1. Pelvic Inflammatory Disease

2. PID: A Neglected Issue • Low disease awareness
• Sub-optimal management
• 50% named correct antibiotic regimen
• < 25% examined the sexual partners

3. Objectives • What is Pelvic Inflammatory Disease?
• Why is it important to treat timely?
• Causative factors and transmission?
• How does the patient present?
• Treatment Plan?
- Drug therapies
- Surgical procedures
- Follow up

4. PID
Incidence acute PID 1-2% of young sexually active women each year 85% of infection in sexually active female of reproductive age 15% of infection occur after procedures that break cervical mucous barrier

5. What is PID ? • Acute/ Chronic clinical syndrome
Spectrum disease involve cx, uterus, tubes, and ovaries
• Ascending spread of infection from the vagina and endocervix to the endometrium, fallopian tubes, ovaries, &/ or adjoining structures
• Upper genital tract infection, salpingitis endometritis, parametritis, tubo-ovarian abscess & pelvic peritonitis

6. Transmission • Sexual transmission via the vagina & cervix
• Gynecological surgical procedures
• Child birth/ Abortion
• A foreign body inside uterus (IUCD)
• Contamination from other inflamed structures in
abdominal cavity (appendix, gallbladder)
• Blood-borne transmission (pelvic TB)

7. Pathogenesis

8. Predisposing Factors • Frequent sexual encounters, many partners
• Young age, early age at first intercourse
• Exposure immediately prior to menstruation.
• Relative ill-health & poor nutritional status.
• Previously infected tissues (STD/ PID)
• Frequent vaginal douching

9. Predisposing Factors Increase risk IUD user (multifilament string
surgical procedure
previous acute PID
Reinfection  untreated male partners 80%
Decrease risk
- barrier method
- OC
Risk factors

10. Infective Organisms • Sexually transmitted - Chlamydia trachomatis
Neisseria gonorrhoeae
• Endogenous Aerobic – Streptococci
Haemophilus
E. coli
• Anaerobes - Bacteroides, Peptostrptococcus
- Bacterial Vaginosis
- Actinomyces israelii
• Mycoplasma hominis, Ureaplasma
• Mycobacterium tuberculosis & bovis

11. C. trachomatis slow growth (48-72 hr) intracellular organism
insidious onset
remain in tubes for months/years after initial colonization of upper genital tract
more severe tubes involvement

12. N. gonorrhoeae gram –ve diplococcus rapid growth (20-40 min)
rapid & intense inflammatory response
2 major squeals : infertility & ectopic pregnancy, strong asso. with prior Chlamydia infection

13. Why is it Important to Treat PID ?
• Systemic upset / Tubo-ovarian abscess
• Chronic Pain (15-20 %)→ Hysterectomy
● Ectopic pregnancy (6-10 fold)
● Infertility (Tubal): 20% ~ 2 episodes % ~ 3 episodes
● Recurrence (25%)
● Cancer Cervix/ Ovarian Cancer ?

14. Presentation: Acute PID
• Severe pain & tenderness lower abdomen
• Fever, Malaise, vomiting, tachycardia
• Offensive vaginal discharge
• Irregular vaginal bleeding
• B/L adnexal tenderness
• cervical excitation
• Tubo-ovarian mass
• Fitz-Hugh-Curtis Syndrome
Poor sensitivity & specificity
Correct diagnosis : 45 – 70%

15. Presentation: Chronic PID
• Chronic lower abdominal pain, Backache • General malaise & fatigue • Deep dyspareunia, Dysmenorrhea • Intermittent offensive vaginal discharge • Irregular menstrual periods • Lower abdominal/ pelvic tenderness • Infertility •Bulky, tender uterus

16. PID: Differential Diagnosis
Ectopic Pregnancy
Torsion/ Rupture adnexal mass
Appendicitis
Endometriosis
Cystitis/ pyelonephritis

17. Laboratory Studies • Pregnancy test • Complete blood count, ESR, CRP
• Urinalysis
• Gonorrhea, Chlamydia detection (Gram
stain/ Cultures / ELISA/ DNA )
• Tests for TB, syphilis, HIV
• Pelvic Ultrasound
• Culdocentesis
• Laparoscopy

18. Treatment Therapeutic goal eliminate acute infection & symptoms
prevent long-term sequelae

19. Sequelae Ectopic pregnancy increase 6-10 fold
50% occur in fallopian tubes (previous salpingitis)
mechanism ; interfere ovum transport entrapment of ovum

20. Sequelae Chronic pelvic pain TOA 10% Mortality
4 times higher after acute salpingitis
caused by hydrosalpinx, adhesion around ovaries
should undergo laparoscope  R/o other disease
TOA 10%
Mortality
acute PID 1%
rupture TOA 5-10%

21. Sequelae Infertility ¼ of pt have acute salpingitis
infertility rate increase direct with number of episodes of acute pelvic infection

22. Endometritis (thickened heterogenous endometrium)

23. Hydrosalpinx (anechoic tubular structure)

24. Hydrosalpinx.

25. Pyosalpinx (tubular structure with debris in adnexa

26. Tuboovarian abscess resulting from tuberculosis

27. Right hydrosalpinx with an occluded left fallopian tube

28. Syndromic Diagnosis of PID Minimum Criteria for Diagnosis (CDC 2002)
• Lower abdominal tenderness on palpation • Bilateral adnexal tenderness • Cervical motion tenderness No other established cause Negative pregnancy test

29. Additional Criteria (CDC 2002)
• Oral temperature > 38.3°C (101°F)
• Abnormal cervical / vaginal discharge
• Elevated ESR
• Elevated C-reactive protein
• WBCs on saline micro. of vaginal sec.
• Lab. documentation of cervical infection with
N. gonorrhoeae/ C. trachomatis

30. Definitive Criteria (CDC 2002)
• Endometrial biopsy with histopathology
evidence of endometritis
• TVS/ MRI: Thickened fluid filled tubes/
free pelvic fluid / tubo-ovarian complex
• Laparoscopic abnormalities consistent with PID

31. Management Issues • Inpatient vs. outpatient management ?
• Broad-spectrum antibiotic therapy
without microbiological findings vs.
Antibiotic treatment adapted to the
microbiological agent identified ?
• Oral vs. Parenteral therapy?
• Duration of the treatment ?
• Associated treatment ?
• Prevention of re-infection ?

32. Criteria for Hospitalization (CDC 2002)
• Surgical emergencies can not be excluded (appendicitis)
• Severe illness/ nausea/ vomit/ high fever
• Tubo-ovarian abscess
• Clinical failure of oral anti-microbials
• Inability to follow/ tolerate oral regimen
• Pregnancy
• Immunodeficient (HIV ē low CD4 counts,
immunosuppressive therapy)

33. Antibiotic Therapy Gonorrhea : Cephalosporin , Quinolones
Chlamydia: Doxycycline, Erythromycin & Quinolones (Not to cephalosporin)
Anaerobic organisms: Flagyl, Clindamycin and in some cases to Doxycycline.
Beta hemolytic streptococcus and E. Coli Penicillin derivatives, Tetracycline, and Cephalosporin. E. Coli is most often treated with the penicillin or gentamicin.

34. Antibiotic Regimens (CDC 2002)
Parenteral regimen A
Cefoxitin 2 g IV q 6h / cefotetan 2 g IV q 12h +
Doxycycline 100 mg PO/IV q12h +
Metronidazole or Clindamycin (TO abscess)
Parenteral regimen B
Clindamycin 900 mg IV q 8h +
Gentamicin Loading dose 2 mg/kg IV/IM,
maintenance 1.5 mg/kg IV/ IM q 8h

35. Other 2nd/ 3rd Generation Cephalosporins
Ceftizoxime - Cefizox,
Cefotaxime - Omnatex,
Ceftriaxone - Monocef,
Cefoperazone - Magnamycin,
Ceftizidime - Fortum

36. Alternative Parenteral Regimens (CDC 2002)
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

37. Outpatient Antibiotic Therapy Regimen A (CDC 2002)
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

38. Outpatient Antibiotic Therapy Regimen B (CDC 2002)
Ceftriaxone 250 mg IM once OR
Cefoxitin 2 g IM ē probenecid 1 g PO once +
Doxycycline 100 mg PO bid for 14
WITH OR WITHOUT
Metronidazole 500 mg BD x 14 d

39. Surgical treatment Laparotomy for Laparoscopy
surgical emergencies
definite Rx of failure medical treatment
Laparoscopy
consider in all pt with ddx of PID & without contraindication
R/O surgical emergency
Evidence of current / previous abscess
Acute exacerbation of PID with bilateral TOA

40. PID

41. CDC Recommendations regimens
• No efficacy data compare parenteral with oral
regimens
• Clinical experience should guide decisions reg. transition to oral therapy

42. When should treatment be stopped ?
• Parenteral changed to oral therapy after 72 hrs, if
substantial clinical improvement
• Continue Oral therapy until clinical & biological signs (leukocytosis, ESR, CRP) disappear or for at least 14 days
• If no improvement, additional diagnostic tests/ surgical intervention for pelvic mass/ abscess rupture

43. Fitz-Hugh-Curtis syndrome :
1-10%
perihepatic inflammation & adhesion
s/s ; RUQ pain, pleuritic pain, tenderness at RUQ on palpation of the liver
mistaken dx ; acute cholecystitis, pneumonia

44. Fitz-Hugh-Curtis

45. Associated treatment Rest at the hospital or at home
Sexual abstinence until cure is achieved
Anti-inflammatory treatment
Dexamethasone 3 tablets of 0.5 mg a day or Non steroidal anti-inflammatory drugs
Oestro-progestatives: contraceptive effect + protection of the ovaries against a peritoneal inflammatory reaction + cervical mucus induced by OP has preventive effect against re-infection.

46. Conclusion ● PID in women - “Silent epidemic” health professionals.
● Can have serious consequences.
● Be aware of limitations of clinical diagnosis.
● Adequate analgesia and antibiotics.
● Proper follow up is essential.
● Treatment of male partner
● Educational campaigns for young women and
health professionals.
● Prevention by appropriate screening for STD
and promotion of condom usage.

47. THANK YOU