acute and subclinical infection of the upper genital tract in females

1. Pelvic
Inflammatory
Disease

2. Contents
• Introduction
• Epidemiology
• Causes and their Causative agents
• Mode of Infection
• Risk factors
• Clinical Manifestations
• Acute and Chronic PID
• Clinical Stages of PID
• Diagnosis
• Diagnosis Criteria
• Diagnosis Approach
• Differential Diagnosis
• Treatment
• Prevention
• Complications
• References

3. What is
PID?
1

4. • Pelvic inflammatory disease (PID)
refers to acute and subclinical
infection of the upper genital tract in
females
• It involves any or all of the uterus,
fallopian tubes, and ovaries
• It is often accompanied by
involvement of the neighboring pelvic
organs resulting in endometritis,
salpingitis, oophoritis, peritonitis,
perihepatitis, and/or tubo-ovarian
abscess.
Pelvic Inflammatory Disease

5. • PID commonly affects young sexually active women. For
some, PID causes a range of symptoms while for others, it
does not cause any.
• Sexually transmissible infections (STIs) - chlamydia,
mycoplasma genitalium and gonorrhoea are the most common
cause of PID

7. Epidemiology
• PID is commonly associated with Sexually
Transmitted Diseases (STDs).
• Incidence is on rise due to rise in STDs.
• Among sexually active women: Incidence is 1-2 % per
year
• About 85% are spontaneous infection in sexually
active females of reproductive age.
• Remaining 15% follow procedures, which favors the
organism to ascend up
• latrogenic procedures favor organism to ascend.
Examples include Endometrial biopsy, uterine
curettage, insertion of IUD and
hysterosalpingography
STDs Iatrogenic

8. Causes
• have more than 1 sexual partner
• have a history of STIs
• have had PID in the past
• are under 25
• started having sex at a young age

9. Primary Organisms
Sexually Transmitted
Secondary Organisms
Aerobic: Non-hemolytic streptococcus, E. coli,Group- streptococcus &
staphylococcus
Anaerobic: Bacteroides species- fragilis & bivius,Peptostrepococcus &
peptococcus
Causative Agents
N. gonorrhoeae Chlamydia trachomatis
Mycoplasma hominis Others

10. • The main cause of PID is through STIs such
as chlamydia, gonorrhoea or mycoplasma genitalium.
• These bacteria usually only infect the cervix, where they can be
easily treated with antibiotics.
• But if they're not treated there's a risk the bacteria could travel into
the female reproductive organs.
• If you have chlamydia and it's left untreated, it may develop into PID
within a year.

11. Mode of Infections
• Ascending
• Blood borne
• Direct Spread
Cervicitis Endometritis
Salpingitis/
oophoritis/ tubo-
ovarian abscess
Peritonitis
Pathway of Ascendant Infection

12. • Prior infection with
chlamydia or gonorrhea
• Younger age at onset of
sexual activity
• STIs
• Non-use of barrier
contraceptives
• Unprotected sex with
multiple partners
• IUD use
• Low socio-economic status
• Substance abuse
• Douching
• High frequency of coitus
• Cigarette smoking
• Intercourse during
menstruation
Risk Factors
Weak Evidence
Strong Evidence

13. Clinical
Signs and
Stages
2

14. Clinical Manifestations
When to suspect PID?
PID often does not cause any obvious symptoms.
Most symptoms are mild and may include 1 or more of the following:
•pain around the pelvis or lower stomach
•discomfort or pain during sex that's felt deep inside the pelvis
•pain when peeing
•bleeding between periods and after sex
•Heavy periods
•Painful periods
•Unusual vaginal discharge, especially if it's yellow, green or smelly

15. Acute And Chronic PID
ACUTE CHRONIC
Organism Highly virulent Low virulency
Symptoms Generalized No/Mild
Duration Few Days Many months
Course Reoccur in episodes Progressive organ damage
and change
Fate Very infectious Acute exacerbation

16. Clinical Stages of Acute PID
Stages Involvement
1 Acute salpingitis without peritonitis
2 Acute salpingitis with peritonitis
3
Acute salpingitis with superimposed tubal occlusion or tubo-
ovarian complex
4 Ruptured tubo-ovarian abscess
5 Tubercular salpingitis

17. Diagnosis
3

18. Diagnosis
•Medical history. Mainly about sexual habits, history of sexually transmitted infections
and method of birth control.
•A pelvic exam. During the exam, the pelvic region is checked for tenderness and
swelling. Cotton swabs will be used to take fluid samples from the vagina and cervix. The
samples will be tested at a lab for signs of infection and organisms such as gonorrhea
and chlamydia.
•Blood and urine tests. These tests may be used to test for pregnancy, human
immunodeficiency virus (HIV) or other sexually transmitted infections, or to measure
white blood cell counts or other markers of infection or inflammation.
•Ultrasound

20. •Laparoscopy
•Endometrial biopsy: The tissue is tested for signs of infection and inflammation.
•Pelvic exam: Pressing down on the abdomen at the same time, the uterus, ovaries and
other organs are examined

21. PID Diagnostic Criteria
Major criteria
• Temperature >38°C
• Abnormal cervical discharge
• Pelvic abscess or inflammatory complex on bimanual examination
• Gram stain of the endocervix showing gram negative intracellular
diplococci
• Positive Chlamydia test
• Leucocytosis >10x109 WBC/L
• Elevated ESR
• Elevated C-reactive protein
Minor criteria
• Cervical motion tenderness
• Uterine motion tenderness
• Adnexal tenderness

22. Diagnostic Approach
History, physical examination and pregnancy test
Pregnancy
Right lower quadrant abdominal pain or pain
migration from periumbilical area to right lower
quadrant of abdomen
Cervical motion, uterine, or adnexal tenderness?
Evaluate for ectopic pregnancy with
quantitative beta-subunit of HCG
test and transvaginal USG
Consider surgical consultation and
laparotomy for appendicitis; if
diagnosis in doubt, consider USG or
abdominal and pelvic CT with IV
contrast media
Consider PID; obtain transvaginal USG
to evaluate for tubo-ovarian abscess
No
No
No
Yes
Yes
Yes

23. Pelvic mass on examination?
Dysuria and WBC on urinalysis?
Transvaginal USG to evaluate for others diagnosis
Consider ovarian cyst, ovarian
torsion, degenerating uterine fibroid,
or endometriosis; obtain transmaginal
USG
Evaluate for UTI or pyelonephritis;
obtain urine culture
No
No
Yes
Yes

24. Differential Diagnosis
• Appendicitis
• Ectopic Pregnancy
• Endometritis
• Ovarian Cysts
• Ovarian torsion

25. Treatment
4

26. Treatment
Parenteral Treatment
REGIMEN A
Cefoxitin 2g IV every 6 hours for 14
days
Doxycycline 100mg orally or IV every 12
hours for 14 days
REGIMEN B
Clindamycin 900mg IV every 8 hours
Gentamycin loading dose (2mg/kg) IV or
IM followed by a maintenance dose
(1.5mg/kg) every 8 hours

27. Treatment
Oral Treatment
REGIMEN A
• Levofloxacin 500mg once daily for
14 days
OR
Ofloxacin 400 twice daily for 14 days
• Metronidazole 500mg twice a day for
14 days
REGIMEN B
• Ceftriaxone 250mg IM single dose
• Cefoxitin 2g IM single dose
• 3rd gen Cephalosporin
• All the above drugs with Doxycycline
100mg orally twice daily for 14 days
+/- Metronidazole 500mg orally twice
daily for 14 days

28. • Rupture abscess invade to peritoneum
• Failure medical treatment 48-72 hours
• Abscess does not go away after 2-3 week with persistent abdominal pain
When is Surgery Opted?

29. The number one cause of PID is untreated sexually transmitted infections. To prevent
PID
● Avoiding multiple sexual partners
● Using barrier methods of birth control, like condoms, even if she is on the birth
control pill or other contraceptive methods
● Seeking treatment immediately for unusual discharge, pelvic pain, or bleeding
between periods
Prevention

30. Complications
• Fitz-Hugh-Curtis syndrome: involvement of intraperitoneal structures by advanced PID by spread
of infection via right paracolic gutter or lymphatics accompanied by right upper quadrant pain.
Infection may become chronic, characterized by intermittent exacerbations and remissions.
• A tubo-ovarian abscess: is the collection of pus in the. It can accompany acute or chronic infection
and is more likely if treatment is late or incomplete. Pain, fever, and peritoneal signs are usually
present and may be severe. The abscess may rupture, causing progressively severe symptoms and
possibly septic shock.
• Recurrent PID
• Hydrosalpinx is fimbrial obstruction and tubal distention with nonpurulent fluid; it is usually
asymptomatic but can cause pelvic pressure, chronic pelvic pain, dyspareunia, and/or infertility.
• Salpingitis may cause tubal scarring and adhesions, which commonly result in chronic pelvic
pain, infertility, and increased risk of ectopic pregnancy.
• Infertility
• Ectopic Pregnancy

31. Fitz-Hugh-Curtis syndrome

32. References
• Goje O, Markwei M, Kollikonda S, et al: Outcomes of minimally invasive management of tubo-
ovarian abscess: A systematic review. J Minim Invasive Gynecol 28 (3):556–564, 2021. doi:
10.1016/j.jmig.2020.09.014
• Website, N. (2024, March 11). Pelvic inflammatory disease. nhs.uk.
https://www.nhs.uk/conditions/pelvic-inflammatory-disease-
pid/#:~:text=Symptoms%20of%20pelvic%20inflammatory%20disease,felt%20deep%20inside
%20the%20pelvis
• Pelvic Inflammatory Disease (PID) - STI treatment guidelines. (n.d.).
https://www.cdc.gov/std/treatment-guidelines/pid.htm
• Adolescent Pelvic Inflammatory Disease (PID) - Children’s health. (n.d.).
https://www.childrens.com/specialties-services/conditions/pelvic-inflammatory-
disease#:~:text=What%20is%20Adolescent%20Pelvic%20Inflammatory,such%20as%20chlamydia%20or%
20gonorrhea.

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