Ascending infection of the upper female genital tract and includes –Endometritis –Salpingo-oophritis –Pelvic peritonitis –Parametritis –Perihepatitis

Vaginal flora Lactobacilli Diphtheroids Staph. Epidermidis Strep. Fecalis GBS E.Coli C. Albicans G. Vaginalis B. Fragilis M. Hominis Peptococci Cl. Welchii Listeria Grade 1 (Normal) Grade III (Vaginosis)

Microbiology of PID STD N. gonorrhoea C. trachomatis Respiratory Pathogens H.Influenza Strep. Pyogenes Pneumococci Endogenous Pathogens G. Vaginalis E. coli Anaerobic streptococci B. Fragilis M. Hominis

How does the organism overcome the genital barrier? Menstruation Instrumentation Sperm transport IUCD

Adolescent PID Westrom in 1980 gave the following figures in sexually active adolescent girls Age in years Risk of PID 15 1/8 16 1/ /80 Why the incidence is high? Sexual activity Cervical ectopy Poor sex education

Factors That Enhance or Inhibit the Development of Acute Salpingitis Enhancing Factors Inhibitory Factors CervicitisCervical mucus N. gonorrhoea Bactericidal antibodies C. trachomatis Oral contraceptive s Endometritis Bacterial vaginosis Douching Intrauterine device

Risk factors Sexual PID Sexual activity Sexual partners Sex –During menses –Orogenital sex Non-sexual PID Instrumentation Pregnancy termination IUD-related Douching

Ascending infection

Incidence of PID Difficulty of estimation –Silent PID –Atypical PID –No confirmatory Lap. 3% of women have PID during their lifetime It is more in adolescents, blacks and prostitutes Risk of recurrence is 25%

Acute salpingitis

Pyosalpinx

Chronic PID

Manifestations of PID Essential criteria Tender lower abdomen Tender tubal points Cervical motion tenderness Additional criteria Fever > C (PO) Mucopurulent cervicitis Lab ESR > 40 mm/hr CRP > 5 mg% Leucocytosis > 10 4 /  l Positive smear Positive culture Serodiagnosis Elaborate criteria Plasma cell endometritis Sonography X-ray Culdocentesis Lap.

Fluid per culdocentesis BloodDisturbed ectopic Leaking corpus haematoma Retrograde menstruation PusLeaking TOA Appendicular abscess Diverticular abscess Cloudy fluidPeritonitis Adnexal torsion Ovarian cyst

Differential diagnosis of PID Spontaneous abortion Appendicitis Ectopic pregnancy Ruptured ovarian cyst Degenerating myoma Endometriosis IBD Diverticulitis

Atypical PID Silent PID Recurrent PID Fitz-Hugh-Curtis syndrome

Silent PID three times manifest PID 1. No clinical manifestations 2. Tubal infertility 3. Antibody to chlamydia trachomatis

Long-term sequelae of PID Infertility Ectopic pregnancy Pelvic pain –Hydrosalpinx –Pyosalpinx –Tubo-ovarian abscess –Pelvic abscess –Pelvic adhesion

Westrom in 1980 gave the following statistics Previous PIDInfertilityEctopic No 1 attack 2 attacks 3 attacks 10% 11% 23% 54% 0.5% 5% 10% 20%

Fate of tubal infection Recovery Tubal deciliation Tubal occlusion Pelvic abscess Pelvic adhesion

Chronic PID Tuberculosis Actinomycosis Schistosomiasis

Pelvic infection ItemPelvic abscessPelvic cellulitis CausePID Appendicitis Diverticulitis Post-hysterectomy Post-partum Post-cconisation MassFluctuant Tender Cul-de-sac Ill-defined diffuse Tender Side of pelvis Pain++++ FertilityImpairednormal ComplicationsRupturePointing in 7 site DVT Septic emboli TreatmentAntibiotic Colpotomy Antibiotic Heparin Drainage

Non-specific IBD ItemCrohn diseaseUlcerative colitis SiteSmall gut (Ileum) Large gut (Rectum) LesionGranuloma Transmural affection Skip area Fistulas Crypt abscesses Mucosal affection Diffuse No fistula AgeYoungAged CancerNoYes ResectionIs not curativeCurative

Prevention of PID Sex education Barrier contraceptives Antibiotic for high risks, HSG, IUCD Aggressive treatment

Indications for hospitalization Poor patient compliance Severe clinical disease Suspected anaerobiosis Uncertain diagnosis

General advice Bed rest (Fowler position) Avoidance of sex Treatment of male partner Screen for STD Any patient with fever and abdominal pain is not given antibiotic unless the diagnosis is certain or laparotomy is decided

Indications for laparoscopy Uncertain diagnosis Poor responders Recurrent case

Laparoscopic adhesiolysis

Antibiotic therapy Parenteral versus oral therapy Monotherapy versus multiple ones Before versus after microbial diagnosis

Inpatient regimen Regimen 1 Mefoxin 2g IV/6hr 1w doxycycline 100 mg bid 2 w Regimen II Dalacin 0.9 g IV/8hr 1w Garamycin 60 mg/8hr 1 w doxycycline 100 mg bid 2 w Antibiotic therapy Outpatient regimen Regimen 1 Mefoxin 2g IM doxycycline 100 mg bid 2 w Regimen II Amoxicillin 3g PO (Probenecid) doxycycline 100 mg bid 2 w

Failure of antibiotic therapy Question the diagnosis of PID Causes of failure –Capsule that protects from phagocytosis –L-form of bacteria –B-lactamase production

Fertility Surgery?????