Katie DePlatchett, M.D. AM Report January 4 th, 2010

Pelvic Inflammatory Disease An infection in the upper genital tract not associated with pregnancy or intraperitoneal pelvic operations

Anatomy 101

Epidemiology Annual incidence: 300,000 cases ~20% of 1.5 million cases of GC/Chlamydia 85% of infections are spontaneous in sexually active females. 15% of infections develop following procedures that break the cervical mucus barrier

Risk Factors age at first voluntary intercourse less than 18 nonuse of barrier contraception less than 12 years of education more than one male sexual partner in the previous 30 days prior gonorrhea infection intercourse during menses

Pathogenesis Ascending infection - Along mucosa - Bacterial colonization fallopian tubes & endometrium - Chlamydia trachomatis - Neisseria gonorrhoeae

Complications Tuboovarian abscesses Perihepatitis, also known as Fitz-Hugh–Curtis syndrome tubal factor infertility ectopic pregnancy chronic pelvic pain

Symptoms according to ACOG Abnormal vaginal discharge Pain in the lower abdomen (often of a mild, aching nature) Fever and chills Dysuria Nausea and vomiting Dysparunea

Diagnosis, per CDC Guidelines Minimum Criteria :  Sexually active  Lower abdominal tenderness or Adnexal tenderness or Cervical motion tenderness  No other plausible causes Routine Criteria:  Oral temperature >38° C  Abnormal cervical or vaginal discharge (mucopurulent)  Presence of abundant WBCs on microscopy of vaginal secretions  Elevated erythrocyte sedimentation rate  Elevated C-reactive protein  Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis

Diagnosis, per CDC Guidelines Definitive Criteria for Diagnosing PID Histopathologic evidence of endometritis on endometrial biopsy Transvaginal sonography or MRI showing thickened fluid-filled tubes with or without free pelvic or tuboovarian complex Laparoscopic abnormalities consistent with PID

Diagnosis Gold Standard = Direct visualization via the laparoscope However… operative laparoscopy during acute infection has not been proven to reduce the prevalence of long-term sequelae. Hence, the diagnosis of the majority of episodes of acute PID is made on the basis of clinical history and physical examination.

Imaging Ultrasonography sensitivity 75%–82% helpful in documenting an adnexal mass, especially during difficult pelvic examination (tenderness or BMI) CT sensitivity 90%–100%

CDC Ambulatory Management of Acute PID Levofloxacin 500 mg PO once daily for 14 days PLUS Metronidazole 500 mg PO bid for 14 days OR Ceftriaxone 250 mg IM in a single dose OR other parenteral third-generation cephalosporin PLUS Doxycycline 100 mg PO bid for 14 days Metronidazole 500 mg PO bid for 14 days

Admission Worthy Surgical emergencies (eg, appendicitis) cannot be excluded Pregnancy The patient does not respond clinically to oral antimicrobial therapy The patient is unable to follow or tolerate an outpatient oral regimen Severe illness, nausea and vomiting, or high fever The patient has a TOA (tuboovarian abscess)

Inpatient Treatment Cefotetan 2 g intravenously (IV) every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours “carefully monitored for an adequate response to antibiotics and any signs of rupture of the TOA and discharged after sufficient response to parenteral antibiotics is demonstrated “

Surgical Management life-threatening infections ruptured tuboovarian abscesses laparoscopic drainage of a pelvic abscess persistent masses in older women for whom future childbearing is not a consideration removal of a persistent symptomatic mass.

Back to our patient… Studies have demonstrated an overall 70% success rate with conservative medical management of TOAs Success of medical management has been demonstrated to be inversely proportional to the size of the TOA. Reed and colleagues evaluated 119 women with TOAs >10 cm  60% required surgery 4 to 6 cm  20% required surgery

What about IUDs?? Increase risk in developing PID in the first month after insertion The PID risk in IUD users is modified by: the number of sexual partners of the IUD user and that of her partner(s) community prevalence of STDs age of the IUD user Case reports of pelvic/abdominal actinomyces abscesses in IUD users, mostly out of Europe

Why Should You Care? Chronic Pain -- pelvic pain --dyspareunia -- abdominal pain

Why should you care? Lifetime cost of $1060 to $3180 per case. During 2008: $15.9 billion annually spent on tx of STDs $166 million was spent on treatment of chronic pelvic pain $295 million was spent on treatment of ectopic pregnancies $360 million was spent on infertility treatments as a direct result of previous PID infection.

What Can You Do? CDC recommends : 1. yearly chlamydia testing of all sexually active women age 25 or younger. 2. Older women with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners),

References Katz. Comprehensive Gyn, 5 th Ed Pelvic Inflammatory Disease and Tubo-ovarian Abscess. Infectious Disease Clinics of North America - Volume 22, Issue 4 (December 2008). Infectious Disease Clinics of North AmericaVolume 22, Issue 4 Centers for Disease Control and Prevention: 2006 Guidelines for treatment of sexually transmitted disease. MMWR 55:11, 2006 Intrauterine devices - upper and lower genital tract infections. Contraception Jun;75(6 Suppl):S41-7. Yeh J., Hook, III, IIIE., Goldie S.: A refined estimate of the average lifetime cost of pelvic inflammatory disease. Sex Transm Dis Rein D.B., Kassler W.J., Irwin K.L., et al: Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial. Obstet Gynecol