorrhoea andendocervicalfor Chlamydia)
shouldbetaken, payingattentionto using thecorrect
technique.
●Midstreamspecimenof urineshould besent for
microscopyandculture.
●FullbloodcountandC-reactiveprotein areimportantif
thewomanis systemicallyunwell,andureaand electrolytes
shouldbeanalysedifsheis vomiting.
●Serologicaltestfor syphilisshouldbecarriedout for both
thepartnersin
allcases.

150. Investigations
●Ultrasoundscanwillexcludea largetubo-ovarian
collection,butis usually normalwithPIDexceptfor
possiblefreeperitonealfluid, whichis a non-specific
finding.
●Culdocentesis:Aspirationofperitonealfluid andits
whitecell count, if exceeds30,000per mL. is
significantinacute PID.Bacterialculturefrom thefluid
is notinformativebecauseof vaginalcontamination.
●Investigationsarealso to beextendedtomale partner
and smearand
culturearemadefromurethralsecretion.
●Laparoscopyis indicatedifthediagnosisis
unclearor there is no responseto treatment
after 48hours.

151. Steps in the evaluation of
women suspected with PID
1. Abdominal Examination
2. Vaginal Speculum exam
3. Bi-manual examination
4. Collection of samples of cervico-vaginal
discharge (for microscopy, and NAAT)

152. Acute PID
More prominent
walls due to edema
Adjacent peritoneal
fat increase and
more prominent

153. Thickened uterine
serosa/adhesions
Tubal Blockage/hypoechoictubal
fluid = Pyosalpinx

154. Pyosalpinx–adjacent
peritoneal fat increase and
more prominent

155. Pyosalpinx: Thick walls
>5mm/hyperechoicmural
nodules (“COGWHEEL SIGN”)

156. Tubal hyperemia in color flow
mapping

157. Best marker of Tubal Inflammatory disease =
presence of incomplete septum of the tubal wall
Thick wall + cogwheel sign = Acute
Thin wall + beads on string = Chronic

158. Tubo-ovarian Complex
Ovaries inflamed
Ovaries adherent to the
fallopian tube but still
visualized as a discrete
structure
Dilated tube with
hypoechoicfluid
Hyperemia of tubal walls
and adhesions

159. Tubo-ovarian abscess

160. MRI TVS
Sensitivity95% 81%
Specificity89% 78%
Accuracy93% 80%

162. Chronic PID

167. Laparoscopy
24
●Laparoscopyis consideredthe"gold
standard".
●Whileitis the most reliable aid to support the
clinicaldiagnosisbut itmaynot be feasibleto
doinall cases.
●Itis reservedonlyinthose casesinwhich
differentialdiagnosisincludessalpingitis,
appendicitisor ectopicpregnancy.
●Laparoscopyhelpstoaspiratefluidorpusfor
microbiologicalstudyfromthefallopiantube,
ovaryorpouchofDouglas.
●Nonrespondingpelvicmass needs
laparoscopicclarification.

168. Laparoscopy
25
Laparoscopic findingsand severityof
PID:
●Mild:Tubes:edema,erythema,no
purulent exudatesandmobile.
●Mod: Purulentexudatesfromthe
fimbrial ends, tubesnotfreely
movable.
●Severe:Pyosalpinx,inflammatory
complex, abscess.
●‘Violinstring’likeadhesionsin
thepelvis andaroundtheliver
suggestschlamydial infection.

170. Treatment
To prevent reinfection.03
To prevent infertilityandlate sequelae.02
Tocontrol theinfectionenergetically.01
THE PRINCIPLES OF THERAPYARE:

171. Indicationsfor
hospitalization
•Surgical emergenciescannotbeexcluded
•Thepatientispregnant
•Thepatientdoesnotrespondclinically
to oral antimicrobial therapyfor 72
hours
•Thepatientisunableto followor
tolerateanoutpatientoral regimen
•Thepatienthassevereillness,nausea
and vomiting, orhigh fever
•Thepatienthastubo-ovarian abscess
CDC 2010STDTreatment
Guidelines

172. •Cefotetan2gIVevery12hoursOR
•Cefoxitin2gIVevery 6hoursPLUS
•Doxycycline100mgorallyorIVevery12
hours
CDC2015STDTreatmentGuidelines

173. CDC2015STDTreatmentGuidelines

174. CDC2015STDTreatmentGuidelines

175. CDC2015STDTreatmentGuidelines

176. •Discontinueparenteraltherapy24
hoursafterclinical improvement:
Doxycycline 100mgevery12hourstocomplete
14days
•Fortubo-ovarianabscess:
•Add oralclindamycinormetronidazole to
provide moreeffectiveanaerobic
coverage
CDC2010STDTreatmentGuidelines

177. Treatment
Indicationsofsurgery:
Theindicationsof surgeryarecomparatively
less.Theunequivocalindicationsare:
●Generalizedperitonitis.
●Pelvicabscess.
●Tubo-ovarianabscesswhichdoes not
respond(48–72hours) to antimicrobial
therapy.

178. Followup
•Clinicalimprovementwithin3days after
initiationoftherapy

179. Management ofSex
Partners
•Malepartnersof women whohavePID
causedbyC.trachomatisand/orN.
gonorrhoeaefrequentlyare
asymptomatic.
•shouldbeexaminedandtreatedifthey
hadsexualcontactduringthe60days
precedingthepatient’sonset ofsymptoms
•If>60days,must betreated
•Abstainfromsexualintercourseuntil
therapyiscompleted.
CDC2010STDTreatmentGuidelines

180. Management ofSexPartners
•Abstainfromsexualintercourseuntil therapyis
completed.
CDC2015STDTreatmentGuidelines

181. SEXUAL
ASSAULT&
STDs

182. Adolescents andAdults
•Trichomoniasis,bacterial vaginosis,
gonorrhea,andchlamydialinfectionare
themostfrequentlydiagnosed
infectionsamongwomenwhohave
beensexuallyassaulted.
•Chlamydialandgonococcalinfectionsin
womenareof particularconcern
becauseofthepossibility of ascending
infection.

183. •HBVinfectioncanbepreventedthrough
postexposurevaccination.
•HPVvaccinationisalsorecommended
forfemalesthroughage26years.
•Reproductive-agedfemalesurvivors
shouldbeevaluatedforpregnancy.
Adolescents andAdults

185. CDC2015STDGuidelines