2. CLASSIFICATION OF GENITAL TRACT
INFECTIONS
2
A.According to etiology:
- Specific (caused by N.gonorrhoeae and TB)
- Nonspecific (caused by Staphyloccocus, Streptococus,
E.Coli, Proteus, Chlamydia trachomatis, Mycoplasma
hominis, viruses, etc.)
B.According to clinical picture:
- Acute
- Chronic
3. CLASSIFICATION OF GENITAL TRACT
INFECTIONS
3
C. According to localization:
- Lower genital tract infections (vulvo-vaginitis,
cervicitis)
- Upper genital tract infections (salpingitis,
endometritis, pelvioperitonitis)
D. According to history of recent delivery:
- Puerperial
- Nonpuerperial
4. Definition
4
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.
● It is attributed to the ascending spread of microorganisms
from the cervicovaginal canal to the contiguous pelvic
structures causing endometritis, salpingitis, pelvic peritonitis
or tubo-ovarian abscess.
The cervicitis is not included in the list.
● The clinical syndrome is not related to pregnancy and
surgery.
6. Epidemiology
● The incidence of pelvic infection is on the rise due to the rise in sexually
transmitted diseases.
● The incidence varies from 1–2 percent per year among sexually active
women.
6
8. ● Two-thirds are restricted to young women of less than 25 years and the
remaining one-third limited among 30 years or older.
Epidemiology
66%
33%
30 years or older
less than 25
years
8
9. Risk factors
● Menstruating teenagers.
● Multiple sexual partners.
● Absence of contraceptive pill use.
● Previous history of acute PID.
● IUD users.
● Area with high prevalence of sexually transmitted
diseases.
9
10. Microbiology
Acute PID is usually a polymicrobial infection caused by organisms ascending
upstairs from downstairs.
➔ The primary organisms are sexually transmitted and limited
approximately to:
◆ N. gonorrhoeae in 30%
◆ Chlamydia trachomatis in 30%
◆ Mycoplasma hominis in 10%.
10
11. Microbiology
➔ The secondary organisms normally found in the vagina are almost always
associated sooner or later.
These are:
◆ Aerobic organisms—non-hemolytic streptococcus.
E. coli, group B streptococcus and staphylococcus.
◆ Anaerobic organisms—Bacteroides species –
fragilis and bivius, peptostreptococcus and
peptococcus.
11
12. Mode of affection
● The classic concept is that the gonococcus ascends up to
affect the tubes through mucosal continuity and contiguity.
This ascent is facilitated by the sexually transmitted vectors
such as sperm and trichomonads.
● Reflux of menstrual blood along with gonococci into the
fallopian
tubes is the other possibility.
● Mycoplasma hominis probably spreads across the
parametrium to affect the tube.
● The secondary organisms probably affect the tube through
lymphatics.
13
13. Pathology
13
● The involvement of the tube is almost always bilateral and usually
following menses due to loss of genital defence.
● The pathological process is initiated primarily in the
endosalpinx.
● There is gross destruction of the epithelial cells, cilia and
microvilli and may becomes edematous and hyperemic (in
severe infection).
14. The exfoliated cells along with the exudate pour into the
lumen of the tube and agglutinate the mucosal folds. The
abdominal ostium is closed by the indrawing of the
edematous fimbriae and by inflammatory adhesions. The
uterine end is closed by congestion. The closure of both
the ostia results in pent up of the exudate inside the tube.
15. Pathology
15
● Depending upon the virulence, the exudate may be
watery producing hydrosalpinx or purulent
producing pyosalpinx.
● The purulent exudate then changes the microenvironment and
favors growth of other organisms resulting in deeper
penetration and more tissue destruction.
● There will be adhesions of the tube with the surrounding
structures.
● On occasions, the exudate pours through the abdominal
ostium to produce pelvic peritonitis and pelvic abscess or may
affect the ovary producing ovarian abscess.
16. CLINICAL FEATURES
16
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.
17. CLINICAL FEATURES
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.
17
18. CLINICAL FEATURES
18
Signs
● The temperature is elevated to beyond 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, which increases more with movement of the cervix. There
may be thickening or a definite mass felt through the fornices.
22. Investigations
22
● 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 endocervical for Chlamydia) should be taken, paying attention to using
the correct technique.
● 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.
23. Investigations
23
● 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.
● Investigations are also to be extended to male partner and smear and
culture are made from urethral secretion.
● Laparoscopy is indicated if the diagnosis is unclear or there is no
response to treatment after 48 hours.
24. Laparoscopy
24
● Laparoscopy is considered the "gold
standard".
● While it is the most reliable aid to support
the clinical diagnosis but it may not be
feasible to do in all cases.
● It is reserved only in those cases in which
differential diagnosis includes salpingitis,
appendicitis or ectopic pregnancy.
● Laparoscopy helps to aspirate fluid or pus
for microbiological study from the fallopian
tube, ovary or pouch of Douglas.
● Nonresponding pelvic mass needs
laparoscopic clarification.
25. Laparoscopy
25
Laparoscopic findings and severity of PID:
● Mild: Tubes: edema, erythema, no purulent
exudates and mobile.
● Mod: 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.
27. Differential diagnosis
The clinical condition may be confused with:
(1) Appendicitis
(2) Disturbed ectopic pregnancy
(3)Torsion of ovarian pedicle, haemorrhage or
rupture of ovarian cyst
(4) Endometriosis
(5) Diverticulitis
(6) Urinary tract infection
The two conditions—acute appendicitis and disturbed ectopic pregnancy
must be ruled out, because both the conditions require urgent laparotomy
whereas acute salpingitis is to be treated conservatively. 27
28. Complications of PID
28
IMMEDIATE:
(1)Pelvic peritonitis or
even generalized
peritonitis.
(2)Septicemia —
producing arthritis or
myocarditis.
LATE:
(1) Dyspareunia.
(2)Infertility rate is 12%, after two episodes
increases to 25% and after three raises to 50%. It
is due to tubal damage or tubo-ovarian mass.
(3) Chronic pelvic inflammation is due to recurrent
or associated pyogenic infection.
(4)Formation of adhesions or hydrosalpinx or
pyosalpinx and tubo-ovarian abscess.
(5) Chronic pelvic pain and ill health (24–75%).
(6) Increased risk of ectopic pregnancy (6-10 fold).
29. Treatment
To prevent reinfection.03
To prevent infertility and late sequelae.02
To control the infection energetically.01
THE PRINCIPLES OF THERAPY ARE:
30. Treatment
Outpatient therapy:
● Apart from adequate rest and analgesic, antibiotics are to
be prescribed even before the microbiological report is
available.
● As because the infection is polymicrobial in nature, instead
of single, combination of antibiotics should be prescribed.
● Out-patients antibiotic therapy for acute PID is given in the
next Table.
30
31. Treatment
● All patients treated in
the outpatients are
evaluated after 48
hours and if no
response, are to be
hospitalised.
31
33. Treatment
Inpatient therapy:
● Bed rest is imposed. Oral feeding is restricted.
● Dehydration and acidosis are to be corrected by intravenous fluid.
● Intravenous antibiotic therapy is recommended for at least 48 hours but
may be extended to 4 days, if necessary.
● Improvement of the patient is evidenced by remission of temperature,
improvement of pelvic tenderness, normal white blood cell count and
negative report on bacteriological study.
33
35. Treatment
Indications of surgery:
The indications of surgery are comparatively
less. The unequivocal indications are:
● Generalized peritonitis.
● Pelvic abscess.
● Tubo-ovarian abscess which does not
respond (48–72 hours) to antimicrobial
therapy.
35
36. Prevention
The following formalities are to be rigidly followed to prevent reinfection:
● Educating the patient to avoid reinfection and the potential hazards of it.
● The patient should be warned against multiple sexual partners.
● To use condom.
● The sexual partner or partners are to be traced and properly investigated
to find out the organism(s) and treated effectively. If they have got non-
gonococcal urethritis, they should be treated with tetracycline 500 mg 6
hourly or doxycycline 100 mg twice daily for 7 days.
36
37. Pregnancy
● PID is extremely uncommon in
pregnancy, probably due to the mucous
cervical plug and the pregnancy itself
impeding passage of organisms into
the fallopian tubes.
● In pregnancy or breastfeeding,
penicillin or ceftriaxone can be used
instead of ciprofloxacin.
● Erythromycin should be used instead of
doxycycline or azithromycin, although
azithromycin is not known to be
harmful.
37
38. Follow-up
● Repeat smears and cultures from the
discharge are to be done after 7 days
following the full course of treatment.
● The tests are to be repeated following
each menstrual period until it becomes
negative for three consecutive reports
when the patient is declared cured.
● Until she is cured and her sexual partner
have been treated and cured, the patient
must be prohibited from intercourse.
● The only unequivocal proof of successful
treatment after salpingitis is an intrauterine
pregnancy. 39
39. REFERENCES
1. SALLY COLLINS, SABARATNAM ARULKUMARAN, KEVIN HAYES,
SIMON JACKSON, LAWRENCE IMPEY. Pelvic inflammatory disease.
Oxford Handbook of Obstetrics and Gynaecology, 2013, 3rd edition,
P.561-563.
2. HIRALAR KONAR. Pelvic inflammatory disease. Dc dutta’s textbook of
gynecology, 2013, 6th edition. P.127-133.
3. BARRY O’REILLY, CECILIA BOTTOMLEY, JANICE RYMER. Pelvic
Inflammatory
Disease. Essentials of Obstetrics and Gynaecology, 2012, 2nd edition,
P.130-133.
4. Pelvic Inflammatory Disease. Centers for Disease Control and Prevention,
June 4, 2015 [Viewed on 27 January 2018]. Available from :
https://www.cdc.gov/std/tg2015/pid.htm 40
