Pelvic inflammatory disease (PID) is an infection of the female upper genital tract that can cause long-term complications like infertility and ectopic pregnancy. Common causes are sexually transmitted bacteria like Chlamydia and gonorrhea. Diagnosis involves examining for cervical tenderness and confirming with tests like endometrial biopsy or laparoscopy. Treatment aims to eliminate the infections with antibiotics and prevent complications through follow up testing and partner treatment. Long term risks counseling is important due to potential issues like chronic pelvic pain.

1. Pelvic Inflammatory Disease www.freelivedoctor.com

2. CREOG Educational Objectives: Pelvic Inflammatory Disease Describe the diagnostic criteria for PID List the common infectious agents implicated in PID Elicit a pertinent history from a patient suspected to have PID Perform a physical exam to confirm the diagnosis of PID www.freelivedoctor.com

3. CREOG Educational Objectives: Pelvic Inflammatory Disease Describe the appropriate diagnostic tests to confirm PID, including: Indications for the tests How to perform the tests Interpretation of the results Endocervical swab for culture or nucleic acid probe Endometrial biopsy Laparoscopy www.freelivedoctor.com

4. CREOG Educational Objectives: Pelvic Inflammatory Disease Treatment of PID with appropriate antimicrobial and surgical options Summarize the potential long-term effects [of PID] and counsel patients regarding the risks of further complications, including: Chronic pelvic pain Infertility Ectopic pregnancy www.freelivedoctor.com

5. Pelvic Inflammatory Disease Upper genital tract infections that involve the endometrium (endometritis), fallopian tubes (salpingitis), and pelvic peritoneum (peritonitis). These infections result from ascending spread of lower genital tract infection www.freelivedoctor.com

6. Infectious agents - STDs PID – Ascending infection www.freelivedoctor.com

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8. Pelvic Inflammatory Disease Estimates of the annual incidence of PID in the United States are: Between 9.5 to 14 cases per 1,000 fertile women, with a higher rate of 18 to 20 per 1,000 among women aged 15 to 24 years. As many as 1,000,000 cases of PID occur annually in the United States resulting in approximately 200,000 hospitalizations. Due to under reporting, incidence figures are unreliable www.freelivedoctor.com

9. Risk Factors for PID: Adolescents Younger age at first intercourse Older sex partners Involvement with child protection agency Prior suicide attempt(s) Consumption of alcohol before sex Current chlamydia infection www.freelivedoctor.com

10. Pelvic Inflammatory Disease The most common etiologic agents in PID are: Neisseria gonorrhoeae , Chlamydia trachomatis Anaerobic bacterial species found in the vagina, particularly Bacteroides spp., Anaerobic gram-positive cocci, (Peptostreptococci), E. coli Mycoplasma hominis www.freelivedoctor.com

11. Pelvic Inflammatory Disease These organisms initially cause lower genital tract infections and then spread into the upper genital tract via the endometrium. Many cases - polymicrobial in etiology. Pure gonococcal or chlamydial PID is possible. The relative frequency of the various agents depends somewhat on the population tested, the site cultured (i.e., cervix, endometrium, or Fallopian tubes), the sensitivity of the diagnostic tests performed. www.freelivedoctor.com

12. PID: History and Examination Symptoms suggestive of PID include: Abdominal pain (usually bilateral and in the lower quadrants), Dyspareunia, [abnormal] Vaginal discharge, Menometrorrhagia, Dysuria, Onset of pain in association with menses, Fever, and/or chills Nausea or vomiting www.freelivedoctor.com

13. PID: History and Examination Women with endometritis may present with: vaginal discharge or intermenstrual bleeding, and have uterine tenderness on pelvic exam www.freelivedoctor.com

14. PID: Additional Considerations PID is difficult to accurately diagnose, in part, because manifestations range from mild to quite severe All young, sexually active women presenting with lower abdominal pain should be carefully evaluated for the presence of salpingitis and endometritis Routine bimanual and abdominal exams should be done on all women with an STD, since some women with salpingitis or endometritis will not complain of lower abdominal pain. www.freelivedoctor.com

15. Diagnosis of Acute PID – CDC Criteria Minimum findings: Cervical motion tenderness and uterine and adnexal tenderness, along with WBCs seen on vaginal wet mount Additional supportive criteria to increase the specificity: - Oral temperature higher than 101ºF (38.3ºC) - Abnormal cervical or vaginal mucopurulent discharge - Elevated erythrocyte sedimentation rate - Elevated C-reactive protein level - Laboratory documentation of cervical infection with N gonorrhoeae or C trachomatis www.freelivedoctor.com

16. Diagnosis of PID – Laboratory Tests 1. Gram-stained endocervical smear (to quantify PMNs/1000x field and to look for intracellular Gram-negative diplococci) 2. Endocervical NAAT or endocervical (and rectal) cultures for N. gonorrhoeae 3. Culture of endocervical swab or NAAT for endocervical swab or first void urine for C. trachomatis 4. Wet prep for WBCs 5. If menses is late or if the patient is not using reliable contraception - check pulse and blood pressure (supine and seated); - obtain serum or sensitive urine pregnancy test if ectopic pregnancy is suspected. www.freelivedoctor.com

17. Diagnosis of PID: Association of LGTI Evaluation of vaginal discharge Underutilized Consistent predictor Criteria Inflammatory cells outnumber all other cellular elements Absence for WBCs plus clear mucous – high negative predictive value www.freelivedoctor.com

18. Diagnosis of PID – Endometrial biopsy Prevalence and manifestations of endometritis among women with cervicitis. Paavonen J , Kiviat N , Brunham RC , Stevens CE , Kuo CC , Stamm WE , Miettinen A , Soules M , Eschenbach DA , Holmes KK . Thirty-five women referred from an STD Clinic, because of suspected cervicitis, studied for the presence of endometritis by transcervical endometrial biopsies and cervical and endometrial cultures. Fourteen (40%) of the patients had histologic evidence of endometritis. Findings that significantly correlated with endometritis included a history of intermenstrual vaginal bleeding, the presence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Streptococcus agalactiae in the cervix, and the presence of serum antibodies to C. trachomatis or to Mycoplasma hominis. www.freelivedoctor.com

19. Diagnosis of PID: Laparoscopy “ Gold Standard” University of Helsinki study: (N=33) Confirmed PID in 20 (61%) 11 (33%) other diseases 2 (6%) no evidence of disease Final diagnosis in 91% Lysis of adhesions, drainage, irrigation, extirpation www.freelivedoctor.com

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21. Laparoscopic findings – Acute PID Pyosalpinx www.freelivedoctor.com

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23. CT Scan Findings – Acute PID Thickened Fallopian tube Thickened Fallopian tube www.freelivedoctor.com

24. Diagnosis of PID – Additional considerations Enlargement or induration of one or both fallopian tubes, a tender pelvic mass, and direct or rebound abdominal tenderness may also be present. Temperature may be elevated but is normal in many cases In general, clinicians should err on the side of over-diagnosing and treating milder cases. Some women have chlamydial infection of the upper genital tract without apparent clinical manifestations of PID (i.e., “silent salpingitis”). www.freelivedoctor.com

25. Treatment Strategies www.freelivedoctor.com

26. Treatment of PID Often unclear, based on cervical samples, which etiologic agents are causative in a given patient, thus: broad spectrum antimicrobial coverage should be provided to cover gonorrhea, chlamydia, and anaerobes. Patients should be advised to: Rest for 1 to 3 days or until symptoms have resolved or pain is significantly improved (pain score decreased by 50%) and to, Abstain from sexual intercourse until follow-up cultures are negative (usually a minimum of 2 weeks). An IUD should be removed in moderate to severe cases of PID. www.freelivedoctor.com

27. Treatment of PID: CDC Criteria for Hospitalization Surgical emergencies such as appendicitis cannot be excluded Pregnancy No clinical response to oral antimicrobial therapy Inability to follow or intolerance of the outpatient oral regimen Severe illness, nausea and vomiting, or high fever Tubo-ovarian abscess www.freelivedoctor.com

28. Outpatient Treatment of PID: CDC Treatment Guidelines 2002 Regimen A Either of the following: - Ofloxacin 400 mg orally twice a day for 14 days - Levofloxacin 500 mg orally once daily, with or without Metronidazole 500 mg orally twice a day for 14 days. Regimen B Any of the following: - Ceftriaxone 250 mg IM once, - Cefoxitin or Cefotetan 2 g IM plus Probenecid, 1 g orally in a single dose, [Other parenteral third-generation cephalosporins (e.g., ceftizoxime or cefotaxime),] plus - Doxycycline 100 mg orally twice a day for 14 days, with or without Metronidazole 500 mg orally twice a day for 14 days. www.freelivedoctor.com

29. Inpatient Treatment of PID: CDC Treatment Guidelines 2002 Regimen A Either of the following: Cefotetan 2 g IV every 12 hours, Cefoxitin 2 g IV every 6 hours, plus Doxycycline 100 mg orally or IV every 12 hours. Regimen B Clindamycin 900 mg IV every 8 hours, plus Gentamicin loading dose IV or IM (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted. www.freelivedoctor.com

30. Inpatient Treatment of PID: CDC Treatment Guidelines 2002 Alternative parenteral regimens Limited data supports the use of other parenteral regimens, but the following three regimens have been investigated in at least one clinical trial, and they have broad spectrum coverage. - Ofloxacin 400 mg IV every 12 hours, - Levofloxacin 500 mg IV once daily with or without Metronidazole 500 mg IV every 8 hours, - Ampicillan/Sulbactam 3 g IV every 6 hours plus Doxycycline 100 mg orally or IV every 12 hours. www.freelivedoctor.com

31. Treatment of PID: Additional Considerations In non-PID patients, Chlamydia and anaerobes in the cervix / vagina ascend to the endometrium in 45-60% of cases (only 20% for N. gonorrhoeae ). Outpatient regimens are effective in eradicating N. gonorrhoeae from the endometrium and although C. trachomatis and anaerobic flora are variably reduced (<50%), they are not eliminated from the endometrium. Ofloxacin and clindamycin appear to be more effective in clearing the endometrium of anaerobic organisms than ceftriaxone and doxycycline, but (at 4 weeks) appear to be no different in improving histopathologic evidence of endometritis. www.freelivedoctor.com

32. Transvaginal Ultrasound Guided Aspiration Wayne State University Medical Center N=22 women; 27 pelvic abscesses (13 TOA, 14 POA) Mean age 30 Mean duration (d) - diagnosis to drainage 5.6/2.0 Mean diameter - 86mm Volume of purulent material 70-750cc Cultures positive in 51% “ Successful” in 25/27 cases www.freelivedoctor.com

33. Treatment of PID: Follow-up The follow-up schedule should be individualized, but an ideal follow-up schedule would be: 1. 1 to 3 days after starting treatment: The patient’s therapy should be reevaluated in light of microbiological results at the 3-day follow-up visit. In patients who are not improved after 3 days of treatment, consideration should be given to hospitalizing the patient for parenteral therapy and further diagnostic evaluation. 2. 7 to 10 days after completing treatment: Repeat endocervical and rectal gonorrhea cultures (applies to both gonococcal and nongonococcal PID). Repeat endocervical chlamydia culture or NAAT (although a positive NAAT could be due to non-viable organisms after effective treatment). www.freelivedoctor.com

34. Treatment of PID: Follow-up MANAGEMENT OF SEX PARTNERS Examination and urethral smear and culture for gonorrhea and NAAT for chlamydia for all sex partners within the preceding 4 weeks, regardless of symptoms. Empirically treat partners with cefixime and doxycycline or azithromycin to cover C. trachomatis and N. gonorrhoeae , regardless of the apparent etiology of the PID. Cases should be reported to the state/local health department www.freelivedoctor.com

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36. Sequelae of Pelvic Inflammatory Disease Reported sequelae occurs in up to 25% of cases - Infertility (12% to 50%) - Ectopic Pregnancy (6 to 10 fold increase) - Chronic Pelvic Pain (18%) - 100,000 surgical procedures Psychological Problems: devastating www.freelivedoctor.com

37. PID: Postmenopausal Women Exact mechanism unclear Direct extension from adjacent viscera Risks Uterine instrumentation Structural abnormalities (stenosis, polyps, etc) “ Forgotten” IUD Degenerating myomas Postmenopausal vaginal flora (anaerobic) www.freelivedoctor.com

38. PID: Postmenopausal Women Presenting symptoms include: Vaginal spotting, bleeding, pain, fever, nausea, change in bowel habits Majority have tuboovarian abscess – USG or CT Differential diagnosis Diverticulitis, appendicitis, bowel perforation Liberal use of laparoscopy www.freelivedoctor.com

39. PID: Postmenopausal Women Treatment Hospitalization IV antibiotics Remove IUD Early surgical intervention Mortality up to 25% www.freelivedoctor.com

40. PID: Where Do We Go From Here? 1. Reduction in risk factors – effective behavioral interventions 2. Vaccine development (chlamydial and gonococcal infection) 3. Better screening a. More sensitive screening tests (specificity can be compromised) b. Broader based and more frequently applied screening programs 4. Better diagnostics a. Identification of STD agents more quickly –sensitive specific methods b. Identification of “silent PID” 5. Better evaluation of therapy using outcome measures to assess efficacy a. Short term eradication of infecting agents, evidence of tissue healing b. Long term - fertility www.freelivedoctor.com

41. Prevention of PID: Screening Adolescents Annual exams History of change of sex partners Every 6 months Prior to initiating contraception All women < 25 for annual exams All women reporting signs & symptoms of vaginitis or PID www.freelivedoctor.com