4. No specific international data are available for PID incidence
worldwide
The annual rate of PID in high-GNP countries has been reported to
be as high as 10-20 per 1000 women of reproductive age (most < 25
year-old)
24% of visits to the E. departments for gynecological pain are
attributable to PID
Annual cost: $ 10 billion (acute care and sequelae: tubal factor
infertility, ectopic pregnancy, chronic pelvic pain, recurrent
infection, life treatening condition if TOA rupture)
Potter AW. RadioGraphics 2008
Crossman SH. American Family Physician. 2006
Srikar Adhikari. The Journal of Emergency Medicine, 2008
PID
5. RISK FACTORS FOR PID
Young age
Multiple sex partners
High coital frequency
Low socioeconomic status
Douching
Use of intrauterine device (particularly during the first few months
of insertion)
Barret S et al. International Journal of STD & AIDS 2005
Mindy M. Horrow. Ultrasound Quarterly 2004
6. Extension to: parametrial structures
Direct ascent to the upper genital tract: pyosalpinx, TOA
salpingitis
endometritis
Acquisition of a vaginal or cervical infection: endocervicitis
Soper DE. Obstet Gynecol 2010
PID
PATHOPHYSIOLOGY
Beyond the pelvis
7. Less commonly:
- Direct spread from nearby appendicitis or diverticulitis
- Hematogenous, lymphatic, peritoneal spread: TB salpingitis
PID
8. 70%
• N. Gonorrhoeae
• C. Trachomatis
• Mycoplasma genitalium
30%
• Polymicrobial
• Streptococcus species,
Escherichia coli, Hemophylus
influenza, Bacteroides species,
Peptostreptococcus,
Peptococcus…………..
MICROBIAL ETHIOLOGY
Barret S. Int J STD AIDS. 2005
Soper DE.Obstetrics and Gynecology 2010
10. PID should be suspected and treatment initiated if:
- High risk of PID and
- Uterine, adnexal, or cervical motion tenderness on bimanual pelvic examination
Findings that support the diagnosis (1 or more)
- Cervical or vaginal mucopurulent (green or yellow) discharge
- Elevated erytrocyte sedimentation rate or C -reactive protein
- Laboratory confirmation of gonorrheal or chlamydial infection
- Oral temperature (38.3ºC) or greater
- White blood cells on vaginal secretion saline wet mount ( peripheral white blood cell
count is commonly normal)
Elaborate criteria (additional findings)
- Positive laparoscopy or endometrial biopsy
- Pyosalpinx, TOA on imaging
CDC: Centers for Disease Control and Prevention guidelines on sexually transmitted
diseases. MMWR Recomm Rep 2006.
CDC DIAGNOSTIC CRITERIA FOR PID
PID DIAGNOSIS
PHYSICAL EXAMINATION AND LABORATORY STUDIES
11. TREATMENT
Up to 90% of women have mild PID - treated as outpatients
10% of women have severe PID: complications
The identification of patients who require hospitalization
are usually accomplished with imaging studies
12.
13. Imaging is required:
- to determine the origin and the extent of the process, if
symptoms are nonspecific
- to evaluate for complications such as abscess, if the patient is not
responding as expected to treatment, and
- to decide if a known abscess is amenable to percutaneous
drainage.
Maryam Rezvani. RadioGraphics 2011
Abraham A. Ghiatas, Eur Radiol 2004
PID DIAGNOSIS
IMAGING
14. US
Transvaginal
Sensitivity: 81%
Specificity:78%
Accuracy: 80%
Transabdominal
CT
Sensitivity: <65%
Specificity: >90%
Accuracy: 84%
- After-hours availability
- Symptoms are nonspecific
- Process beyond the pelvis
- Limiting factor: ionizing radiation
MR
Sensitivity: 95%
Specificity: 89%
Accuracy: 93%
- No radiation
- Limiting factor: expensive, less available
- Pregnant patient
- Complex adnexal mass
- Diff. pyosalpinx/ hematosalpinx
- Chronic PID: fibrosis, adhesions
Tukeva TA et al. Radiology 1999
Young SI et al. J. Obstet. Gynaecol. Res.2011
- No cooperate because
they are suffering from
excessive pain
- Large amounts of gas
preventing ultrasound
penetration
- Obesity
15. US
Transvaginal
Transabdominal
CT
MRACR: 9
ACR: 5 - Gyn
9 - N- Gyn
ACR: 6 - Gyn
3 - N- Gyn
• ACR Appropriateness Criteria® acute pelvic pain in the reproductive age group.
http://www.guidelines.gov/content.aspx?id=15779&search=Acute+pelvic+pain
• Heverhagen JT. RadioGraphics 2009
The American College of Radiology Appropriateness Criteria® still rate MR imaging below
CT and US for the evaluation of acute abdominal and pelvic conditions
1 = least appropriate; 9 = most appropriate
16. EARLY STAGE OF PID
IMAGING FINDINGS
Normal
Non- specific findings:
. Fluid in the endometrial and
endocervical cavities
. Mild enlargement or
indistinctness of the uterus
. Enlarged ovaries with “polycystic
” appearance
. Fluid in the cul-de-sac (50% of
patients with PID)
Horrow MH. Ultrasound Quarterly 2004
17. Endometritis
Abnormal endometrial
enhancement and fluid
Mild oophoritis
Sam JW.RadioGraphics 2002
MILD STAGE OF PID
IMAGING FINDINGS
Mild salpingitis
Not tubal dilatation but wall
tickening (> 5mm),
enhancement, and surrounding
inflammation
18. Mild pelvic edema
Thickening of the uterosacral ligaments and haziness of
the pelvic fat
Sam JW.RadioGraphics 2002
MILD STAGE OF PID
IMAGING FINDINGS
19. Pyosalpinx
ADVANCED STAGES OF PID
Most specific
sign of PID at
CT
Sam JW.RadioGraphics 2002
Potter AW. Radiographics 2008
20. - Stranding of the
pelvic fat
- Lymphadenopathy
ADVANCED STAGES OF PID
Jung SI et al. J. Obstet. Gynaecol. Res. 2011
Peritonitis
- Thickening of
pelvic
ligaments
- Obscuration of
the pelvic
fascial planes
25. HYDROSALPINX VS PYOSALPINX
PYOSALPINX:
- Active and acute infection with obstruction of the FT
-Thick enhancing wall and surrounding inflammation
- Image: depends on the content of protein
US: hipoechoic-hyperechoic.
MR: hypointense, heterogeneous T1W, hyperintense T2W
HYDROSALPINX:
- Chronic disease
- Results from the obstruction of the ampullary segment: PID, tubal surgery….
- Thin-thick wall, no enhancement and no surrounding inflammation
- Image: US: anechoic
MR: hypointense T1W, hyperintense T2W
26. CE T1 w
Courtesy: Dr. John SpencerTubal and peritubal adhesions with obstruction of
the fimbrial end lead to:
Tubal shape changes
- Sharp change of shape: “ beak sign”
27. HYDROSALPINX
”cogwheel sign”: or
small round projections
on axial imaging--
thickened longitudinal
folds
Accurate findings for diagnosing hydrosalpinx
Tubular “C” “S”
“waist sign”:
incomplete septa
result from the
distended tube
folding on itself
28. 1/3 women with severe PID
TOA
Heterogeneous mass
Indistinct ovaries
- Fluid-containing
mass with a thick
enhancing wall and
septations
-Anterior
displacement of
thickened broad
ligament
Kim SH. RadioGraphics 2004
- Pyosalpinx
adjacent to or in a
portion of TOAs
29. - Extension to form
abdominal abscesses
TOA
- A more specific sign of tubo-
ovarian abscess: gas bubbles
30. TOA
30 % of patients with TOA respond to treatment: (parenteral
antibiotics 48 h ---- oral antibiotics for up to 14 days)
If conservative treatment fails:
- Image-guided percutaneous (US, CT) or surgical drainage
(laparotomy, laparoscopy)
Levenson RB. J Vasc Interv Radiol 2011
31. PID
ABDOMINAL COMPLICATIONS
Spread of infection via the
right paracolic gutter
Rezvani M.RadioGraphics 2011
-Perihepatitis: thickening and enhancement of the
anterior liver capsule
- Subcapsular and periportal alterations of
perfusion
Fitz-Hugh-Curtis Syndrome
40. Chronic infection by Actinomyces israelii
Opportunistic pathogen: normally present in oral cavity or colon
Gynecological Actinomycosis is highly associated with the use
of IUDs.
Chronic suppurative disease
Abundant granulation
Dense fibrous tissue
Multiple abscesses
Sinus tracts
ACTINOMYCOSIS
41. Heterogeneous, well or badly defined adnexal masses, contrast
enhancement (rim-enhancement) in the solid portion
ACTINOMICOSIS
IMAGING
Courtesy: Dr. A. J Van der Molen
42. ACTINOMICOSIS
IMAGING
- Abscess
- Thick, linear, enhancing lesions
extending into the adjacent tissue
planes, which reflects the invasive
nature of actinomycosis
Courtesy: Dr. A. J Van der Molen
43. Genital tract involvement is detected in 1.3% of female patients
with tuberculosis: endometrium (72%), salpinx (34%), ovary
(12.9%), and cervix (2.4%).
It can mimic ovarian cancer by both radiological findings and
clinical settings (elevated serum CA-125)
TUBERCULOSIS
44. Findings can be various
according to the stage and the
route of this infection
General peritoneal tuberculosis,
minimal salpingitis with enlarged
FT, without obstruction
Image findings mimic those of
peritoneal carcinomatosis
TUBERCULOSIS AT IMAGING
45. TUBERCULOSIS AT IMAGING
Tubo-ovarian involvement is usually caused by
hematogenous or lymphatic spread.
-Cystic or both solid and cystic adnexal masses,
usually bilateral
-Ascites, omental or mesenteric infiltrations,
and peritoneal thickening
(*peritoneal carcinomatosis from ovarian
cancer)
-Calcifications, not frequently observed
- Lymph node enlargement
Pelvic infection can be divided into 2 important categories according to the origin of the infection: Gynaecological and non-gynaecological causes. PID and intestinal diseases are the most frequent causes of acute pelvic infection.In the next 19 minutes we are going to see, the broad spectrum of PID presentation and some of its mimics and possible complications
As many as 24%It represents an amount of$ 10 billion as annual cost related to the acute care and sequelae of PID.
Strong association with sexually transmitted disease (STD).
At presentation, women with PID may range from no symptoms (30%) – non-specific and may simulate urinary or gastrointestinal pathology
There are physical and laboratory findings that support the diagnosis and elaborate criteria such as laparoscopy, or imaging studies as additional findings .
Therefore the diagnosis of PID remains clinical in nature.
US is the initial study in female patients with pelvic sympthomatology.MR imaging is not traditionally used in the acute setting or in the evaluation of PID because MR still is expensive, less available. MR imaging can be particularly useful in the evaluation of a complex adnexal mass, in the setting of chronic PID in helping differentiate pyosalpinx from hematosalpinx in the context of endometriosis. And in the chronic setting of PID to define fibrosis and adhesions..
The fallopian tubes become edematous
The fallopian tubes become edematous
On the other hand Pyosalpinx, depends on the protein of the fluid, but more frequently is
The fallopian tube becomes elongated, C- or S-shaped anechoic tubular structure which contains fluid which, may appear anechoic (clear).
Differential diagnosis of PID in a young woman includes other non infectious gynecological issues, and And other infectious pelvic diseases, with the same clinical presentation most of the cases
In postmenopausal women, ascending PID is very rare. If it is suspected clinically, we have to think of a direct spread from a nearby appendicitis or diverticulitis, like in this patient.