1. Pelvic Inflammatory Disease (PID)
Max Brinsmead PhD FRANZCOG
July 2011

2. This talk What is Pelvic Inflammatory Disease? Why it is important
How it is spread
Diagnosis
Treatment
Prevention

3. What is PID? Inflammation of female pelvic structures
Ascending spread of infection from the the cervix through the uterus, to fallopian tubes, ovaries and adjacent peritoneum
Upper genital tract infection
It is not infection in the vagina or vulva

4. Anatomy

5. PID comes in two forms... Acute Chronic
Patient has generalised symptoms
Lasts a few days
May recur in episodes
Very infectious in this stage
Chronic
Patient may have no symptoms
Occurs over months and years
Progressive organ damage & change
May burn out (arrest)

6. Why PID is important Affects up to 1:4 women in PNG
Many hospital admissions
Sometimes fatal
Chronic damage causes infertility
Predisposes to ectopic pregnancy
Can affect a baby during birth
Lung inflammation
Eye infections
Is a common cause of chronic menstrual problems

7. Cause of PID
85 – 95% is due to specific sexually transmitted organisms
Neisseria gonorrhoea
Chlamydia trachomatis
Others e.g. Mycoplasma species
5 – 15% begins after reproductive tract damage
From pregnancy
From surgical procedures e.g. D&C
Includes insertion of IUCD

8. Cause of PID (2) Endogenous infection occurs from commensal organisms
Anaerobes e.g. Bacteroides
Aerobes e.g. E Coli, Streptococcus species
Actinomycosis with IUCD
A smaller number of PID is due to Tuberculosis (TB)
Bloodborne spread after primary lung infection

9. Etiology
Infection can occur after procedures that break cervical mucous barrier
The adult vagina is lined by stratified squamous epithelium like skin
But the cervix has mucous to receive sperm
Organisms can access higher when mucous is receptive
Endometrium sheds regularly so is infrequently a site of chronic infection
Fallopian tubes and peritoneum should be sterile

10. Chlamydia trachomatis
Produces a mild form of salpingitis
Slow growing in culture (48-72 hr)
An intracellular organism
Insidious onset
Remain in tubes for months/years after initial colonization of upper genital tract
Can cause severe damage/changes over long periods

11. Neissera gonorrhoea Gram negative Diplococcus
Grows rapidly in culture (doubles every min)
Causes a rapid & intense inflammatory response
May occur after prior Chlamydia infection
More likely to be symptomatic in the male partner

12. Risk Factors for PID Age of 1st intercourse Number of sexual partners
Number of sexual contacts by the sexual partner
Cultural practices
Polygamy,
Prostitutes
Attitudes to menstruation and pregnancy
Frequency of intercourse (Age)
IUCD design
Poor health resources
Antibiotic exposure (resistance)

13. Pathology

14. Uterus, Bilateral Fallopian Tubes, and OvariesC F O M
U: Uterus
C: Cervix
F: Fallopian Tube
O: Normal Ovary
M: Inflamed Tubo-
Ovarian Mass
Note the hemorrhagic, oedematous fallopian tubes, architecture of the right tube and ovary is obscured. The surface of this tubo-ovarian mass is red and shaggy.
This fibrinogen exudate is deposited as fibrin, a sign of increased vascular permeability.

15. Normal Fallopian Tube - Low Power
M: Mucosal Folds
L: Lumen
W: Wall of Tube
Note the delicate mucosal folds lined by epithelium and a vascularized stroma. There are no inflammatory cells in the lumen or in the mucosa.

16. Fallopian Tube – from a PIDW M L
W: Muscular Wall
M: Inflamed Mucosa
L: Lumen with Inflammatory
Cells
Notice the inflammatory infiltrate in the mucosa and muscular wall. Inflammatory cells have nearly obscured the lumen.

17. Diagnosis of PID
Requires a high index of suspicion in a patient “at risk” when there is:
Lower abdominal pain (90%)
Fever (sometimes with malaise, vomiting)
Mucopurulent discharge from cervix
Pelvic tenderness
Tests
Raised WCC
Endocervical swab for organisms or PCR
Ultrasound evidence of pelvic fluid collections
Laparoscopy

18. Fitz-Hugh-Curtis

19. Fitz-Hugh-Curtis Syndrome
Perihepatic inflammation & adhesions
Occurs with 1 – 10% acute PID
Causes RUQ and pleuritic pain
May be confused with cholecystitis or pneumonia

20. Endometritis (thickened heterogenous endometrium)

21. Hydrosalpinx (anechoic tubular structure)

22. Hydrosalpinx.

23. Differential Diagnosis for PID
Endometriosis
Appendicitis & other gastro conditions
Appendicitis is unilateral and right sided
PID is bilateral
Ectopic pregnancy
Always do a pregnancy test
Urinary tract infection or stone
“Ovarian cysts”
Lower genital tract infection

24. PID Sequelae Chronic Pelvic Pain (15-20 %)
Ectopic pregnancy (6-10 fold ↑Risk)
At least 50% of tubal pregnancies have histology of PID
Infertility (Tubal)
10 – 15% after one episode
20% ~ 2 episode
>40% ~ 3 episodes
Recurrence of acute PID at least 25%
Male genital disease in 25%

25. Treatment of PID Antibiotics Surgical Rest and analgesia
Needs appropriate spectrum of activity
Specific or broad spectrum?
Issues of compliance
Oral or parenteral?
Follow current guidelines
Surgical
Drain abscess
Selective or radical removal
Rest and analgesia
NSAID’s useful

26. Antibiotic Therapy Gonorrhea : Cephalosporins, Quinolones
Chlamydia: Doxycycline, Erythromycin & Quinolones (Not cephalosporins)
Anaerobic organisms: Metronidazole, Clindamycin and, in some cases, Doxycycline.
Beta hemolytic Streptococcus and E. Coli Penicillin derivatives, Tetracyclines, and Cephalosporins , Gentamicin.

27. Follow up for PID
Partner or sexual contact tracing and testing or treatment
Look for other STD’s
STS, Hep B and HIV
Lower genital tract infections
Counselling and support
Pregnancy care

28. Criteria for hospitalization

29. Special Situations Pregnancy - Augmentin or Erythromycin
- Hospitalization
Concomitant HIV infection
- Hospitalization and i.v. antimicrobials
- More likely to have pelvic abscesses
- Respond more slowly to antimicrobials
- Require changes of antibiotics more often
- Concomitant Candida and HPV infections

30. Prevention of PID Screen & treat asymptomatic disease
Sexual health counselling
Barrier contraceptives
Progestin-based contraception
COC & POP
Depot and Implanon
?Mirena
Sexual fidelity or abstinence
Improving the education and status of women

31. PID – What we have covered
What it is
Why it is important
How it is spread
How it is diagnosed
How it is treated
How it might be prevented

32. Any Questions?
Thank you