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Pelvic Inflammatory Disease
- 2. Etiology Anatom y Staging Sympto ms Signs DD’s PID is a spectrum of infection and inflammation of the upper genital tract organs ,typically involving : The uterus (endometrium), Fallopian tubes, Ovaries, Pelvic peritoneum and Surrounding structures Definition
- 3. Epidemiolo Anatom y Staging Sympto ms Signs DD’s 85% 15% Following procedures Spontaneous infection in sexually active females 33% 30 years or older less than 25 years EPIDEMIOLOGY 66%
- 4. Etiology Anatom y Staging Sympto ms Signs DD’s • Sexually transmitted • Gonococcus • Chlamydia • Mycoplasma • Trichomonas • Pyogenic • Aerobes • Staphylococci • Streptococci • E. coli • Anaerobes • Bacteroides fragilis, Peptococcus, Clostrididium • Actinomyces (IUD) • Tubercular salpingitis Organisms responsible for pelvic inflammatory disease
- 5. Etiology Patholog y Staging Sympto ms Signs DD’s Intact hymen. The acidity of the vaginal secretion . The cervical canal has a relatively small lumen and is normally filled with a plug of alkaline mucus. The ciliary movement of endometrial lining. Natural barriers
- 6. STDMENSTRUATION 01 02 03 04 05 ABORTION INTRA UTERINE MANIPULATIONS IUCD SEX WORKERS06 APPENDICITIS07 DIVERTICULITIS08 RISK FACTORS
- 8. Etiology Anatom y Staging Sympto ms Signs DD’s Contraceptive practice ● Barrier methods, specially condom, diaphragm with spermicides. ● Oral steroidal contraceptives have got two preventive aspects. ○ Produce thick mucus plug preventing ascent of sperm and bacterial penetration. ○ Decrease in duration of menstruation, creates a shorter interval of bacterial colo- nization of the upper tract. Protective and preventive factors
- 9. Etiology Anatom y Patholog y Sympto ms Signs DD’s Acute salpingitis Surest sign of salpingitis is the discharge of seropurulent fluid from the fimbrial end . The inflammatory exudate –mainly at the ampullary end. The mucous membrane – first affected Mucous membrane - oedematous, ulceration The ulceration Adhesion Tubal blockage Pelvic abscess Pyosalpinx
- 10. Etiology Anatom y Patholog y Sympto ms Signs DD’s Acute salpingitis Bilateral tubo-ovarian abscess Retort shaped pyosalpinx
- 11. Etiology Anatom y Patholog y Sympto ms Signs DD’s Acute salpingitis Infection may spread upward and cause peritonitis paralytic ileitis subdiaphragmatic and perinephric abscess
- 15. Etiology Anatom y Sympto ms Signs DD’s Symptoms ● Patients with acute PID present with a wide range of non-specific clinical symptoms. ● Symptoms usually appear at the time and immediately after the menstruation. ● Bilateral lower abdominal and pelvic pain which is dull in nature. The onset of pain is more rapid and acute in gonococcal infection (3 days) than in chlamydial infection (5–7 days). ● There is fever, lassitude and headache. ● Irregular and excessive vaginal bleeding is usually due to associated endometritis. ● Abnormal vaginal discharge which becomes purulent and or copious
- 16. Etiology Anatom y Staging Patholog y Sympto ms DD’s Nausea and vomiting. Dyspareunia Fitz-Hugh- Curtis syndrome Fever, lassitude and headache. vaginal discharge and vaginal bleeding Bilateral lower abdominal and pelvic pain
- 17. Etiology Anatom y Sympto ms Signs DD’s Symptoms ● Nausea and vomiting. ● Dyspareunia. ● Pain and discomfort in the right hypochondrium due to concomitant perihepatitis (Fitz-Hugh-Curtis syndrome) may occur in 5–10% of cases of acute salpingitis. ● The liver is involved due to transperitoneal or vascular dissemination of either gonococcal or chlamydial infection.
- 18. Etiology Anatom y Signs Staging DD’s 18 Signs ● The temperature >38.3°C. ● Abdominal palpation reveals tenderness on both the quadrants of lower abdomen. The liver may be enlarged and tender. ● Vaginal examination reveals: (1)Abnormal vaginal discharge which may be of purulent. (2)Congested external urethral meatus or openings of Bartholin’s ducts through which pus may be seen escaping out on pressure. (3)Speculum examination shows congested cervix with purulent discharge from the canal. (4)Bimanual examination reveals bilateral tenderness on fornix palpation.
- 20. SEPTIC ABORTION 06 RUPTURED ENDOMETRIOTIC CYST 05 A TWISTED OVARIAN CYST 04 DIVERTICULITIS03 ECTOPIC GESTATION 02 ACUTE APPENDICITIS 01 07CHOLECYSTITIS DIFFERENTIAL DIAGNOSIS OF ACUTE PID
- 21. O 1UTERINE FIBROIDS O 2 PELVIC ENDOMETRIOSISO 3OVARIAN TUMOR, TUBERCULAR TUBO OVARIAN MASS O 4 ECTOPIC GESTATION DD’S OF CHRONIC PID
- 22. Etiology Anatom y Staging Sympto ms Signs DD’s AcutepiddIagnosticapproach History, physical examination, & pregnancy test 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 intravenous contrast media Consider PID; obtain transvaginal USG to evaluate for tubo-ovarian abscess Pregnancy Yes Yes Yes No Right lower quadrant No No
- 23. Etiology Anatom y Staging Sympto ms Signs DD’s Pelvic mass on examination? Dysuria and white blood cells on urine analysis? Consider ovarian cyst, ovarian torsion, degenerating uterine fibroid, or endometriosis; obtain transvaginal USG Evaluate for urinary tract infection or pyelonephritis; obtain urine culture Yes Yes No No Transvaginal USG to evaluate for other diagnosis
- 24. BLOOD HAEMOGLOBIN BLOOD COUNT ESR CERVICAL AND HIGH VAGINAL SWAB CULTURE URETHRAL SWAB CULTURE BLOOD CULTURE BLOOD UREA SERUM ELECTROLYTES CULDOCENTESIS LAPROSCOPIC EXAMINATION C-REACTIVE PROTIEN USG,CT,MRI INVESTIGATIONS
- 25. Etiology Anatom y Staging Sympto ms Signs Investigatio ns ● A pregnancy test should always be performed to exclude the important differential diagnosis of ectopic pregnancy. ● High vaginal and endocervical swabs (high vaginal for Trichomonas vaginalis, Candida and bacterial vaginosis, endocervical for gonorrhoea and Chlamydia) should be taken. ● Midstream specimen of urine should be sent for microscopy and culture. ● Full blood count and C-reactive protein are important if the woman is systemically unwell, and urea and electrolytes should be analysed if she is vomiting. ● Serological test for syphilis should be carried out for both the partners in all cases. investigations
- 26. Etiology Anatom y Staging Sympto ms Signs Investigatio ns investigations Ultrasound scan will exclude a large tubo-ovarian collection, but is usually normal with PID except for possible free peritoneal fluid, which is a non- specific finding. Culdocentesis: Aspiration of peritoneal fluid and its white cell count, if exceeds 30,000 per mL. is significant in acute PID. Bacterial culture from the fluid is not informative because of vaginal contamination. Laparoscopy is indicated if the diagnosis is unclear or there is no response to treatment after 48 hours.
- 28. Etiology Anatom y Staging Sympto ms Signs Investigatio ns laproscopy ● Laparoscopy is considered the "gold standard". ● Most reliable aid but not feasible to do in all cases. ● It is reserved only in those cases in which differential diagnosis includes salpingitis, appendicitis or ectopic pregnancy. ● Sure sign of PID- pus extruding from fimbrial end and adhesions.
- 29. Etiology Anatom y Staging Sympto ms Signs Investigatio ns laproscopy Laparoscopic findings and severity of PID: ● Mild: Tubes: edema, erythema, no purulent exudates and mobile. ● Moderate: Purulent exudates from the fimbrial ends, tubes not freely movable. ● Severe: Pyosalpinx, inflammatory complex, abscess. ● ‘Violin string’ like adhesions in the pelvis and around the liver suggests chlamydial infection.
- 30. Etiology Anatom y Staging Sympto ms Signs Investigatio ns laproscopy Violin-string" adhesions of chronic Fitz-Hugh-Curtis
- 31. Etiology Anatom y Staging Sympto ms Signs Investigatio ns ultrasound Ultrasound showing pelvic abscess USG showing pelvic mass
- 32. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Treatment To prevent reinfection.03 To prevent infertility and late sequelae.02 To control the infection energetically.01 THE PRINCIPLES OF THERAPY ARE: Aim : Treat infection, Minimize tubal damage and Prevent adhesions.
- 33. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Treatment Acute PID The mild cases of acute PID are treated at home with antibiotics. Moderate and severe cases of PID need hospitalization. Treatment modalities comprise: Medical treatment, antimicrobial. Minimal invasive surgery. Major surgery.
- 34. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Treatment Hospital management Rest. Intravenous fluids in presence of dehydration or vomiting. Correction of electrolyte imbalance. Analgesics, once the diagnosis is confirmed. Antibiotics. Antibiotics effective are: Tetracycline 500 mg qid 10 days. Erythromycin 500 mg 7 days. Doxycycline 100 mg bd 10 days. Clindamycin 450 mg qid 10 days. Gentamycin 80 mg 8 hourly 5 days.
- 35. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Treatment The following are the newer antibiotic regimens: 1. Cefoxitin 2 g IV 6-hourly + Doxycycline, 100 mg IV followed by oral route. 2. Azithromycin 500 mg IV 6-hourly for 2 days, then orally for chlamydia. 4. Levofloxacin 500 mg bd for 14 days with or without metronidazole. 5. Clindamycin 900 mg intravenously every 8-hourly + gentamicin loading dose IV or IM (2 mg/kg) followed by maintenance dose (1.5 mg/kg) 8-hourly Placentrex (aqueous extract of fresh placenta) -multipronged anti-inflammatory action. It also causes tissue regeneration, wound healing, and has significant immunotropic action involving both humoral and cellular immunity.
- 36. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Treatment Surgical Treatment. Indications Drainage of a pelvic abscess by colpotomy Dilatation and evacuation of septic products of conception Acute spreading peritonitis resistant to full course of chemotherapy. Intestinal obstruction. Suspected intestinal injury as diagnosed in a criminal abortion. Ruptured tubo ovarian abscess.
- 37. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Minimal invasive surgery Indications: 1. The size of the abscess is more than 10 cm. 2. The abscess fails to respond to antibiotics in 48–72 h. 3. Abscess ruptures. 4. Pyoperitoneum. Minimal invasive surgery is done by posterior colpotomy. Ultrasound-guided vaginal aspiration of pelvic abscess. Percutaneous abscess drainage (PAD) under CT. Disadvantages of PAD: Septicaemia, Bladder and bowel injury, Haemorrhage and recurrence. late complicatios: Recurrence, chronic PID, tubal blockage, chronic pelvic pain.
- 38. Etiology Anatom y Staging Sympto ms Investigatio ns Treatme nt Prognosis Boer–Meisel system • Extent of adhesions. • Nature of adhesions, such as flimsy or dense adhesions. •Size of hydrosalpinx. •Macroscopic condition of hydrosalpinx. •Thickness of the tubal wall. Prophylaxis • Hospital delivery is ideal. • Sex education. • Contraception. • Contact tracing and treatment of partner.
- 39. Thank You