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Pelvic Inflammatory
Disease(PID)
Dr manal behery
Professor ob&gyne
Faculty of medicine , zagazig university
What is PID?
• Inflammation of female pelvic
structures
• Ascending spread of infection from the
the cervix through the uterus, to
fallopian tubes, ovaries and adjacent
peritoneum
• Upper genital tract infection
• It is not infection in the vagina or vulva
3
Pathway of Ascending Infection
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tubo-
ovarian abscess
Peritonitis
Pathogenesis
PID comes in two forms...
• Acute
• Patient has generalised symptoms
• Lasts a few days
• May recur in episodes
• Very infectious in this stage
• Chronic
• Patient may have no symptoms
• Occurs over months and years
• Progressive organ damage & change
• May burn out (arrest)
Why PID is important
• Affects up to 1:4 women in CBP
• Many hospital admissions
• Sometimes fatal
• Chronic damage causes infertility
• Predisposes to ectopic pregnancy
• Can affect a baby during birth
• Lung inflammation
• Eye infections
• Is a common cause of chronic menstrual
problems
Cause of PID
• 85 – 95% is due to specific sexually
transmitted organisms
• Neisseria gonorrhoea
• Chlamydia trachomatis
• Others e.g. Mycoplasma species
• 5 – 15% begins after reproductive tract
damage
• From pregnancy
• From surgical procedures e.g. D&C
• Includes insertion of IUCD
Cause of PID (2)
• Endogenous infection occurs from
commensal organisms
• Anaerobes e.g. Bacteroides
• Aerobes e.g. E Coli, Streptococcus species
• Actinomycosis with IUCD
• A smaller number of PID is due to
Tuberculosis (TB)
• Bloodborne spread after primary lung infection
Pathogenesis
• Infection can occur after procedures that
break cervical mucous barrier
• The adult vagina is lined by stratified
squamous epithelium like skin
• But the cervix has mucous to receive sperm
• Organisms can access higher when mucous is
receptive
• Endometrium sheds regularly so is
infrequently a site of chronic infection
• Fallopian tubes and peritoneum should be
sterile
Chlamydia trachomatis
• Produces a mild form of salpingitis
• Slow growing in culture (48-72 hr)
• An intracellular organism
• Insidious onset
• Remain in tubes for months/years after
initial colonization of upper genital tract
• Can cause severe damage/changes over
long periods
10
Normal Human Fallopian Tube Tissue
Source: Patton, D.L. University of Washington, Seattle, Washington
Pathogenesis
11
C. trachomatis Infection (PID)
Source: Patton, D.L. University of Washington, Seattle, Washington
Pathogenesis
Neissera gonorrhoea
• Gram negative Diplococcus
• Grows rapidly in culture (doubles every
20-40 min)
• Causes a rapid & intense inflammatory
response
• May occur after prior Chlamydia infection
• More likely to be symptomatic in the male
partner
Risk Factors for PID
• Age of 1st intercourse
• Number of sexual partners
• Number of sexual contacts by the sexual partner
• Cultural practices
• Polygamy,
• Prostitutes
• Attitudes to menstruation and pregnancy
• Frequency of intercourse (Age)
• IUCD design
• Poor health resources
• Antibiotic exposure (resistance)
Pathology
Diagnosis of PID
• Requires a high index of suspicion in a patient
“at risk” when there is:
• Lower abdominal pain (90%)
• Fever (sometimes with malaise, vomiting)
• Mucopurulent discharge from cervix
• Pelvic tenderness
• Tests
• Raised WCC
• Endocervical swab for organisms or PCR
• Ultrasound evidence of pelvic fluid collections
• Laparoscopy
Fitz-Hugh-Curtis Syndrome
• Perihepatic inflammation & adhesions
• Occurs with 1 – 10% acute PID
• Causes RUQ and pleuritic pain
• May be confused with cholecystitis or
pneumonia
Endometritis (thickened heterogenous endometrium)
Hydrosalpinx (anechoic tubular structure)
Hydrosalpinx.
PID BY LAPROSCAPY
By laparoscapy
Differential Diagnosis for PID
• Endometriosis
• Appendicitis & other gastro conditions
• Appendicitis is unilateral and right sided
• PID is bilateral
• Ectopic pregnancy
• Always do a pregnancy test
• Urinary tract infection or stone
• “Ovarian cysts”
• Lower genital tract infection
PID Sequelae
• Chronic Pelvic Pain (15-20 %)
• Ectopic pregnancy (6-10 fold ↑Risk)
• At least 50% of tubal pregnancies have
histology of PID
• Infertility (Tubal)
• 10 – 15% after one episode
• 20% ~ 2 episode
• >50% ~ 3 episodes
• Recurrence of acute PID at least 25%
• Male genital disease in 25%
Treatment of PID
• Antibiotics
• Needs appropriate spectrum of activity
• Specific or broad spectrum?
• Issues of compliance
• Oral or parenteral?
• Follow current guidelines
• Surgical
• Drain abscess
• Selective or radical removal
• Rest and analgesia
• NSAID’s useful
Antibiotic Therapy
Gonorrhea : Cephalosporins, Quinolones
Chlamydia: Doxycycline, Erythromycin &
Quinolones (Not cephalosporins)
Anaerobic organisms: Metronidazole,
Clindamycin and, in some cases,
Doxycycline.
Beta hemolytic Streptococcus and E. Coli
Penicillin derivatives, Tetracyclines, and
Cephalosporins , Gentamicin.
Follow up for PID
• Partner or sexual contact tracing and
testing or treatment
• Look for other STD’s
• STS, Hep B and HIV
• Lower genital tract infections
• Counselling and support
• Pregnancy care
Criteria for hospitalization
Pregnancy
- Augmentin or Erythromycin
- Hospitalization
Concomitant HIV infection
- Hospitalization and i.v. antimicrobials
- More likely to have pelvic abscesses
- Respond more slowly to antimicrobials
- Require changes of antibiotics more often
- Concomitant Candida and HPV infections
Special Situations
Prevention of PID
• Screen & treat asymptomatic disease
• Sexual health counselling
• Barrier contraceptives
• Progestin-based contraception
• COC & POP
• Depot and Implanon
• ?Mirena
• Sexual fidelity or abstinence
• Improving the education and status of
women
31
History: Jane Wheels
Case Study
• 24-year-old female who reports lower abdominal pain,
cramping, slight fever, and dysuria for four days.
• G1P1, LMP two weeks ago (regular without dysmenorrhea).
Uses oral contraceptives (for two years).
• Reports gradual onset of symptoms of lower bilateral
abdominal discomfort, dysuria (no gross hematuria),
abdominal cramping and a slight low-grade fever in the
evenings for four days. Discomfort has gradually worsened.
• Denies GI disturbances or constipation. Denies vaginal
discharge.
• States that she is happily married in a monogamous
relationship. Plans another pregnancy in about six months.
No condom use.
• No history of STDs. Reports occasional yeast infections.
• Douches regularly after menses and intercourse; last
douched this morning.
32
Physical Exam
• Vital signs: blood pressure 104/72, pulse 84,
temperature 38°C, weight 132 lbs.
• Neck, chest, breast, heart, and musculoskeletal exam
within normal limits. No flank pain on percussion. No
CVA tenderness.
• On abdominal exam the patient reports tenderness in
the lower quadrants with light palpation. Several small
inguinal nodes palpated bilaterally.
• Normal external genitalia without lesions or discharge.
• Speculum exam reveals minimal vaginal discharge with
a small amount of visible cervical mucopus.
• Bimanual exam reveals uterine and adnexal tenderness
as well as pain with cervical motion. Uterus anterior,
midline, smooth, and not enlarged.
Case Study
33
Questions
1. What should be included in the
differential diagnosis?
2. What laboratory tests should be
performed or ordered?
Case Study
34
Laboratory
Results of office diagnostics:
• Urine pregnancy test: negative
• Urine dip stick for nitrates: negative
• Vaginal saline wet mount: vaginal pH was 4.5.
Microscopy showed WBCs >10 per HPF, no clue
cells, no trichomonads, and the KOH wet mount
was negative for budding yeast and hyphae.
3. What is the presumptive diagnosis?
4. How should this patient be managed?
5. What is an appropriate therapeutic regimen?
Case Study
35
Partner Management
Sex partner: Joseph (spouse)
• First exposure: four years ago
• Last exposure: one week ago
• Frequency: two times per week
(vaginal only)
6. How should Joseph be managed?
Case Study
36
Partner Management
• Male partners of women who have PID caused
by C. trachomatis or N. gonorrhoeae are often
asymptomatic.
• Sex partners should be treated empirically with
regimens effective against both C. trachomatis
and N. gonorrhoeae, regardless of the apparent
etiology of PID or pathogens isolated from the
infected woman.
Prevention
PID – What we have covered
• What it is
• Why it is important
• How it is spread
• How it is diagnosed
• How it is treated
• How it might be prevented
Any Questions or Comments?

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PID for undergraduate

  • 1. Pelvic Inflammatory Disease(PID) Dr manal behery Professor ob&gyne Faculty of medicine , zagazig university
  • 2. What is PID? • Inflammation of female pelvic structures • Ascending spread of infection from the the cervix through the uterus, to fallopian tubes, ovaries and adjacent peritoneum • Upper genital tract infection • It is not infection in the vagina or vulva
  • 3. 3 Pathway of Ascending Infection Cervicitis Endometritis Salpingitis/ oophoritis/ tubo- ovarian abscess Peritonitis Pathogenesis
  • 4. PID comes in two forms... • Acute • Patient has generalised symptoms • Lasts a few days • May recur in episodes • Very infectious in this stage • Chronic • Patient may have no symptoms • Occurs over months and years • Progressive organ damage & change • May burn out (arrest)
  • 5. Why PID is important • Affects up to 1:4 women in CBP • Many hospital admissions • Sometimes fatal • Chronic damage causes infertility • Predisposes to ectopic pregnancy • Can affect a baby during birth • Lung inflammation • Eye infections • Is a common cause of chronic menstrual problems
  • 6. Cause of PID • 85 – 95% is due to specific sexually transmitted organisms • Neisseria gonorrhoea • Chlamydia trachomatis • Others e.g. Mycoplasma species • 5 – 15% begins after reproductive tract damage • From pregnancy • From surgical procedures e.g. D&C • Includes insertion of IUCD
  • 7. Cause of PID (2) • Endogenous infection occurs from commensal organisms • Anaerobes e.g. Bacteroides • Aerobes e.g. E Coli, Streptococcus species • Actinomycosis with IUCD • A smaller number of PID is due to Tuberculosis (TB) • Bloodborne spread after primary lung infection
  • 8. Pathogenesis • Infection can occur after procedures that break cervical mucous barrier • The adult vagina is lined by stratified squamous epithelium like skin • But the cervix has mucous to receive sperm • Organisms can access higher when mucous is receptive • Endometrium sheds regularly so is infrequently a site of chronic infection • Fallopian tubes and peritoneum should be sterile
  • 9. Chlamydia trachomatis • Produces a mild form of salpingitis • Slow growing in culture (48-72 hr) • An intracellular organism • Insidious onset • Remain in tubes for months/years after initial colonization of upper genital tract • Can cause severe damage/changes over long periods
  • 10. 10 Normal Human Fallopian Tube Tissue Source: Patton, D.L. University of Washington, Seattle, Washington Pathogenesis
  • 11. 11 C. trachomatis Infection (PID) Source: Patton, D.L. University of Washington, Seattle, Washington Pathogenesis
  • 12. Neissera gonorrhoea • Gram negative Diplococcus • Grows rapidly in culture (doubles every 20-40 min) • Causes a rapid & intense inflammatory response • May occur after prior Chlamydia infection • More likely to be symptomatic in the male partner
  • 13. Risk Factors for PID • Age of 1st intercourse • Number of sexual partners • Number of sexual contacts by the sexual partner • Cultural practices • Polygamy, • Prostitutes • Attitudes to menstruation and pregnancy • Frequency of intercourse (Age) • IUCD design • Poor health resources • Antibiotic exposure (resistance)
  • 15. Diagnosis of PID • Requires a high index of suspicion in a patient “at risk” when there is: • Lower abdominal pain (90%) • Fever (sometimes with malaise, vomiting) • Mucopurulent discharge from cervix • Pelvic tenderness • Tests • Raised WCC • Endocervical swab for organisms or PCR • Ultrasound evidence of pelvic fluid collections • Laparoscopy
  • 16.
  • 17. Fitz-Hugh-Curtis Syndrome • Perihepatic inflammation & adhesions • Occurs with 1 – 10% acute PID • Causes RUQ and pleuritic pain • May be confused with cholecystitis or pneumonia
  • 23. Differential Diagnosis for PID • Endometriosis • Appendicitis & other gastro conditions • Appendicitis is unilateral and right sided • PID is bilateral • Ectopic pregnancy • Always do a pregnancy test • Urinary tract infection or stone • “Ovarian cysts” • Lower genital tract infection
  • 24. PID Sequelae • Chronic Pelvic Pain (15-20 %) • Ectopic pregnancy (6-10 fold ↑Risk) • At least 50% of tubal pregnancies have histology of PID • Infertility (Tubal) • 10 – 15% after one episode • 20% ~ 2 episode • >50% ~ 3 episodes • Recurrence of acute PID at least 25% • Male genital disease in 25%
  • 25. Treatment of PID • Antibiotics • Needs appropriate spectrum of activity • Specific or broad spectrum? • Issues of compliance • Oral or parenteral? • Follow current guidelines • Surgical • Drain abscess • Selective or radical removal • Rest and analgesia • NSAID’s useful
  • 26. Antibiotic Therapy Gonorrhea : Cephalosporins, Quinolones Chlamydia: Doxycycline, Erythromycin & Quinolones (Not cephalosporins) Anaerobic organisms: Metronidazole, Clindamycin and, in some cases, Doxycycline. Beta hemolytic Streptococcus and E. Coli Penicillin derivatives, Tetracyclines, and Cephalosporins , Gentamicin.
  • 27. Follow up for PID • Partner or sexual contact tracing and testing or treatment • Look for other STD’s • STS, Hep B and HIV • Lower genital tract infections • Counselling and support • Pregnancy care
  • 29. Pregnancy - Augmentin or Erythromycin - Hospitalization Concomitant HIV infection - Hospitalization and i.v. antimicrobials - More likely to have pelvic abscesses - Respond more slowly to antimicrobials - Require changes of antibiotics more often - Concomitant Candida and HPV infections Special Situations
  • 30. Prevention of PID • Screen & treat asymptomatic disease • Sexual health counselling • Barrier contraceptives • Progestin-based contraception • COC & POP • Depot and Implanon • ?Mirena • Sexual fidelity or abstinence • Improving the education and status of women
  • 31. 31 History: Jane Wheels Case Study • 24-year-old female who reports lower abdominal pain, cramping, slight fever, and dysuria for four days. • G1P1, LMP two weeks ago (regular without dysmenorrhea). Uses oral contraceptives (for two years). • Reports gradual onset of symptoms of lower bilateral abdominal discomfort, dysuria (no gross hematuria), abdominal cramping and a slight low-grade fever in the evenings for four days. Discomfort has gradually worsened. • Denies GI disturbances or constipation. Denies vaginal discharge. • States that she is happily married in a monogamous relationship. Plans another pregnancy in about six months. No condom use. • No history of STDs. Reports occasional yeast infections. • Douches regularly after menses and intercourse; last douched this morning.
  • 32. 32 Physical Exam • Vital signs: blood pressure 104/72, pulse 84, temperature 38°C, weight 132 lbs. • Neck, chest, breast, heart, and musculoskeletal exam within normal limits. No flank pain on percussion. No CVA tenderness. • On abdominal exam the patient reports tenderness in the lower quadrants with light palpation. Several small inguinal nodes palpated bilaterally. • Normal external genitalia without lesions or discharge. • Speculum exam reveals minimal vaginal discharge with a small amount of visible cervical mucopus. • Bimanual exam reveals uterine and adnexal tenderness as well as pain with cervical motion. Uterus anterior, midline, smooth, and not enlarged. Case Study
  • 33. 33 Questions 1. What should be included in the differential diagnosis? 2. What laboratory tests should be performed or ordered? Case Study
  • 34. 34 Laboratory Results of office diagnostics: • Urine pregnancy test: negative • Urine dip stick for nitrates: negative • Vaginal saline wet mount: vaginal pH was 4.5. Microscopy showed WBCs >10 per HPF, no clue cells, no trichomonads, and the KOH wet mount was negative for budding yeast and hyphae. 3. What is the presumptive diagnosis? 4. How should this patient be managed? 5. What is an appropriate therapeutic regimen? Case Study
  • 35. 35 Partner Management Sex partner: Joseph (spouse) • First exposure: four years ago • Last exposure: one week ago • Frequency: two times per week (vaginal only) 6. How should Joseph be managed? Case Study
  • 36. 36 Partner Management • Male partners of women who have PID caused by C. trachomatis or N. gonorrhoeae are often asymptomatic. • Sex partners should be treated empirically with regimens effective against both C. trachomatis and N. gonorrhoeae, regardless of the apparent etiology of PID or pathogens isolated from the infected woman. Prevention
  • 37. PID – What we have covered • What it is • Why it is important • How it is spread • How it is diagnosed • How it is treated • How it might be prevented
  • 38. Any Questions or Comments?