Pelvic Inflammatory Disease Prof. Ihab Abdel Fattah

Definition: "Sweet 1985" Acute PID is the acute clinical syndrome attributed to ascending spread of micro-organisms from the vagina and endocervix to the endometrium, fallopian tubes, and / or contiguous structures. So it includes different grades of endometritis, salpingitis, oophritis, and peritonitis.

Epidimiology Secondary epidemic of PID following the Epidemic of STD, with a tertiary epidemic of infertility. Multiple sexual partners. Early age of sexual activity. Late seeking of medical advice Wide spread use of IUDs. Other contraceptives. Race: Non white. Use of vaginal douches. Tobacco use may affect the immune system and increase the risk of PID.

Pathogenesis Direct canalicular spread Endosalpingitis ( NG ). Menstruation - Loss of cervical mucous plug, braked endometrium, blood. attached to mucous, penetrate the cell, cell destruction. Cilia is destroyed. Fimbrial end Blocked to localize infection Spread of infection. Sperm migration into tubal lumen. Lymphatic spread: Perisalpingitis

Microbial etiology Multimicrobial NG C. Trachomatis Bacteroid Species. Bivis, Fragilis Peptococcus, peptostreptococcus. Verllonella parvula G. Vaginalis E. Coli Non hemolytic strept. Group B Strept. Coagulase -ve staph. Other gram -ve organisms. Actinomycetes Israeli.

Early Detection There is no standard screening for pelvic inflammatory disease (PID) at this time, but studies worldwide have found that routine screening of women who are at risk for sexually transmitted diseases (STDs) could reduce the number of cases of PID by nearly half.

Clinical Picture PID may be diagnosed when it is not actually present because it is better to treat every possible PID infection early to prevent any serious complications that can result if PID is left untreated.

Clinical stages of PID Clinical Picture: (Gainesville Stages) By Monif Stage I :Acute endometritis and / or salpingitis Stage II :Acute endometritis and / or salpingitis + peritonitis Stage III :+ Tubal Occlusion, Pyosalpinix, or Tubo- ovarian complex Stage IV :Ruptured TOA Stage V :Respiratory Complications e.g. TB

Pelvic Inflammatory Disease Minimum Diagnostic Criteria Uterine/adnexal tenderness or cervical motion tenderness Additional Diagnostic Criteria Oral temperature >38.3 C Elevated ESR Cervical CT or GC Elevated CRP WBCs/saline microscopy Cx discharge

Pelvic Inflammatory Disease Definitive Diagnostic Criteria Endometrial biopsy with histopathologic evidence of endometritis Transvaginal sonography or MRI showing thick fluid-filled tubes Laparoscopic abnormalities consistent with PID

Criteria for diagnosis of Acute PID: 1- History of lower abdominal pain and the presence of lower abdominal t enderness with or without evidence of rebound 2 - Cervical motion tenderness. 3- Adnexal tenderness. 4- History of sexual activity within 6 months. 5- Normal B- subunite of HCG. 6- U/S not suggestive of alternative diagnosis.

Plus on of these: Temperature >38oc. Leukocytosis > 10.5000 WBC/cmm. CRP is Positive. +ve culdocentesis for peritoneal fluid contaning WBCs or Bacteria. Inflammatory mass. Elevated ESR. More than 5 WBCs / HPF of direct smear , or +ve gram stain from the endocervix for intracellular diplococci of NG, or monoclonal antibody directed smear from the endocervix for C. Trachomatis.

Sequale and Complications: ( all may lead to surgical intervention) Infertility. Ectopic pregnancy. Chronic pelvic pain. Dysparonia. Pelvic adhesions. Residual pelvic inflammation

Treatment General measures: Fowler position. IV fluids. Analgesics, anti-inflammatory, antipyretics. Remove IUD.

Pelvic Inflammatory Disease Oral Regimen A Ofloxacin 400 mg twice daily for 14 days or Levofloxacin 500 mg once daily for 14 days WITH OR WITHOUT Metronidazole 500 mg twice daily for 14 days

Pelvic Inflammatory Disease Oral Regimen B Ceftriaxone 250 mg IM in a single dose or Cefoxitin 2 g IM in a single dose and Probenecid 1 g administered concurrently PLUS Doxycycline 100 mg twice daily for 14 days WITH or WITHOUT Metronidazole 500 mg twice daily for 14 days

Other regimes Amoxicillin- Clavulanic acid 375 mg and Doxycyclin 100mg, both orally twice daily for 14 days.

Follow up A follow-up examination should be performed 48 to 72 hours after treatment is started. Patients should have fewer symptoms and feel less pain when examined. If symptoms come back after treatment, other possible causes for the symptoms should be considered each time. It sometimes takes more than one course of medication treatment to cure PID. It is also possible that a reinfection has occurred or that the original diagnosis may not have been correct.

Pelvic Inflammatory Disease Hospitalization Surgical emergencies not excluded Pregnancy Clinical failure of oral antimicrobials Inability to follow or tolerate oral regimen Severe illness, nausea/vomiting, high fever Tubo-ovarian abscess

Indications of Hospitalization: Offered to all cases. suspected TOA. Temp. > 38oc. Uncertain diagnosis. Nausea and vomiting with oral treatment. Upper peritoneal signs. Failure to respond to ambulatory treatment for 48hr. Current immunodefeciency including HIV infection with low CD4 count.

Pelvic Inflammatory Disease No efficacy data compare parenteral with oral regimens Clinical experience should guide decisions regarding transition to oral therapy Until regimens that do not adequately cover anaerobes have been demonstrated to prevent sequelae as successfully as regimens active against these microbes, regimens should provide anaerobic coverage

At hospital Antibiotics may be given in pills or as a shot in a muscle, or IM or even IV.

Pelvic Inflammatory Disease Parenteral Regimen A Cefotetan 2 g IV q 12 hours or Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg orally/IV q 12 hrs

Pelvic Inflammatory Disease Parenteral Regimen B Clindamycin 900 mg IV q 8 hours PLUS Gentamicin loading dose IV/IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) q 8 hours. Single daily dosing may be substituted.

Pelvic Inflammatory Disease Alternative Parenteral Regimens Ofloxacin 400 mg IV q 12 hours or Levofloxacin 500 mg IV once daily WITH OR WITHOUT Metronidazole 500 mg IV q 8 hours Ampicillin/Sulbactam 3 g IV q 6 hrs PLUS Doxycycline 100 mg orally/IV q 12 hrs

Pelvic Inflammatory Disease Management of Sex Partners Male sex partners of women with PID should be examined and treated for sexual contact 60 days preceding pt’s onset of symptoms Sex partners should be treated empirically with regimens effective against CT and GC

Partner Treatment The partners should be screened for NG and CT and may those found +ve should be treated by a single IM injection of ceftriaxone 125mg plus 100 mg of doxycyclin orally twice daily for 7 days, or a single dose of 1 g oral dose of Azithromycin.

Surgical treatment: No need of laparoscopy to confirm diagnosis, except to exclude ectopic. Drainage of TOA, excision of the complex, adequate drainage, via laparotomy, laparoscopy, or post- colpotomy. Laparoscopic adhesiolysis and tuboplasty.

Chronic PID Chronic Non specific: Hydrosalpinx. Pyosalpinex. Tubo-ovarian complex. May be discovered accidentally during HSG, or Laparoscopy. Chronic pelvic pain. Infertility. Adnexal Swelling. Recurrent PID.

Management of Chronic PID Management is surgical via, laparotomy or laparoscopy. Management of tubal or tubo-peritoneal infertility. Management of tubo-ovarian abscess caused by A. israeli is by Procaine penicillin ( 4.8mU IM) for 3 months.

1-Chronic hydrosalpinx: A catarrhal endosalpingitis the fimbria are occluded and has a retort shape (fimbrial obstruction and tubal distention with nonpurulent fluid) develops if treatment is late or incomplete. The consequent mucosal destruction leads to infertility. Hydrosalpinx is generally asymptomatic but can cause pelvic pressure, chronic pelvic pain, or dyspareunia. The wall is thin and plicae are flattened. There is minimal adhesions and contains serous fluid. HSG: distended sac and liable to torsion, infection and rupture.

2-Chronic pyosalpinx: A purulent endosalpingitis, in which one or both fallopian tubes are filled with pus, may also be present. The fluid may be sterile, but WBCs predominate in it. Fimbria are destroyed and uterine end is closed. It is retort shaped. Its wall is thick opaque and plicae are destroyed and replaced by granulomatous tissue. There is extensive adhesions and contains pus. HSG: appears blocked at cornu and is liable to rupture or recurrent acute infections.

3-Tubo-ovarian cysts and abscesses Tubo-ovarian cyst is the result of communication between hydrosalpinx and functional ovarian cyst (follicular, lutein, tubo-ovarian abscess is the result of communication between pyosalpinx and an ovarian abscess. It develops in about 15% of women with salpingitis. It can accompany acute or chronic infection and may require prolonged hospitalization, sometimes with surgical percutaneous drainage. Rupture of the abscess is a surgical emergency, rapidly progressing from severe lower abdominal pain to nausea, vomiting, generalized peritonitis, and septic shock

4-Peritubal adhesions Peritubal adhesions or adhesions of the tube to the ovary or surrounding viscera may be the result of salpingitis or appendicitis, diverticulitis, cystitis. It causes: 1- Infertility due to interference with pick-up of ovum, or ovum transport, 2- Ectopic. 3- Pelvic pain.

5-Fitz-Hugh-Curtis syndrome: Can be a complication of gonococcal or chlamydial salpingitis. It is characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis. Acute cholecystitis may be suspected, but symptoms and signs of PID are present or develop rapidly.

Chronic specific Salpingitis: TB. Syphilis.