TOA

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  • Uterine and adnexal tenderness should be prominent for diagnosis of PID.
  • + stain increases probability, - means littleIncreased WBCs is 78% sensitive but only 39% specificIn series of 120 women, probability of PID 11 percent in women with normal WBCs and < or = 3 WBC/hpf from vaginal fluid. No pt with normal ESR had PID.
  • TOA

    1. 1. PID and TOA<br />Morgan Taylor<br />
    2. 2. Clinical Features<br />Lower abdominal pain<br />Bilateral<br />Recent onset<br />Worsens with coitus<br />Worsens with jarring movements<br />Onset during or shortly after menses<br />AUB in 1/3 of patients<br />New vaginal discharge<br />Fever and chills<br />
    3. 3. Risk Factors<br />&lt;25yo<br />Early coitarche<br />New, multiple, or symptomatic sexual partners<br />Nonbarrier contraception<br />Also, factors facilitating PID include hx PID, sex during menses, vaginal douching, BV, and IUDs.<br />
    4. 4. Physical Examination<br />½ have fever<br />Diffuse tenderness, greater in LQs<br />May or may not be symmetrical<br />RUQ pain may be perihepatitis<br />Purulent endocervical discharge<br />Acute cervical motion tenderness<br />Adnexal tenderness (sign that correlates best with the finding of endometritis)<br />
    5. 5. Perihepatitis<br />Fitz-Hugh Curtis Syndrome<br />Infection of liver capsule and peritoneal surfaces<br />Patchy purulent and fibrinousexudate in the acute phase that primarily affects anterior surfaces of the liver<br />Sudden onset of RUQ pain with pleuritic component sometime referred to right shoulder<br />Can be mistaken for cholecystitis<br />AST/ALT abnormal in ½ of patients<br />
    6. 6. Diagnostic Criteria<br />Empiric therapy for women with abdominal pain and one of the following:<br />Cervical motion or uterine/adnexal tenderness<br />Temp &gt; 38.3<br />Peripheral leukocytosis<br />Cervical or vaginal mucopurulent discharge<br />WBCs on saline microscopy of vaginal secretions<br />Elevated ESR<br />Elevated CRP<br />
    7. 7. Diagnostic Criteria II<br />Patients with pelvic pain and tenderness and one or more of following are confirmed cases:<br />Endometritis or acute salpingitis on biopsy<br />GC or Chl in genital tract<br />Gross salpingitis seen at laparoscopy or laparotomy<br />Isolation of pathogenic bacteria from clean specimen from the upper genital tract<br />Inflammatory/purulent pelvic peritoneal fluid w/o another source<br />
    8. 8. Definitive Diagnosis<br />Histologic evidence of endometritis<br />Imaging revealing thickened fluid filled oviducts<br />Laparoscopic abnormalities consistent with PID (tubal erythema, edema, adhesions, purulent exudate or cul-de-sac fluid, abnormal fimbriae)<br />
    9. 9. Testing<br />Labs:<br />Pregnancy test<br />UA<br />CBC (fewer than ½ of PID pts have leukocytosis)<br />Gram stain and microscopic eval of vaginal D/C <br />GC/Chl<br />Occult blood test<br />CRP (optional)<br />
    10. 10. Imaging<br />Transvaginal USG<br />In one series of 55 women with definitive PID who underwent TVUSG, the findings of abnormal oviducts, multicystic ovaries, and increased cul-de-sac fluid were 32%, 42%, and 37% sensitive and 97%, 86%, 58% specific.<br />
    11. 11. Indications for hospitalization<br />Pregnancy<br />Lack of response or tolerance to oral meds<br />Nonadherence<br />Inability to take meds 2ndary to N/V<br />Severe illness (high fever, N/V, severe pain)<br />Pelvic abscess<br />Possible surgical intervention or diagnostic exploration<br />
    12. 12. Pathogens<br />Two most important pathogens are Chlamydia Trachomatis and Neisseriagonorrhoeae<br />Should also have coverage for:<br />A and B streptococci<br />E. Coli, Klebs, Proteus<br />BV flora<br />
    13. 13. Rec’d Regimens<br />GC becoming more and more resistant to fluoroquinolones.<br />Parenteral<br />1) Cefoxitin or Cefotetan plus Doxycycline<br />2) Clindamycin plus Gentamicin<br />3) Ampicillin-sulbactam plus Doxycycline<br />Doxycycline causes pain when infused intravenously so PO administration is recommended. <br />
    14. 14. Rec’d Regimens<br />Oral therapy<br />1) Ceftriaxone IM plus Doxycyclinew/ or w/o Metronidazole<br />2) Cefoxitin IM with Probenecid plus Doxycyclinew/ or w/o Metronidazole<br />3) 3G Cephalosporin IM like Cefotaxime or Ceftizoxime plus Doxycyclinew/ or w/o Metronidazole<br />Metro added for pelvic abscess, suspected Trichomonas or BV, hx of gynecologic instrumentation<br />
    15. 15. Duration of treatment<br />Optimal duration unknown but most studies used 14 days and CDC guidelines use this.<br />If outpatient therapy selected, must F/U within first 48-72hrs to ascertain clinical improvement.<br />
    16. 16. TOA<br />Epidemiology<br /> TOA occurs in up to 1/3 of patients.<br /> Estimated 100,000 cases per year<br /> Most commonly in women 20-40yo<br /> Previous PID not more common in TOA pts<br /> Does not appear to be increased risk with newer IUD devices<br /> …no clear risk factors for TOA in PID<br />
    17. 17. Diagnosis<br />TOA should be suspected in any PID patient.<br />Absence of fever and/or leukocytosis is not an argument against TOA (60-80% have).<br />Abdominal findings of ileus may be more common in PID patients with TOA.<br />Unclear whether pelvic examination helps<br />One study showed 90% were clinically appreciated<br />Unsuspected TOA seen with high frequency when laparotomy performed for failure of medical therapy.<br />
    18. 18. USG<br />Test of choice to R/O TOA.<br />One study, TVUSG identified 32 of 33 surgically confirmed TOAs, and ruled out 33 of 34 patients.<br />Appears as one or more homogeneous, somewhat symmetrical, cystic, thin-walled, well-demarcated mass(es) which are usually contiguous. Septations and AFLs may be seen.<br />USG indicated in patients with PID and 1) palpable mass, 2) severely ill, 3) those failing medical therapy 4) adequate exam unable to be performed.<br />
    19. 19. Medical Therapy for TOA?<br />Retrospective review of 119 cases of TOA showed a 75% success rate with a trial of medical therapy.<br />When medical therapy not successful, or large abscess is identified, drainage procedures should be employed.<br />
    20. 20. Transvaginal Drainage<br />Largest study had 302 women, 282 of which were successfully treated with ultrasound-guided aspiration and medical therapy. <br />The sizes of the abscesses in the study ranged from 3 to 15cm.<br />Although 1/3 of patients needed more than one aspiration, only 7% eventually underwent surgery.<br />Size of abscess or multilocularity not important<br />Patient tolerance was excellent<br />Laparoscopic drainage with concurrent medical therapy is aother option.<br />
    21. 21. Surgery<br />Almost all patients failing to respond within four days require surgery.<br />Closure of the skin and subcutaneous layer is primarily appropriate for those with no free pus in abdomen.<br />

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