Important aspects of Pelvic inflammatory disease in summarised manner..

1. PELVIC INFLAMMATORY
DISEASE
Nimesha Dinusanka Jayawardana

2.  Inflammation of the uterus fallopian tubes and
ovaries as it progress to scar formation with adhesion
to near by tissue and organs
Definition

3.  Infection and Inflammation ascending from
endocervix leading to inflammation in
 endometrium – Endometritis
 Fallopian tubes – Salphyngitis
 Ovaries – Oophoritis
 Parametrium – Parametritis
 Pelvic peritoneum – Pelvic peritonitis
 Tubo-ovarian abscess

4.  Neisseria gonorrhoeae
 Chlamydia trachomatis
 Anaerobes
 Gardnerella vaginalis
 Mycoplasma genitalium
Common Causative Organisms

5. Neisseria Gonorrhoea
 Gram negative diplococci
 Infect cuboidal and columnar epithelium
 Co-infection with trichomonas
 Investigations
 Endo-cervical swab(rectum and Pharynx)
 Gram stain
 Culture- Agar medium
 Nucleic acid amplification test

6. Chlamydia trachomatis
 Obligate intra-cellular bacteria
 Affect columnar epithelium
 Cause PID, Conjunctivitis, Perihepatitis
 Diagnostic test-
 Nucleic acid amplification test,
 PCR
 Culture

7.  Fever
 Vaginal discharge
 Mucopurulent offensive
 Heavy/Inter-menstrual bleeding, Dysmenorrhea
 Pain
 Pelvic pain
 Bilateral Lower abdominal Pain
 Deep dyspareunia
 Pelvic masses
Clinical Features - Symptoms

8.  Pyrexia - >380C
 Abdominal Examination:
 Bilateral lower abdominal and Pelvic tenderness
 Palpable pelvic mass
 Speculum Examination:
 Cervicitis
 Bimanual VE:
 Cervical excitation/Cervical motion tenderness
(Chandelier sign)
 Tender adnexal mass/ Adnexal tenderness
Signs

9.  Damage to Fallopian tubes
 Peritoneal inflammation
 Adhesion formation –
 Between pelvic structures
 Omental
 Perihepatic – Fitz-Hugh-Curtis syndrome
 Abscess formation –
 Tubo -ovarian abscess
 Hydrosalpinx
 Pyosalpinx
 Subfertility
 Sepsis
Complications

10. Tubo-ovarian abscess Bilateral Pyosalpinx

11.  Ectopic Pregnancy
 Acute Appendicitis
 Endometriosis
 Torsion or rupture of an ovarian cyst
 UTI
 Functional pain
Differential Diagnosis

12.  Full blood count
 Raised WBC – Neutrophilia
 Reduced WBC - Neutropenia
 CRP & ESR
 Elevated
 USS
 Tubo-ovarian mass
 Pelvic mass
 Endocervical Swab microscopy and Culture
 Test for Chlamydia & Gonorrhoea
 Laparoscopy
 Urine hCG
Investigations

13. Minimal Criteria
1. Pelvic Tenderness
2. Adnexal Tenderness
3. Cervical Tenderness
Supportive Criteria
1. Temperature > 38.3
2. Elevated ESR,CRP and WBC
3. Offensive Vaginal discharge
4. Positive N. Gonorrhoea and Chlamydia
Diagnosis

14. Definitive Criteria
1. Histological evidence of endometritis
2. Tubo-ovarian mass on ultra sound
3. Laparoscopic evidence

15.  Depends on severity of disease
 Out patient treatment
 Mild/moderate disease
 Inward treatment
 Severe infection
 Adnexal masses suspicious of abscess
 Generalized sepsis
 Poor/inadequate response to oral treatment
 Severe pelvic/abdominal pain requiring strong analgesics
 IUCD if present has to removed
 Pregnancy test in all cases to exclude ectopic
Management

16.  Adequate supportive care:
 Rest and analgesics
 Fluid balance
 Antibiotics
 Surgical Treatment
 Patient Counseling
Principles of Management

17.  Triple antibiotic therapy – Directed towards
Chlamydia, Gonorrhoea and anaerobes
 Single IM Ceftriaxone 500mg
 Oral Doxycycline 100mg bd – 14 days
 Metronidazole 400mg bd – 14 days
 Non- gonococcal infections
 Oral ofloxacin 400mg bd/ Levofloxacin 500mg daily - 14
days
 Metronidazole 400mg bd – 14 days
Antibiotic Treatment

18.  In patients with pelvic abscess or not responding to
therapy
 Laparoscopy done
 Can exclude other DDx – Appendicitis, endometriosis,
ovarian pathology
 Drainage of abscess done
 Adhesiolysis in chronic cases
 Affected tube/ovary may have to be removed
Surgical Treatment

19.  Screening of Partner and other sexual contacts for
Gonococcus, Chlamydia, HIV & Other STDs
 Treat them early to prevent reinfection
 Barrier contraception use until treatment completed
 Explain the possibility of ectopic pregnancy, chronic
pelvic pain and subfertility as sequelae of reinfection
 Prompt and early treatment reduce risk of subfertility
 Seek early medical advise if pregnant, due to risk of
ectopic pregnancy
Patient Counseling