PID

Pelvic Inflammatory Disease

Conditions causing acute pelvic pain

Defence mechanisms

Pelvic inflammatory disease (PID)

is an infection of the upper genital tract in females, which affects the uterus, fallopian tubes and ovaries.

Classification

accoding to aetiology (specific (NG and TB) vs non-specific (staph, strep, E.coli, proteus, clamydia trachomatis, mycoplasma hominis, viruses etc)according to clinical picture (acute vs chronic)according to localisation (lower GTI - vulvovaginitis, cervicitis vs upper GTI - salpingitis, endometritis, pelviperoitonitis)according to history of recent delivery (puerperial vs non-puerperial)

hydrosalpinx vs pyosalphinx

FINALLY SEPTICAEMIA

It is a relatively common condition, with a diagnosis rate in primary care of approximately 280/100,000 person-years. It has the highest prevalence in sexually active women aged 15 to 24.

In this article we shall look at the pathophysiology, clinical features and management of pelvic inflammatory disease.

Chronic PID can be misdiagnosed with endometriosis

Pathophysiology

elvic inflammatory disease refers to an infective inflammation of the endometrium, uterus, fallopian tubes (salpingitis), ovaries and peritoneum. It is caused by the spread of bacterial infection from the vagina or cervix to the upper genital tract.

Chlamydia trachomatis and Neisseria gonorrhoea are responsible for approximately 25% of cases, with other bacteria such as Streptococcus, bacteriodes and anaerobes also implicated.

Risk Factors

The risk factors for pelvic inflammatory disease include:

Sexually active

Aged under 15-24 (mestruating teenagers!)

Recent partner change, multiple, affected

Intercourse without barrier contraceptive protection

History of STIs

Personal history of pelvic inflammatory disease

IUD users

absence of contraceptive use !!??

Pelvic inflammatory disease can also occur via instrumentation of the cervix – inadvertently introducing bacteria into the female reproductive tract. Such procedures include gynaecological surgery, termination of pregnancy (septic abortions), and insertion of an intrauterine contraceptive device.

ALso miscarriages + normal pregnancy too

Clinical Features

The signs and symptoms of pelvic inflammatory disease are elicited from the medical and sexual history, and a gynaecological examination. Whilst it can be asymptomatic, symptoms include:

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In advanced cases, women can experience severe lower abdominal pain, fever (>38° C), and nausea and vomiting.

On vaginal examination, there may be tenderness of uterus/adnexae or cervical excitation (on bimanual palpation). There may be a palpable mass in the lower abdomen, with an abnormal vaginal discharge noted.

By clinical, meaning by history and examination. When they ask how to diagnose always start with how to diagnose or suspect clinically!!!!!!!

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earlier most common cause used to be gonoorhea but now with the rampant use of antiobiotics the most common cause is now chlamydia

Most common cause of acute PID?

Most of chlamydia infections are actually aympomatic, slowly eating away at the fallopian tube abd presenting with infertility years later. (chronic)

Differential Diagnosis

The differential diagnoses for pelvic inflammatory disease include:

Disturbed Ectopic pregnancy (a pregnancy test is mandatory to exclude this) (need to be ruled out due to urgent laparotomy)

Appendicitis (need to be ruled out coz urgent laparotomy)

Haemorrhage or Ruptured ovarian cyst or torsion of ovarian pedicale

Endometriosis

Divercutolosis

Urinary tract infection

symptoms isnt needed for the minimum criteria

cervicsal tenderness actually denotes inlfaamtion of the peritoneal lining of the cervix

what are the ultrasound findings?

tubo-ovarian mass or fluid in tubes and uterus...hydrosalpinx

What are the lap findings?

distended tubes, pus coming off of tubes or abcess.

can diagnose clinically and treat...no need to go for the definitive crtieria unless theres suspicion....

then can go for a definitive criteria and diagnose defnietely..but otherwise clinically is enough

also tuboovairan mass should also be interpreted with clinical findigns like fever and pain....then we can say its an abcess

NEED TO RESORT TO DEFINITIVE CRITERIA only under certain clinical suspicion and mostly when investigating for other pesentations like inferitlity. then can diagnose definietely even without symptoms.

adhesions in laporocopy and special kind of adhesions under the liver from pelvic inflammation is the sydrome.

Investigations

The initial investigations in suspected pelvic inflammatory disease involves identifying the infective organism.

High vaginal and Endocervical swabs (high vaginal for trichomonas vaginalis, candida and bacterial vaginosis, endocervical for gonorrhea and clamydia) should be taken to test for gonorrhea and chlamydia, and a high vaginal swab for trichomonas vaginalis and bacterial vaginosis. In the UK, testing is via nucleic acid amplification (NAAT). Negative swabs do not exclude the diagnosis.

Further investigations include:

Blood culture

Full STI screen – (HIV, syphilis, gonorrhoea and Chlamydia as a minimum) should be offered to all women with PID.

Urine dipstick +/- MSU – to exclude urinary tract infection (M&C)

FBC and CRP if systemically unwell. U&E if vomitting.

Pregnancy test – to exclude pregnancy.

Transvaginal ultrasound scan – if there is severe disease or diagnostic uncertainty.

Laparoscopy – used to observe gross inflammatory changes, and to obtain a peritoneal biopsy. This is indicated only in severe cases where there is diagnostic uncertainty or no response to treatment after 48 hours.

Serological test for syphilis for both partners

Management

instead of cefttriaxone can take IM of a cephalosporin or other or even oral 400mg.

AND METRONIDAZOLE BY ANAERBIC COVER and for bacterial vaginosis

alcohol shouldnt be used with metronidzaole

Doxy against chlamydia and ceft agaisnt gonorrhea

doxy injection is very painful so siwtch to oral as fast aspossible

PID can irritate the gut and cause diarrhea

The mainstay in the management of pelvic inflammatory disease is antibiotic therapy.

Treatment is a 14-day course of broad spectrum antibiotics with good anaerobic coverage. This should be commenced immediately, before the results of swabs are available. Options include:

Doxycycline, ceftriaxone and metronidazole

Ofloxacin and metronidazole

Analgesics such as paracetamol should be considered.

The patient should be advised to rest, and avoid sexual intercourse until the antibiotic course is complete and partner(s) are treated.

Oral feeding is restricted. Dehydration and acidosis are to be corrected by IV fluids.

All sexual partners from the last 6 months should be tested and treated to prevent recurrence and spread of infection.

Pus formation - peritoneal washing/lavage and drain?

pevic abcess - first diagnose with ultra sound...and then try to clear with antibiotics and then utrasound guided draininage and then if not suitable and deteriorating then laporotmy and drainage that way.

There are some situations in which women should be admitted to hospital:

If pregnant and especially if there is a risk of ectopic pregnancy.

Severe symptoms: nausea, vomiting, high fever.

Signs of pelvic peritonitis.

Unresponsive to oral antibiotics, need for IV therapy.

Need for emergency surgery or suspicion of alternative diagnosis.

Sometimes TAH + BS for perimenapausal to reduce suffering lu

Complications

MMEDIATE COMPLICATIONS - pelvic perotonitis or even generalised periotnitis, septicaemia (produing arthris or myocarditis)

Delaying treatment or having repeated episodes of pelvic inflammatory disease (recurrent PID) can increase risks of serious and long term complications:

Ectopic pregnancy – due to narrowing and scarring of the fallopian tubes

Infertility – affects 1 in 10 women with PID.

Tubo-ovarian abscess

Chronic pelvic pain

Fitz-Hugh Curtis syndrome – perihepatitis that typically causes right upper quadrant pain

Follow up

Screening

can lead to abcess formation or pus in the fallopian tube and if chronic can be swollen and fibrosed (hydrosalpin)

can lead to infertility as well.

PID in pregancy ⇒ chorioamniotis ⇒ sepsis in pregnancy

refer for HIV testing

and immunization agaisnt heb B

Female Genital TB

most common secondary from hematogepus spread. thats why vagina is affected less commonly.

leading to ashermans syndrome

growth on the cervix is very rare but can mimic CA cervix. so for CA cervix this is one of the DD. To exclude must do a biospy.

Diagnosis of TB

the investigation will depend on clinical findings (history and examintion)

like the below

endometrial biospy if endometrum is involved..otherwise if only tube is involved then its difficult. 1, staining 2 culture 3 pcr 4 mantoux test 4. gold standard

biospy for culture, afb and pcr.

very difficult to isolate emicrobacterium tb so wont show on afb etc so sometimes we just treat emprically based on degree of clinical suspicion.

HSG is contraindicated is you suspect tb but these were done when tb wasnt suspected and then diagnosed by these appearance

notice that dye didnt spill so tube blockage is there,

These arent confirmatory diagnosis. To confirm must go lap and tae biospy and show.

the tube is normally wobbe wobble but if straight then it looks like a lead pipe