Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that is usually caused by sexually transmitted pathogens like Chlamydia trachomatis and Neisseria gonorrhoeae. It is diagnosed clinically based on symptoms of pelvic or lower abdominal pain along with cervical motion tenderness and can be confirmed with laparoscopy. Treatment involves broad-spectrum antibiotics to cover common causes. Complications include infertility, ectopic pregnancy, and chronic pelvic pain if left untreated. Prevention focuses on sexual health education, screening, and prompt treatment of infections.

1. PRE-TEST
1. Pelvic inflammatory disease involve all of the following
except
a. Endometritis
b. Salphingitis
c. Oopharitis
d. Cervicitis
2. PID is frequently associated with the following organisms
a. N.gonorrhea
b. C.trachomatis
c. M.genitalium
d. None of the above
e. All of the above

2. PRE-TEST
3. All are risk factors of PID except
a. Barrier contraceptive
b. IUCD
c. Early coitarchy
d. Low socioeconomic status
4. The gold standard diagnostic radiologic procedure for PID is
a. Transvaginal ultrasonography
b. Computed tomography
c. Laparoscopy
d. Magnetic resonance imaging

3. PRE-TEST
5. All are features of Fitz-Hugh-Curtis Syndrome except
a. Cause by infected peritoneal fluid leaks from the pelvis to
the peri-hepatic area
b. Adhesion bands between the liver capsule and the
visceral peritoneum
c. Present with left quadrant pain
d. Present with right hypochondrial tenderness
6. Parenteral treatment of PID includes a cephalosporin and
which of the following agent
a. Clindamycin
b. Doxy.cycline
c. Ofloxacin
d. metronidazole

4. MANAGEMENT OF PELVIC
INFLAMMATORY DISEASE
DEPARTMENT OF FAMILY MEDICINE
MMSH.
BY: AISHA LAMIDO
MODERATOR: DR AISHA BELLO

5. OUTLINE
• INTRODUCTION
• DEFINITION
• EPIDEMIOLOGY
• ETIOLOGY
• PATHOPHYSIOLOGY
• RISK FACTORS
• CLINICAL FEATURES
• CLASSIFICATION
• MANAGEMENT OF PID
• DIFERRENTIALS
• COMPLICATIONS
• PREVENTION
• CONCLUSION

6. INTRODUCTION
• Pelvic inflammatory diseases (PID) is a major
cause of gynaecological morbidity world wide
• It is an infection involving the upper female
genital tract
• It is typically an ascending infection spreading
from lower genital tract
• The majority of cases are related to sexually
transmitted infections (STI)
• The diagnosis is primarily clinical and should be
suspected in any young female patient with lower
abdominal or pelvic pain and genital tract
tenderness

7. INTRODUCTION
• If poorly treated PID is strongly associated
with infertility and or increased risk of ectopic
pregnancy.

8. DEFINITION
• Pelvic inflammatory disease (PID) is
polymicrobial infectious and inflammatory
disorder of the upper female genital tract,
including the uterus, fallopian tubes, ovaries
and adjacent pelvic structures, that primarily
affects young sexually active women (mainly
young females in their reproductive years).

9. IMAGE

10. EPIDEMIOLOGY
• A major clinical and public health problem
globally accounting for 5-20% gynecological
hospital admission
• It occurs most frequently in women age 15-25yrs
• The higher the STI prevalence in a country the
higher the PID prevalence
• Prevalence in the USA is about 4.4% among
sexually active women
• Prevalence in Nigeria is 11-70% among women
of reproductive age.
• Prevalence is higher among women with risky
sexual behavior and sexual promiscuity.

11. ETIOLOGY
• A polymicrobial infection with variety of
organisms involved
• 85% of PID is frequently associated with STI
micro-organisms (Chlamydia trachomatis, N.
gonorhoeae, Trichomona vaginalis).
• Gonorrheal PID is more severe than PID due to
other causes
• Chlamydia usually causes subclinical PID with
little or no symptoms and can still cause adverse
long term complications

12. ETIOLOGY
• Other cervical microbes implicated in PID
include: mycoplasma genitalium,
peptostreptococcus species, Staph.aureus,
E.coli, S. faecalis, P. aeruginosa, S. pyogenes,
K. pneumoniae, P. rettgeri, P. mirabilis

14. PATHOPHYSIOLGY
• Infection most likely starts with a single STI agent
which causes inflammation of upper genital tract
thereby facilitating the ascendance of other
infective agents.
• This leads to inflammatory damage resulting in
scarring, adhesions and obstruction of fallopian
tubes.
• Also causes loss of ciliated epithelial cells along
the fallopian tube and icreases risk of infertility
and ectopic pregnancy

15. PATHOPHYSIOLOGY
• Resulting scarring and adhesion formations could
result in tubo-ovarian abscess.
• Mucopurulent exudates via the fimbrial terminus
causes peritonitis.
• Infected peritoneal fluid leaks from the pelvis to
the peri-hepatic area leading to peri-hepatitis.
This leads to the concomitant formation of
adhesion bands between the liver capsule and
the visceral peritoneum. This causes right upper
quadrant pain and tenderness resulting in the so
called: Fitz-Hugh-Curtis Syndrome.

16. IMAGE

17. RISK FACTORS
• Young age
• multiple sexual partners
• Sexual relationship with a person who has more than
one sex partner
• Lack or inconsistent use of barrier contraceptive
• Douching
• Previous history of PID or STI
• Recent trans-vaginal instrumentation.
• IUCD insertion
• Induced abortion
• Low socioeconomic status

18. PROTECTIVE FACTORS
• Barrier contraceptive methods
• Oral steroids
• Monogamy
• Partner who had vasectomy
• Pregnancy
• menopause

19. CLINICAL FEATURES
SYMPTOMS
• Asymptomic in subclinical disease
• Mild to severe lower abdominal pain
• Fever
• Nausea, vomiting and dizziness
• Abnormal or heavy vaginal discharge
• Dysmenorrhoea
• Abnormal uterine bleeding (inter-menstrual, coital or
post-coital)
• Dyspareunia (especially deep)
• Dysuria

20. CLINICAL FEATURES
SIGNS
• Muco-purulent cervical discharge
• Adnexal tenderness
• Cervical excitation tenderness
• Pelvic/adnexal mass

22. CLASSIFICATION
• SUBCLINICAL
– No obvious classical symptoms or signs of PID
– A major problem as damage continues
– Responsible for most cases of tubal factor infertility
• MILD TO MODERATE
– Occurred in 36% of patients
– Lower abdominal/ pelvic pain, post coital vaginal
bleeding, vaginal discharge, urinary symptoms, mild
fever, and adnexal or cervical motion tenderness

23. CLASSIFICATION
• SEVERE
– Occurred in about 4% of patients
– Present with high grade fever, purulent vaginal
discharge, nausea, vomiting and elevated
inflammatory markers.

24. MANAGEMENT
HISTORY
• A thorough history including sexual history and physical
examination is crucial as PID is primarily a clinical diagnosis
• Clarification on onset and character of pain should be
obtained while excluding differentials
• FIFE
EXAMINATION
• General physical examination
• Abdominal exam
• Pelvic exam to evaluate cervical discharge, cevical motion
tenderness, adnexal tenderness or masses

25. Bimanual pelvic examination

26. MANAGEMENT
ANCILLARY INVESTIGATIONS
• FBC (elevated WBC in 60% of cases),
• ESR (>15mm/h found in 75% of acute PID)
• C-reactive protein (a CRP >10 mg/dL has sensitivity of
93% and specificity of 83% in the diagnosis of PID).
• Endocervical swab m/c/s for N.gonorrhea and nucleic
acid amplification test for C.trachomatis where
available
• Endometrial biopsy, culdocentesis
• Pregnancy test to exclude ectopic pregnancy

27. ANCILLARY INVESTIGATION
• Ultrasonography is the imaging method of
choice. Transvaginal is preferred to
transabdominal approach. Also helpful in
guiding needles to drain abscesses.
• MRI is expensive but more sensitive.
• Computed tomography (CT) is reserved for
evaluation of the extent of PID.
• Laparoscopy: This is considered the “gold
standard” diagnostic procedure for PID.

28. ANCILLARY INVESTIGATION
• Laparoscopic criteria for acute salpingitis
include finding:
1. pronounced hyperaemia of the tubal
surface;
2. oedema of the tubal wall;
3. sticky exudate on the tubal surface and
from the fimbrial ends when the tube is patent.
• However cases of endometritis without
salpingitis may be missed.

29. Laparoscopic findings in PID

30. DIAGNOSIS
CDC diagnostic criteria

31. DIAGNOSIS
• Presence of symptoms suggestive of PID in a
sexually active young reproductive age woman
plus demonstrable,
- Adnexal/Pelvic tenderness
- Cervical excitation tenderness
- Muco-purulent cervical discharge
- Pelvic/Adnexal mass
• Provides presumptive diagnosis of PID in the out
patient/emergency department.

32. TREATMENT
• Negative results do not exclude diagnosis of PID
• Treatment should be started based on clinical suspicion
• Aim is to relieve acute symptoms, eradicate current
infection and minimize the risk of long term sequelae.
• Treatment should include empirical broad-spectrum
antibiotics to cover the full complement of common
causes.
• Antibiotics chosen should be effective against
Chlamydia trachomatis and Neisseria gonorrhoeae, as
well as against gram-negative facultative organisms,
anaerobes, and streptococci.
• Immediate IUCD removal is not recommended unless
symptoms persist after 48 hours

33. TREATMENT
Mild to moderate should be treated at OPD
1 st Line:
• IM ceftriaxone 1g single STAT dose PLUS
• Oral doxycycline 100mg BD PLUS
• Oral metronidazole 400mg BD for 14 days
• If lab results show presence of M. genitalium,
this is indication to add oral moxifloxacin
400mg OD for 14 days

34. TREATMENT
OPD FOLLOW-UP
• Significant clinical improvement should be
demonstrable within 72-hours .
• Failure to show improvement after standard
treatment on outpatient basis indicates the
need for re-evaluation of diagnosis and or
hospital admission
• Patient should be advised to return for test of
cure 4-weeks after treatment with GP.

35. TREATMENT
Indications for hospital admission:
• When surgical emergency (eg appendicitis,
ectopic pregnancy) cannot be excluded.
• PID in pregnancy.
• Poor response to antibiotics after 72 hours.
• If patient is unable to tolerate the oral antibiotic
regimen.
• Severely ill patient with fever >38 °C, nausea and
vomiting.
• Presence of tubo-ovarian abscess.

36. TREATMENT
1 st Line in-patient
• IV ceftriaxone 2g daily until sustained clinical improvement
for at least 24-hours AND
• Oral doxycycline 100mg BD and
• Oral metronidazole 400mg BD for 14 days.
2nd Line
• IV Clindamycin 900mg 8 hourly and IV Gentamicin,
continued until sustained clinical improvement for 24-hours
THEN oral clindamycin 450mg QDS to complete 14 days’
treatment
• OR oral doxycycline 100mg BD and metronidazole 400mg
BD to complete 14 days’ treatment.

37. TREATMENT IN PREGNANCY
• All pregnant women should be managed as
having complicated PID
1 st Line:
• Give IV ceftriaxone 2g daily and
• IV erythromycin 500mg 6hourly and
• IV metronidazole 500 mg 12hourly, until there is
clinical improvement for 24- hours THEN
• Oral erythromycin 500mg qds AND oral
metronidazole 400mg BD to complete 14 days
treatment

38. TREATMENT IN PREGNANCY
2nd Line
• Give IV Clindamycin 900mg and IV Gentamicin
(2mg/kg loading dose followed by a maintenance
dose 1.5mg/Kg 8 hourly or single daily dose of 3-
5mg/Kg); continue until there is clinical
improvement for 24-hours THEN
• Oral clindamycin 450mg qds to complete 14 days
treatment.
• Alternative parenteral therapies that have also
being used include Ampicillin/sulbactam,
azithromycin/metronidazole.

39. TREATMENT
SURGERY INDICATION
• Generalized peritonitis
• Pelvic abscesses
• Tubo-ovarian abscesses
• Severe adhesions

41. DIFFERENTIALS
These are numerous and include:
• Appendicitis
• Ectopic pregnancy
• Cervicitis
• pyelonephritis
• Endometriosis
• Ovarian cyst / ovarian cyst torsion;
• Interstitial cystitis
• Adnexal tumour

42. COMPLICATIONS
• Recurrent PID
• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
• Fitz-Hugh-Curtis Syndrome (gonococcal peri-
hepatitis)

44. PREVENTION
PRIMARY
• Health education on abstinence, faithfulness and
use of contraceptive
• Delay in the initiation of sexual activity
• Screening programs for high risk groups
SECONDARY
• Early diagnosis and prompt treatment with
appropriate anti-microbial agents
TERTIARY
• Treatment of complications and rehabilitation

45. CONCLUSION
• PID is a common and serious complication of
STDs
• It has a debilitating sequelae on reproductive
health of women
• Accurate diagnosis, appropriate treatment
and close follow up are required to prevent its
serious complications.

46. THANK YOU…

47. References
• Hussen et al. Prevalence of chlamydia trachomatis infection among reproductive age women
in sub Saharan Africa: a systematic review and meta-analysis. BMC Infectious Diseases (2018)
18:596 https://doi.org/10.1186/s12879-018-3477-
• Newman L, et al. Global Estimates of the Prevalence and Incidence of Four Curable Sexually
Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. PLoS One.
2015 Dec 8;10(12):e0143304. doi: 10.1371/journal.pone.0143304. eCollection 2015
• Howells IO, Okwudili EO. Acute Pelvic Inflammatory Disease and Its Long – Term Sequelae:
The University of Port Harcourt Experience. Journal of Advances in Medicine and Medical
Research 26(8): 1-11, 2018; Article no.JAMMR.41437 ISSN: 2456-8899
• Nyengidiki KT. Pelvic inflammatory disease, correlation between clinical and laparoscopic
diagnosis – A review. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-
0853, p-ISSN: 2279-0861. Volume 7, Issue 5 (May.- Jun. 2013), PP 16-20 www.iosrjournals.org
• Jaiyeoba O, Soper DE. A Practical Approach to the Diagnosis of Pelvic Inflammatory Disease.
Infect Dis Obstet Gynecol, 2011, Article ID 753037, doi:10.1155/2011/753037

48. POST-TEST
1. Pelvic inflammatory disease involve all of the following
except
a. Endometritis
b. Salphingitis
c. Oopharitis
d. Cervicitis
2. PID is frequently associated with the following organisms
a. N.gonorrhea
b. C.trachomatis
c. M.genitalium
d. None of the above
e. All of the above

49. PRE-TEST
3. All are risk factors of PID except
a. Barrier contraceptive
b. IUCD
c. Early coitarchy
d. Low socioeconomic status
4. The gold standard radiologic diagnostic procedure for PID is
a. Transvaginal ultrasonography
b. Computed tomography
c. Laparoscopy
d. Magnetic resonance imaging

50. PRE-TEST
5. All are features of Fitz-Hugh-Curtis Syndrome except
a. Cause by infected peritoneal fluid leaks from the pelvis to
the peri-hepatic area
b. Adhesion bands between the liver capsule and the
visceral peritoneum
c. Present with left quadrant pain
d. Present with right hypochondrial tenderness
6. Parenteral treatment of PID includes a cephalosporin and
which of the following agent
a. Clindamycin
b. Doxycycline
c. Ofloxacin
d. metronidazole