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20.Pelvic Inflammatory Disease


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20.Pelvic Inflammatory Disease

  1. 1. Pelvic Inflammatory Disease Bibo Yuan M.D.,Ph.D [email_address]
  2. 2. Pelvic Inflammatory Disease <ul><li>PID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. </li></ul><ul><li>It could be acute, subacute, recurrent, or chronic. </li></ul>
  3. 3. Pelvic Inflammatory Disease <ul><li>Cause: </li></ul><ul><li>bacteria, virus, fungi, and parasites. </li></ul><ul><li>Sexually transmitted organisms, are implicated in many </li></ul><ul><li>cases; especially N. gonorrhoeae and C. trachomatis , </li></ul><ul><li>Microorganisms that comprise the vaginal flora also have </li></ul><ul><li>been associated with PID. (e.g., anaerobes, G. vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae ) </li></ul><ul><li>In addition, cytomegalovirus might be associated with some cases of PID. </li></ul><ul><li>(CMV), M. hominis, U. urealyticum, and M. genitalium) </li></ul><ul><li>All women who are diagnosed with acute PID should be tested for N. gonorrhoeae and C. trachomatis and should be screened for HIV infection. </li></ul>
  4. 4. Pelvic Inflammatory Disease <ul><li>Three proposed pathways of dissemination of microorganisms in pelvic infections: </li></ul><ul><li>Lymphatic spread of bacterial infection: typified by postpartum, post-abortal, some IUD-related infection </li></ul><ul><li>Intro-abdominal spread of microorganisms (gonorrhea and other pathogenic bacteria): represents more common forms of nonpuerperal PID, pathogenic bacteria gain access to the lining of the uterine tubes, then result in purulent inflamation; </li></ul><ul><li>Hematogenous spread of bacterial infection(tuberclosis) </li></ul>
  5. 5. Acute salpingitis-peritonitis <ul><li>Acute onset of pelvic infection. </li></ul><ul><li>Often associated with invasion by N. gonorrhoeae and involving the uterus, tubes, and ovaries, with varying degrees of pelvic peritonitis. </li></ul><ul><li>Acute stage, redness and edema of tubes and ovaries with purulent discharge oozing from the ostium of the tube. </li></ul>
  6. 6. Acute salpingitis-peritonitis <ul><li>Symptoms and signs </li></ul><ul><li>The symptoms of PID can range from none to mild to severe. </li></ul><ul><li>Acute onset of lower abdominal and pelvic pain, usually is bilateral </li></ul><ul><li>Fever. </li></ul><ul><li>Unusual vaginal discharge that may have a foul odor. </li></ul><ul><li>Painful sexual intercourse. </li></ul><ul><li>Irregular menstrual bleeding. </li></ul><ul><li>Pain during a pelvic exam. </li></ul><ul><li>cervical motion tenderness </li></ul><ul><li>uterine tenderness </li></ul><ul><li>adnexal tenderness </li></ul>
  7. 7. Acute salpingitis-peritonitis <ul><li>Lab findings: </li></ul><ul><li>Leukocytosis with a shift to the left is usually present. </li></ul><ul><li>Gonococci may be find in abnormal vaginal or cervical discharge. </li></ul><ul><li>Culdocentesis samples should be sent for smear, culture and sensitivity testing of organisms. </li></ul><ul><li>Ultrasound: </li></ul><ul><li>A pelvic ultrasound may be done to view the pelvic area to see whether the fallopian tubes are enlarged or an infection is present. Sometimes a laparoscopy may be needed. Ultrasonography is most valuable in following the progression or regression of an abscess. </li></ul>
  8. 8. Acute salpingitis-peritonitis <ul><li>Culdocentesis: </li></ul><ul><li>It may be very helpful in diagnosis of suspected pelvic infection. Generally, culdocentesis samples is production of “reaction fluid” when stain, reveals leukocytes with or without gonococci or other organisms. culture and sensitivity testing of organisms from culdocentesis samples are recommended </li></ul>
  9. 9. Culdocentesis: <ul><li>Provide emotional support and encouragement. If necessary, use local infiltration with lignocaine . </li></ul><ul><li>Gently grasp the posterior lip of the cervix with a tenaculum and gently pull to elevate the cervix and expose the posterior vagina.  </li></ul><ul><li>Place a long needle (e.g. spinal needle) on a syringe and insert it through the posterior vagina, just below the posterior lip of the cervix. </li></ul><ul><li>Diagnostic puncture of the cul-de-sac </li></ul>
  10. 10. Acute salpingitis-peritonitis <ul><li>Diagnostic Considerations </li></ul><ul><li>Acute PID is difficult to diagnose because of the wide variation in the symptoms and signs. Many women with PID have subtle or mild symptoms. a diagnosis of PID usually is based on clinical findings. </li></ul><ul><li>Diagnostic Criteria for PID (based on CDC2006) </li></ul><ul><li>minimum criteria : </li></ul><ul><li>cervical motion tenderness OR </li></ul><ul><li>uterine tenderness OR </li></ul><ul><li>adnexal tenderness. </li></ul>
  11. 11. Acute salpingitis-peritonitis <ul><li>Additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID: </li></ul>• oral temperature >101°F (>38.3°C), • abnormal cervical or vaginal mucopurulent discharge, • presence of abundant numbers of WBC on saline microscopy of vaginal secretions, • elevated erythrocyte sedimentation rate, • elevated C-reactive protein, and • laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
  12. 12. Acute salpingitis-peritonitis <ul><li>The most specific criteria for diagnosing PID include the following: </li></ul><ul><li>endometrial biopsy with histopathologic evidence of endometritis; </li></ul><ul><li>transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or doppler studies suggesting pelvic infection (e.g., tubal hyperemia) and </li></ul><ul><li>laparoscopic abnormalities consistent with PID . </li></ul>
  13. 13. Acute salpingitis-peritonitis <ul><li>Differential Diagnosis : </li></ul><ul><li>Acute appedicitis, </li></ul><ul><li>Ectopic pregnancy; </li></ul><ul><li>Endometriosis; </li></ul><ul><li>Diverticulitis; </li></ul><ul><li>Infected septic abortion; </li></ul><ul><li>Torsion of an adnexal mass; </li></ul><ul><li>Degeneration of a leiomyoma, etc. </li></ul>
  14. 14. Acute salpingitis-peritonitis <ul><li>Treatment </li></ul><ul><li>PID can be cured with antibiotics. But any damage that has already been done to a woman's pelvic organs (uterus, fallopian tubes, and ovaries) before treatment will not be reversed. </li></ul><ul><li>Early treatment for PID is very important. Positive treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on immediate administration of appropriate antibiotics. </li></ul><ul><li>PID treatment regimens must provide empiric, broad spectrum coverage of likely pathogens. </li></ul>
  15. 15. Acute salpingitis-peritonitis <ul><li>Outpatient Therapy : </li></ul><ul><li>Acute salpingitis, but temperature is less than 39C </li></ul><ul><li>Lower abdominal findings are minimal </li></ul><ul><li>The patient is not toxic and can take oral medication </li></ul><ul><li>Treat with antibiotics, IUD removal ,analgesics, and bed rest </li></ul>
  16. 16. Acute salpingitis-peritonitis <ul><li>The following criteria for hospitalization are suggested: </li></ul><ul><li>surgical emergencies (e.g., appendicitis) cannot be excluded; </li></ul><ul><li>the patient is pregnant; </li></ul><ul><li>the patient does not respond clinically to oral antimicrobial therapy; </li></ul><ul><li>the patient is unable to follow or tolerate an outpatient oral regimen; </li></ul><ul><li>the patient has severe illness, nausea and vomiting, or </li></ul><ul><li>high fever; and </li></ul><ul><li>the patient has a tubo-ovarian abscess. </li></ul>
  17. 17. Acute salpingitis-peritonitis <ul><li>Prognosis: </li></ul><ul><li>Outcome is directly related to the promptness with which adequate therapy is begin. </li></ul>
  18. 18. Acute salpingitis-peritonitis <ul><li>Complication </li></ul><ul><li>Pelvic peritonitis or generalized peritonitis; </li></ul><ul><li>Prolonged adynamic ileus; </li></ul><ul><li>Pelvic cellulitis with thrombophlebitis; </li></ul><ul><li>Abscess formation with adnexal destruction and subsequent infertility; </li></ul><ul><li>Intestinal adhesions and obstruction… </li></ul>
  19. 19. Chronic Pelvic Infection <ul><li>Chronic pelvic infection implies the presence of tissue changes in tubes and ovaries. </li></ul><ul><li>Adhesions of peritoneal surfaces to the adnexa, fibrotic changes in the thubal lumen are common. </li></ul><ul><li>It usually are secondary to acute salpingitis. </li></ul>
  20. 20. Chronic Pelvic Infection <ul><li>Symptoms and signs </li></ul><ul><li>History of pelvic infection; </li></ul><ul><li>Abdominal pain unilateral or bilateral; </li></ul><ul><li>Low fever; </li></ul><ul><li>Tenderness upon movement of the uterus, cervix, adnexa; </li></ul><ul><li>Adnexal mass. </li></ul>
  21. 21. Chronic Pelvic Infection <ul><li>Differential diagnosis </li></ul><ul><li>Ectopic pregnancy; </li></ul><ul><li>Endometriaosis; </li></ul><ul><li>Appendicitis; </li></ul><ul><li>Ovarian cyst or neoplasm; </li></ul><ul><li>Acute or chronic cystourethritis, etc. </li></ul>
  22. 22. Chronic Pelvic Infection <ul><li>Complication </li></ul><ul><li>Hydrosalpinx; </li></ul><ul><li>Pyosalpinx; </li></ul><ul><li>Tuboovarian abscess; </li></ul><ul><li>Infertility or ectopic pregnancy; </li></ul><ul><li>Chronic pelvic pain. </li></ul>
  23. 23. Chronic Pelvic Infection <ul><li>Prevention </li></ul><ul><li>Prompt and adequate treatment of acute PID is essential preventive measure. </li></ul><ul><li>Education about avoidance of sexually transmitted diseases (STD) is also important. </li></ul>
  24. 24. Chronic Pelvic Infection <ul><li>Treatment </li></ul><ul><li>Long-term antibiotics is worthy of trial in young woman of low parity, ibuprofen can be used for symptoms relief; if symptoms still remain after 3 weeks of antibiotic treatment, laparoscopy and exploratory laparotomy are needed to rule out other causes; </li></ul><ul><li>If infertility is a problem, verify tubal patency by hysterosalpingography or laparoscopy are recommended; priscrible antibiotics before and after procedure; </li></ul><ul><li>Total abdominal hysterectomy with bilateral adnexectomy may be indicated if disease is far advanced and the woman is symptomatic or if an adenexal mass is demonstrated. </li></ul>
  25. 25. Chronic Pelvic Infection <ul><li>Prognosis </li></ul><ul><li>Depend on damage of pelvic organ; </li></ul><ul><li>Multiple recurrence pelvic infection will increase infertility and ectopic pregnancy incidence; as well as tubo-ovarian and other pelvic abscesses. </li></ul>
  26. 26. Pelvic (CUL-DE-SAC) Abscess <ul><li>May occur as sequela to acute pelvic or postabortal infection; </li></ul><ul><li>Abscess formation is frequently associated with anaerobic species, especially Bacteroides. Occasionally. ressistant gram-negative bacteria can be found. </li></ul>
  27. 27. Pelvic (CUL-DE-SAC) Abscess <ul><li>Clinical findings </li></ul><ul><li>Any symptoms of acute or chronic pelvic inflammation may be present; </li></ul><ul><li>Usually have more severe symptoms, (painful defecation, severe back pain, rectal pain); </li></ul><ul><li>Fluctuant mass filling cul-de-sac and dissecting into the rectovaginal septum; </li></ul>
  28. 28. Pelvic (CUL-DE-SAC) Abscess <ul><li>Differential Diagnosis : </li></ul><ul><li>Tuboovarian abscess; </li></ul><ul><li>Periappendiceal abcess; </li></ul><ul><li>Adnexal torsion; </li></ul><ul><li>Ectopic pregnancy; </li></ul><ul><li>Endometriosis; </li></ul><ul><li>Diverticulitis with perforation; </li></ul><ul><li>Ovarian tumor; </li></ul><ul><li>Torsion of an adnexal mass; </li></ul><ul><li>Degeneration or torsion of a leiomyoma, etc. </li></ul>
  29. 29. Pelvic (CUL-DE-SAC) Abscess <ul><li>Treatment </li></ul><ul><li>Antibiotics target to anaerobic and aerobic pathogen; </li></ul><ul><li>Drainage: </li></ul><ul><li>Colpotomy drainage- if the abscess is dissecting the rectovaginal septum; </li></ul><ul><li>Percutaneous drainage-If fever persists in the face of altered antimicrobial therapy, but there is no evidence of abscess rupture or dissecting the rectovaginal septum; </li></ul><ul><li>Reevaluate abdominal findings frequently to detect peritoneal involvement; Exploratory laparotomy is needed if the patient’s condition deteriorates. </li></ul>
  30. 30. Pelvic (CUL-DE-SAC) Abscess <ul><li>Prognosis </li></ul><ul><li>The prognosis for the patient with well localized abscess is good with early treatment ; </li></ul><ul><li>The prognosis for fertility is very poor. </li></ul>
  31. 31. Tubo-ovarian abscess <ul><li>Tuboovarian abscess (TOA) involving the ovary and fallopian tube most often arises as a consequence of pelvic inflammatory disease (PID). However, TOA can also develop following pelvic surgery, or as a complication of an intraabdominal process, such as appendicitis or diverticulitis. </li></ul><ul><li>Organisms recovered from TOA are those found in PID, namely, a mixed polymicrobial infection with a high prevalence of anaerobes. </li></ul><ul><li>Treatment modalities for TOA include antibiotics, guided drainage, and surgery. </li></ul>
  32. 32. Tubo-ovarian abscess <ul><li>DIAGNOSIS </li></ul><ul><li>Symptoms and signs </li></ul><ul><li>History of previous PID; </li></ul><ul><li>Abdominal and/or pelvic pain are reliable features, present in over 90 percent of patients with TOA; </li></ul><ul><li>Fever and leukocytosis are found in approximately 60 to 80 percent of such patients; </li></ul><ul><li>Nausea and vomiting are common; </li></ul><ul><li>Abdominal tenderness and guarding may present, adequate pelvic examination is often impossible due to tenderness, but an adnexal mass maybe palpated. </li></ul>
  33. 33. Tubo-ovarian abscess <ul><li>DIAGNOSIS </li></ul><ul><li>Ultrasonography </li></ul><ul><li>The test of choice to confirm or exclude TOA is ultrasonography. </li></ul><ul><li>Most importantly, ultrasound is emerging as the imaging technique best suited to guide drainage of these abscesses, which may be a central element of therapy. </li></ul>
  34. 34. Tubo-ovarian abscess <ul><li>Ultrasonography </li></ul><ul><li>TOA appears by sonogram classically as one or more relatively homogeneous, somewhat symmetrical, cystic, thin-walled, well-demarcated mass(es) which are usually contiguous. An air fluid level may be seen; septations are present in multiloculated TOAs. </li></ul><ul><li>Ultrasound examination is indicated in these patients suspected of PID: </li></ul><ul><li>Those with a palpable mass </li></ul><ul><li>Those who are severely ill and/or for whom inpatient therapy is planned </li></ul><ul><li>Those failing to respond to appropriate medical therapy </li></ul><ul><li>Those in whom tenderness or other factors preclude an adequate rectovaginal pelvic examination. </li></ul>
  35. 35. Tubo-ovarian abscess <ul><li>Differential diagnosis </li></ul><ul><li>The differential diagnosis of TOA is extensive; ectopic pregnancy, all of the pelvic neoplasms, ovarian hematoma or torsion, appendiceal and diverticular abscesses, and uterine pyomyoma all must be considered. </li></ul>
  36. 36. Tubo-ovarian abscess <ul><li>TREATMENT CONSIDERATIONS </li></ul><ul><li>Potent new antibiotics, earlier presentation for medical care, improved imaging capabilities have all contributed to a better therapeutic outcome for TOA in recent years. </li></ul><ul><li>The majority of clinicians recommend at least 24 hours of direct inpatient observation for patients who have tuboovarian abscess </li></ul>
  37. 37. Tubo-ovarian abscess <ul><li>Long-term antimicrobials therapy with anaerobic coverage; </li></ul><ul><li>When medical therapy alone is not successful, or a large abscess is identified, drainage procedures need to be employed. Since most women with tubo-ovarian abscess are of reproductive age, the primary aim of management is to be as conservative as possible when considering percutaneous drainage versus open surgery. </li></ul><ul><li>Almost all patients failing to respond within four days require surgery. Laparoscopy or laparotomy is mandatory in all cases of suspected leakage or rupture as well as in all cases that do not respond to medical management and percutaneous drainage. </li></ul>
  38. 38. Tubo-ovarian abscess <ul><li>Transvaginal drainage — Drainage of TOA using ultrasound guidance or laparoscopy is a major therapeutic advance in the treatment of this disorder. </li></ul><ul><li>Laparoscopic drainage — Use of the laparoscope for preemptive drainage is an alternative approach. </li></ul>
  39. 39. Tubo-ovarian abscess <ul><li>There is no current indisputable standard of care for TOA. </li></ul><ul><li>The following protocol can serve as a general guideline for the safe and cost effective treatment of TOA following first diagnosis. </li></ul>
  40. 40. Tubo-ovarian abscess <ul><li>Treatment of tubo-ovarian abscess </li></ul><ul><li>1. Begin intravenous fluids </li></ul><ul><li>2. Begin potent broad-spectrum antibiotics </li></ul><ul><li>a. Ampicillin (2 g IV Q4h) PLUS gentamicin (standard doses) PLUS metronidazole (500 mg PO or IV Q8h), OR </li></ul><ul><li>b. Ofloxacin (400 mg IV Q12h) PLUS metronidazole (500 mg PO or IV Q8h), OR </li></ul><ul><li>c. Single agent therapy with one of the following: ticarcillin clavulanate (3.1 g IV Q4h), piperacillin tazobactam (4 g/0.5 g IV Q8h), or imipenem cilastatin (500 mg IV Q6h) </li></ul><ul><li>3. Survey for sepsis syndrome including: </li></ul><ul><li>a. Vital signs, examination (including mental status) </li></ul><ul><li>b. Blood cell counts and chemistries </li></ul><ul><li>c. Coagulation studies </li></ul><ul><li>d. Chest x-ray, EKG </li></ul><ul><li>e. Urine output </li></ul><ul><li>4. Place nasogastric tube to suction if ileus has developed </li></ul><ul><li>5. Guided drainage of TOA within 24 to 48 hours should be strongly considered </li></ul><ul><li>a. Transvaginal approach using an endovaginal sonographic probe with needle guide should be considered first; if not possible proceed to CT or US guided transcutaneous approach, or laparoscopic approach </li></ul><ul><li>b. Place indwelling catheter if contents too viscous to aspirate </li></ul><ul><li>c. Colpotomy drainage may be used only if the abscess is fixed and distending the low rectovaginal septum in the midline </li></ul><ul><li>d. Send aspirate for microbiologic evaluation (and cytologic analysis if fluid is serous or cloudy) </li></ul><ul><li>6. Correct any underlying medical derangements (eg, anemia, hyperglycemia, hypoproteinemia, hypoxia) </li></ul>
  41. 41. Pelvic Tuberculosis <ul><li>Pelvic Tuberculosis is becoming rare; </li></ul><ul><li>Usually represents secondary invasion from a primary lung infection via the lymphohematogenous route; </li></ul><ul><li>The oviducts were the most frequently involved, and the endometrium next most frequently. </li></ul>
  42. 42. Pelvic Tuberculosis <ul><li>Symptoms and signs </li></ul><ul><li>Infertility-maybe the only complaint; </li></ul><ul><li>Dysmenorrhea; amenorrhea; some other disturbance of cycle; </li></ul><ul><li>Pelvic pain; low-grade fever; asthenia; weight loss; </li></ul><ul><li>Evidence of Tuberculosis peritonitis . </li></ul>
  43. 43. Pelvic Tuberculosis <ul><li>Diagnosis </li></ul><ul><li>Base on complete history, physical examination, chest X-ray and lung scan, tuberculin test, sputum smears and sputum culture. </li></ul><ul><li>Gross ascites with fluid containing more than 3 g of protein per 100 ml of peritoneal fluid is characteristic of tuberculosis peritonitis. </li></ul><ul><li>Pelvic tuberculosis is usually encountered in the course of gynecologic operation done for other reasons. some distinguishing features include: extremely dense adhesions without planes of cleavage, segmental dilatation of the tubes. </li></ul>
  44. 44. Pelvic Tuberculosis <ul><li>Lab findings </li></ul><ul><li>Best direct method of diagnosis is detection of acid-fast bacteria from menstrual discharge, or from curettage or biopsy, or from peritoneal biopsy. </li></ul>
  45. 45. Pelvic Tuberculosis <ul><li>X-ray Findings </li></ul><ul><li>A chest X-ray should be taken in any patient with proved or suspected tuberculosis of other organs or tissues; </li></ul><ul><li>Hysterosalpingography: the tubal lining may be irregular, and areas of dilatation may be present. </li></ul>
  46. 46. Pelvic Tuberculosis <ul><li>Special Examination </li></ul><ul><li>Laparoscopy and aspiration of fluid for culture and biopsy of affected area is possible and often diagnostic. </li></ul>
  47. 47. Pelvic Tuberculosis <ul><li>Differential diagnosis </li></ul><ul><li>Schistosomiasis; </li></ul><ul><li>Enterobiasis; </li></ul><ul><li>Lipoid salpingitis; </li></ul><ul><li>Carcinoma; </li></ul><ul><li>Chronic pelvic inflamation. </li></ul>
  48. 48. Pelvic Tuberculosis <ul><li>Complications </li></ul><ul><li>Sterility and tuberculous peritonitis are possible sequelae of pelvic tuberculosis. </li></ul>
  49. 49. Pelvic Tuberculosis <ul><li>Treatment </li></ul><ul><li>Medical measures: </li></ul><ul><li>Initial therapy should include 4 drugs to prevent the emergence of drug-resistant strains. The drug for 1st 2 months of treatment should include: isoniazid, rifampin,pyrazinamide,and streptomycin or ethambutol. Once drug susceptibility results are available,the drug can be appropriately changed,tratment should continued for 2-3 years. </li></ul>
  50. 50. Pelvic Tuberculosis <ul><li>Treatment </li></ul><ul><li>Specific measures: </li></ul><ul><li>Surgical intervention may be necessary if the following conditions are present: </li></ul><ul><li>Masses not resolving after medical therapy; </li></ul><ul><li>Resistant or reactived disease; </li></ul><ul><li>Persistent menstrual irregularities; </li></ul><ul><li>Fistula formation. </li></ul>
  51. 51. Objectives <ul><li>Master the cause, pathology, clinical manifestations, diagnosis, and differential diagnosis of pelvic inflammatory diseases; </li></ul><ul><li>Know about the significance of prevention and thorough treatment of pelvic inflammatory diseases. </li></ul><ul><li>Master spread, pathologic changes and clinical manifestation of tuberculosis of the female reproductive system; </li></ul><ul><li>Know about assisting tests for tuberculosis of the female reproductive system; </li></ul><ul><li>Be familiar with diagnosis, differential diagnosis and treatment of tuberculosis of the female reproductive system. </li></ul>