Three proposed pathways of dissemination of microorganisms in pelvic infections:
Lymphatic spread of bacterial infection: typified by postpartum, post-abortal, some IUD-related infection
Intro-abdominal spread of microorganisms (gonorrhea and other pathogenic bacteria): represents more common forms of nonpuerperal PID, pathogenic bacteria gain access to the lining of the uterine tubes, then result in purulent inflamation;
Hematogenous spread of bacterial infection(tuberclosis)
Leukocytosis with a shift to the left is usually present.
Gonococci may be find in abnormal vaginal or cervical discharge.
Culdocentesis samples should be sent for smear, culture and sensitivity testing of organisms.
A pelvic ultrasound may be done to view the pelvic area to see whether the fallopian tubes are enlarged or an infection is present. Sometimes a laparoscopy may be needed. Ultrasonography is most valuable in following the progression or regression of an abscess.
It may be very helpful in diagnosis of suspected pelvic infection. Generally, culdocentesis samples is production of “reaction fluid” when stain, reveals leukocytes with or without gonococci or other organisms. culture and sensitivity testing of organisms from culdocentesis samples are recommended
Additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID:
• oral temperature >101°F (>38.3°C), • abnormal cervical or vaginal mucopurulent discharge, • presence of abundant numbers of WBC on saline microscopy of vaginal secretions, • elevated erythrocyte sedimentation rate, • elevated C-reactive protein, and • laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
The most specific criteria for diagnosing PID include the following:
endometrial biopsy with histopathologic evidence of endometritis;
transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or doppler studies suggesting pelvic infection (e.g., tubal hyperemia) and
PID can be cured with antibiotics. But any damage that has already been done to a woman's pelvic organs (uterus, fallopian tubes, and ovaries) before treatment will not be reversed.
Early treatment for PID is very important. Positive treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on immediate administration of appropriate antibiotics.
PID treatment regimens must provide empiric, broad spectrum coverage of likely pathogens.
Long-term antibiotics is worthy of trial in young woman of low parity, ibuprofen can be used for symptoms relief; if symptoms still remain after 3 weeks of antibiotic treatment, laparoscopy and exploratory laparotomy are needed to rule out other causes;
If infertility is a problem, verify tubal patency by hysterosalpingography or laparoscopy are recommended; priscrible antibiotics before and after procedure;
Total abdominal hysterectomy with bilateral adnexectomy may be indicated if disease is far advanced and the woman is symptomatic or if an adenexal mass is demonstrated.
Tuboovarian abscess (TOA) involving the ovary and fallopian tube most often arises as a consequence of pelvic inflammatory disease (PID). However, TOA can also develop following pelvic surgery, or as a complication of an intraabdominal process, such as appendicitis or diverticulitis.
Organisms recovered from TOA are those found in PID, namely, a mixed polymicrobial infection with a high prevalence of anaerobes.
Treatment modalities for TOA include antibiotics, guided drainage, and surgery.
TOA appears by sonogram classically as one or more relatively homogeneous, somewhat symmetrical, cystic, thin-walled, well-demarcated mass(es) which are usually contiguous. An air fluid level may be seen; septations are present in multiloculated TOAs.
Ultrasound examination is indicated in these patients suspected of PID:
Those with a palpable mass
Those who are severely ill and/or for whom inpatient therapy is planned
Those failing to respond to appropriate medical therapy
Those in whom tenderness or other factors preclude an adequate rectovaginal pelvic examination.
The differential diagnosis of TOA is extensive; ectopic pregnancy, all of the pelvic neoplasms, ovarian hematoma or torsion, appendiceal and diverticular abscesses, and uterine pyomyoma all must be considered.
Long-term antimicrobials therapy with anaerobic coverage;
When medical therapy alone is not successful, or a large abscess is identified, drainage procedures need to be employed. Since most women with tubo-ovarian abscess are of reproductive age, the primary aim of management is to be as conservative as possible when considering percutaneous drainage versus open surgery.
Almost all patients failing to respond within four days require surgery. Laparoscopy or laparotomy is mandatory in all cases of suspected leakage or rupture as well as in all cases that do not respond to medical management and percutaneous drainage.
a. Ampicillin (2 g IV Q4h) PLUS gentamicin (standard doses) PLUS metronidazole (500 mg PO or IV Q8h), OR
b. Ofloxacin (400 mg IV Q12h) PLUS metronidazole (500 mg PO or IV Q8h), OR
c. Single agent therapy with one of the following: ticarcillin clavulanate (3.1 g IV Q4h), piperacillin tazobactam (4 g/0.5 g IV Q8h), or imipenem cilastatin (500 mg IV Q6h)
3. Survey for sepsis syndrome including:
a. Vital signs, examination (including mental status)
b. Blood cell counts and chemistries
c. Coagulation studies
d. Chest x-ray, EKG
e. Urine output
4. Place nasogastric tube to suction if ileus has developed
5. Guided drainage of TOA within 24 to 48 hours should be strongly considered
a. Transvaginal approach using an endovaginal sonographic probe with needle guide should be considered first; if not possible proceed to CT or US guided transcutaneous approach, or laparoscopic approach
b. Place indwelling catheter if contents too viscous to aspirate
c. Colpotomy drainage may be used only if the abscess is fixed and distending the low rectovaginal septum in the midline
d. Send aspirate for microbiologic evaluation (and cytologic analysis if fluid is serous or cloudy)
6. Correct any underlying medical derangements (eg, anemia, hyperglycemia, hypoproteinemia, hypoxia)
Base on complete history, physical examination, chest X-ray and lung scan, tuberculin test, sputum smears and sputum culture.
Gross ascites with fluid containing more than 3 g of protein per 100 ml of peritoneal fluid is characteristic of tuberculosis peritonitis.
Pelvic tuberculosis is usually encountered in the course of gynecologic operation done for other reasons. some distinguishing features include: extremely dense adhesions without planes of cleavage, segmental dilatation of the tubes.
Initial therapy should include 4 drugs to prevent the emergence of drug-resistant strains. The drug for 1st 2 months of treatment should include: isoniazid, rifampin,pyrazinamide,and streptomycin or ethambutol. Once drug susceptibility results are available,the drug can be appropriately changed,tratment should continued for 2-3 years.