This was a lecture given during the POGS Cebu chapter 39th Foundation Day Celebration and Postgraduate Course with theme: "POGS Cebu at 39: Revitalize, Reinvigorate, Rejuvenate!" at the Grand Ballroom of the Cebu Country Club

1. Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
POGS Cebu Chapter Postgraduate Course
July 26, 2018
SURGERY FOR PELVIC INFECTIONS:
INDICATIONS AND APPROACHES

2. PELVIC INFLAMMATORY DISEASE

3. PELVIC INFLAMMATORY DISEASE (PID)
comprises a spectrum of inflammatory
disorders of the upper female genital tract,
including any combination of
• endometritis
• salpingitis
• tubo-ovarian abscess
• pelvic peritonitis
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

4. PELVIC INFLAMMATORY DISEASE (PID)
• N. gonorrhoeae and C. trachomatis, are
implicated in many cases
• Microorganisms that comprise the vaginal
flora (e.g., anaerobes, G. vaginalis,
Haemophilus influenzae, enteric Gram-
negative rods, and Streptococcus
agalactiae) have been associated with PID
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

5. PELVIC INFLAMMATORY DISEASE (PID)
• All women who receive a diagnosis of
acute PID should be tested for HIV, as
well as gonorrhea and chlamydia, using
NAAT.
• Screening and treating sexually active
women for chlamydia reduces their risk
for PID by 60%.
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

6. ADDITIONAL CRITERIA
• Oral temperature > 38.3ºC
• Abnormal cervical mucopurulent discharge
or cervical friability
• Presence of abundant numbers of WBC on
saline microscopy of vaginal fluid
• Elevated erythrocyte sedimentation rate
• Elevated C-reactive protein
• Laboratory documentation of cervical
infection with N. gonorrhoeae and C.
trachomatic
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

7. MOST SPECIFIC CRITERIA
• Endometrial biopsy with histopathologic
evidence of endometritis
• Transvaginal sonography or MRI showing
thickened fluid-filled tubes with or without
free pelvic fluid or tubo-ovarian complex
• Laparoscopic findings consistent with PID
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

8. INDICATIONS FOR HOSPITALIZATION
• Surgical emergencies cannot be excluded
• Tubo-ovarian abscess
• Pregnancy
• Severe illness, nausea and vomiting or high
fever
• Unable to follow or tolerate an outpatient oral
regimen
• No clinical response to oral antimicrobial
therapy
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

9. TUBO-OVARIAN ABSCESS
Tubo-ovarian abscess (TOA) is a
complication of PID in 15% of cases and
33% of patients with PID requiring
admission have a TOA.
DeWitt J, Reining A, Allsworth JE, Peipert JF. 2010. Tuboovarian Abscesses: Is Size
Associated with Duration of Hospitalization and Complications?

10. TUBO-OVARIAN ABSCESS
• Mortality with TOA has decreased
drastically over the last 50 years.
• Morbidity associated with TOA:
• Infertility
• Ectopic pregnancy
• Chronic pelvic pain
• Pelvic thrombophlebitis
• Ovarian vein thrombosis
DeWitt J, Reining A, Allsworth JE, Peipert JF. 2010. Tuboovarian Abscesses: Is Size
Associated with Duration of Hospitalization and Complications?

11. RECOMMENDED
PARENTERAL REGIMENS
Cefotetan 2 g IV every 12 hours
PLUS
Doxycycline 100 mg orally or IV
every 12 hours
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

12. RECOMMENDED
PARENTERAL REGIMENS
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV
every 12 hours
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

13. RECOMMENDED
PARENTERAL REGIMENS
Clindamycin 900mg IV every 8 hours
PLUS
Gentamicin loading dose IV (2mg/kg)
followed by a maintenance dose
(1.5mg/kg) every 8 hours. Single daily
dosing (3-5mg/kg) can be substituted.
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

14. ALTERNATIVE
PARENTERAL REGIMENS
Ampicillin/sulbactam 3 g IV
every 6 hours
PLUS
Doxycycline 100 mg orally or
IV every 12 hours
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

15. DE-ESCALATION 24-48 HOURS AFTER
CLINICAL IMPROVEMENT
Oral doxycycline 100 mg twice daily to
complete 14 days of therapy
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

16. TUBO-OVARIAN ABSCESS IS PRESENT
Clindamycin 450 mg orally qid
OR
Metronidazole 500 mg bid
PLUS
Oral doxycycline 100 mg bid to complete
14 days of therapy
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

17. TO MINIMIZE DISEASE
TRANSMISSION
• Abstain from sexual intercourse until
therapy is completed, symptoms have
resolved, and sex partners have been
adequately treated.
CDC Sexually Transmitted Diseases Treatment Guidelines 2015.

18. OPERATIVE TREATMENT OF ACUTE PID
• Operations are restricted to life-
threatening infections, ruptured tubo-
ovarian abscesses, laparoscopic
drainage of a pelvic abscess, persistent
masses in some older women for whom
future childbearing is not a consideration,
and removal of a persistent symptomatic
mass.
Katz, Lentz, Lobo, Gershenson 2007. Comprehensive Gynecology.

19. CONSERVATIVE TREATMENT
• Unilateral removal of a tubo-ovarian
complex or an abscess
• Drainage of a cul-de-sac abscess via
percutaneous drainage or culpotomy
incision
• Percutaneous aspiration or drainage
under CT or ultrasound guidance
Katz, Lentz, Lobo, Gershenson 2007. Comprehensive Gynecology.

20. CONSERVATIVE TREATMENT
• Laparoscopic aspiration of tuboovarian
complexes.
• Operative intervention in a
postmenopausal woman should be
considered early in the disease,
especially if the condition does not rapidly
improve with medical therapy.
Katz, Lentz, Lobo, Gershenson 2007. Comprehensive Gynecology.

21. TUBO-OVARIAN ABSCESS
• Of 373 patients with PID, 135 had TOA
and 31% required management with
drainage and/or surgery.
DeWitt J, Reining A, Allsworth JE, Peipert JF. 2010. Tuboovarian Abscesses: Is Size
Associated with Duration of Hospitalization and Complications?

22. TUBO-OVARIAN ABSCESS
• The mean abscess size for those
requiring drainage or surgery was 7.7cm
versus 6.3 cm for those with successful
conservative management.
• Every 1cm increase in abscess size was
associated with an increase in
hospitalization by 0.4 days.
DeWitt J, Reining A, Allsworth JE, Peipert JF. 2010. Tuboovarian Abscesses: Is Size
Associated with Duration of Hospitalization and Complications?

23. TUBO-OVARIAN ABSCESS
• Abscesses >8cm were associated with
increased risk of complications:
• Need for blood transfusion
• Longer duration of hospitalization
• Longer duration febrile
• Increased need for surgery or
drainage
DeWitt J, Reining A, Allsworth JE, Peipert JF. 2010. Tuboovarian Abscesses: Is Size
Associated with Duration of Hospitalization and Complications?

24. TUBOOVARIAN ABSCESSES
Crespo, Ganesh, Lo, Chin, Norris, Chakhtoura 2014. Surgical, Ultrasoun-Guided Drainage and
Medical Management of Tuboovarian Abscesses

25. Crespo, Ganesh, Lo, Chin, Norris, Chakhtoura 2014. Surgical, Ultrasoun-Guided Drainage and
Medical Management of Tuboovarian Abscesses

26. SURGICAL SITE INFECTIONS

27. PELVIC SURGICAL SITE INFECTIONS
IN GYNECOLOGIC SURGERY
SSIs are infections occurring within 30 days
of an operation occurring in one of 3
locations:
• superficial at the incision site
• deep at the incision site
• in other organs or spaces opened or
manipulated during an operation
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

28. VAGINAL CUFF CELLULITIS
Moderate, but increasing, lower abdominal
pain with purulent yellow vaginal discharge
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.
• Amoxicillin/clavulanate 875/125 mg po bid
• Ciprofloxacin 500 mg po bid + metronidazole 500
mg bid
• TMP-SMX DS po bid + metronidazole 500 mg po
bid

29. PELVIC CELLULITIS AND ABSCESS
Pelvic cellulitis and pelvic hematoma spread
into parametrial soft tissue: fever, vague
abdominal pain, regional tenderness, mass
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.
• clindamycin 900 mg IV q8h OR metronidazole 500
mg IV q12h +
• penicillin 5 million units q6h OR ampicillin 2 g IV
q6h +
• gentamicin 5 mg/kg body weight q24h OR
aztreonam 2 g IV q8h

30. DRAINAGE OR SURGICAL THERAPY
• Routine drainage of pelvic abscesses can
decrease prolonged hospitalizations and
improve reproductive outcomes.
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

31. DRAINAGE OR SURGICAL THERAPY
• Drainage should be performed if an
adequate response to antibiotic therapy is
not registered within 2-3 days or if the
pelvic abscess is >8cm
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

32. CRITERIA FOR FAILURE
• patients with <50% radiological reduction
in abscess size
• patients whose abscess progressively
increased in size
• new onset fever or persistent fever
• clinical deterioration with persistent or
worsening abdominal / pelvic tenderness
despite appropriate antibiotic therapy
• sepsis
• ruptured abscess
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

33. WOMEN WITH ABSCESSES >8CM
OR WHO SHOW NO SIGNS OF
IMPROVEMENT
• Clinically worsening patients, suspected
rupture, and septic patients require
immediate laparotomy which may be life-
saving.
• Laparoscopy has several advantages
compared to laparotomy, if the patient is
hemodynamically stable.
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

34. DRAINAGE
• Percutaneous drainage guided by CT or
ultrasound even with large abscesses
• No required anesthesia
• Immediate pain relief
• Reduced duration of hospital stay
• Pelvic cuff abscess by ultrasound guided
transvaginal aspiration
Lachiewicz, Moulton, Jaiyeoba, 2015. Pelvic Surgical Site Infections in Gynecologic Surgery.

35. REFERENCES
• Kimberly A. Workowski, Bolan GA. Sexually Transmitted
Diseases Treatment Guidelines. Morbidity and Mortality Weekly
Report (MMWR). 2015. 1-137 p. Accessed at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6403a1.htm on
June 6, 2016
• Mark P. Lachiewicz, Laura J. Moulton, and Oluwatosin Jaiyeoba,
“Pelvic Surgical Site Infections in Gynecologic
Surgery,” Infectious Diseases in Obstetrics and Gynecology, vol.
2015, Article ID 614950, 8 pages. doi:10.1155/2015/614950.
Accessed at http://www.hindawi.com/journals/idog/2015/614950/
on June 7, 2016.

36. REFERENCES
• Eckert and Lentz “Infections of the Upper Genital Tract” in Katz,
Lentz, Lobo, Gershenson 2007. Comprehensive Gynecology
Fifith Edition. Mosby Elsevier, Philadelphia, USA: 607-631.
• Crespo FA, Ganesh D, Lo K, Chin K, Norris P, Chakhtoura N.
Surgical, Ultrasound Guided Drainage, and Medical
Management of Tuboovarian Abscesses. Infectious Diseases
Vol 2015, Article ID 501729, 6 pages.
• DeWitt J, Reining A, Allsworth JE, Peipert JF. Tuboovarian
Abscesses: Is Size Associated with Duration of Hospitalization
and Complications? Obstetrics and Gynecology International
Volume 2010, Article ID 847041, 5 pages.

37. #HealthXPH tweetchat
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@helenvmadamba
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These slides are available on
http://www.slideshare.net/HelenMadamba

40. Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
POGS Cebu Chapter Postgraduate Course
July 26, 2018
SURGERY FOR PELVIC
INFECTIONS: INDICATIONS
AND APPROACHES