Surgery for Pelvic Infection

Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
AOGIN-RP CME Lecture, Zamboanga
June 8, 2016
SURGERY FOR PELVIC INFECTIONS:
INDICATIONS AND APPROACHES

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.

• 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

• 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%.

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

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

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

RECOMMENDED
PARENTERAL REGIMENS
Cefotetan 2 g IV every 12 hours
PLUS
Doxycycline 100 mg orally or IV
every 12 hours

RECOMMENDED
PARENTERAL REGIMENS
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV
every 12 hours

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.

ALTERNATIVE
PARENTERAL REGIMENS
Ampicillin/sulbactam 3 g IV
every 6 hours
PLUS
Doxycycline 100 mg orally or
IV every 12 hours

DE-ESCALATION 24-48 HOURS AFTER
CLINICAL IMPROVEMENT
Oral doxycycline 100 mg twice daily to
complete 14 days of therapy

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

TO MINIMIZE DISEASE
TRANSMISSION
• Abstain from sexual intercourse until
therapy is completed, symptoms have
resolved, and sex partners have been
adequately treated.

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.

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

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.

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.

VAGINAL CUFF CELLULITIS
Moderate, but increasing, lower abdominal
pain with purulent yellow vaginal discharge
• 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

PELVIC CELLULITIS AND ABSCESS
Pelvic cellulitis and pelvic hematoma spread
into parametrial soft tissue: fever, vague
abdominal pain, regional tenderness, mass
• 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

DRAINAGE OR SURGICAL THERAPY
• Routine drainage of pelvic abscesses can
decrease prolonged hospitalizations and
improve reproductive outcomes.

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

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

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.

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

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, 2015.
doi:10.1155/2015/614950. Accessed at
http://www.hindawi.com/journals/idog/2015/614950/ on June 7,
2016.

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.

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Surgery for Pelvic Infection

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