Pelvic inflammatory disease (PID) is an ascending infection of the female upper genital tract that is caused by bacteria like Chlamydia trachomatis and Neisseria gonorrhoeae. Risk factors include young age, multiple sexual partners, and previous STIs. The infection spreads from the cervix through the uterus and fallopian tubes, causing inflammation, damage to cilia, and scarring. This scarring can lead to complications like infertility, ectopic pregnancy, and chronic pelvic pain. Clinical features include abdominal and pelvic pain. Treatment involves antibiotics to eliminate the infection. Without treatment, PID can cause long-term reproductive health issues.

1. PELVIC INFLAMMATORY DISEASE
BY
DR M.O. DAODU
UNIVERSITY OF BENIN, NIGERIA.

2. OUTLINE
• DEFINITION
• AETIOLOGIC AGENTS
• RISK FACTORS
• PATHOPHYSIOLOGY
• CLASSIFICATION
• CLINICAL FEATURES
• CLINICAL DIAGNOSIS
• COMPLICATIONS
• TREATMENT
• CONCLUSION
• REFERENCES 2

3. DEFINITION
• Gender-specific (female) ascending infection
of the upper genital tract (uterus, fallopian
tubes, and adjacent pelvic structures) that is
neither linked with surgery nor pregnancy.
3

4. AETIOLOGIC AGENTS
• Chlamydia trachomatis, Neiseria
gonorrhoeae
Ureaplasma urealyticum, Haemophylus
influenza, Mycoplasma hominis, Prevotella
spp, Eschericia coli, Group A Beta
Haemolytic Streptococci, Mycobacterium
tuberculosis etc.
• Actinomyces israelii
Herpes simplex
(Lareau, 2008) 4

5. AETIOLOGY CONT’D
• Most cases of PID are polymicrobial
• Most common pathogens:
– N. gonorrhoeae: recovered from cervix in
30%-80% of women with PID
– C. trachomatis: recovered from cervix in
20%-40% of women with PID
– N. gonorrhoeae and C. trachomatis are
present in combination in approximately
25%-75% of patients
5

6. RISK FACTORS
• young age
• multiple sexual partners
• certain methods of contraception
• previous history of STI
• delayed and decreased access to care
• Single state
• Vaginal douching
• Recent trans-vaginal instrumentation
• Previous history of PID
(Trigg, 2008)6

7. PATHOPHYSIOLOGY
• Contract of infective agent
• Ascension to the upper genital tract
• Inflammation of the genital mucosal lining
• Destruction of the cilia and subsequent
scarring of the tubal lumen.
• Luminal pocketing and partial obstruction
predisposes to ectopic pregnancy
(Ash and Stephen, 2011)
7

8. PATHOPHYSIOLOGY CONT’D
• Mucopurulent exudates via the fimbrial
terminus causes peritonitis.
• Resulting scarring and adhesion formations
could result in tubo-ovarian abscess.
• Infected peritoneal fluid leaks from the pelvis
to the perihepatic area leading to perihepatitis.
This leads to the concomitant formation of
adhesion bands between the liver capsule and
the visceral peritoneum, right upper quadrant
pain and tenderness resulting in the so called:
Fitz-Hugh-Curtis Syndrome.
(Okpere, 2007)
8

9. PATHOPHYSIOLOGY
9
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tubo-
ovarian abscess
Peritonitis

10. Normal Human Fallopian Tube Tissue
10Source: Patton, D.L. University of Washington, Seattle, Washington

11. Abnormal Human Fallopian Tube Tissue
11Source: Patton, D.L. University of Washington, Seattle, Washington
Cilia eroded in C. trachomatis Infection (PID)

12. FITZ-HUGH-CURTIS SYNDROME 12
INFERTIL-
ITY
ECTOPIC
PREGNANCY

13. CLASSIFICATION
• Subclinical
• Mild-moderate
• Severe
• Acute
• Chronic
13

14. CLASSIFICATION...
Severe
symptoms
4%
Subclinical
/silent
60%
Mild to
moderate
symptoms
36%
14
Overt
40%

15. CLINICAL FEATURES
• Uterine tenderness
• Adnexal tenderness
• Cervical motion tenderness
• Temperature >38.3°C (101°F)
• Abnormal cervical or vaginal mucopurulent
discharge
• Presence of abundant numbers of WBCs on saline
microscopy of vaginal secretions
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated C-reactive protein (CRP)
• Gonorrhea or chlamydia test positive
15

16. CLINICAL DIAGNOSIS
• Physical Examination: Lower abdominal tenderness,
adnexal tenderness, pain on manipulation of the cervix
• Laboratory Investigations: ESR, PCR, FBC, gonorrhea
DNA probes and culture, clamydial DNA probes and culture.
• imaging studies: Transvaginal ultrasonography ,
Abdomino- pelvic USS
• procedures: Endometrial
• biopsy
laparoscopy
16

17. COMPLICATIONS
SCARRING INSIDE THE REPRODUCTIVE ORGANS
17
INFERTILITY
ECTOPIC PREGNANCY
FIG-HUGH-CURTIS SYNDROME
CHRONIC PELVIC PAIN

18. COMPLICATIONS
18Frozen pelvis

19. TREATMENT...
• Relief of acute symptoms
• Rradication of current infection
• Minimization of the risk of long term
consequences
• Administration of antibiotics: Regimens must
provide coverage of N. gonorrhoeae, C.
trachomatis, anaerobes, Gram-negative
bacteria, and streptococci
• Surgery (remove or drain a tubo-ovarian
abscess).
19

20. TREATMENT...
• CRITERIA FOR HOSPITALIZATION
• Inability to exclude surgical emergencies
• Pregnancy
• Non-response to oral therapy
• Inability to tolerate an outpatient oral regimen
• Severe illness, nausea and vomiting, high fever or
tubo-ovarian abscess
• HIV infection with low CD4 count
20

21. TREATMENT...
• CDC-recommended oral regimen A
– Ceftriaxone 250 mg IM in a single dose, PLUS
– Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
– Metronidazole 500 mg orally 2 times a day for 14
day
• CDC-recommended oral regimen B
– Cefoxitin 2 g IM in a single dose and Probenecid 1 g
orally in a single dose, PLUS
– Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
– Metronidazole 500 mg orally 2 times a day for 14
days 21

22. TREATMENT...
• CDC-recommended oral regimen C
– Other parenteral third-generation
cephalosporin (e.g., Ceftizoxime,
Cefotaxime), PLUS
– Doxycycline 100 mg orally 2 times a day
for 14 days
With or Without
– Metronidazole 500 mg orally 2 times a
day for 14 days
22

23. TREATMENT...
Follow-up:
• Patients should demonstrate substantial
improvement within 72 hours.
• Patients who do not improve usually require
hospitalization, additional diagnostic tests, and
surgical intervention.
• Some experts recommend re-screening for C.
trachomatis and N. gonorrhoeae 4-6 weeks after
completion of therapy in women with
documented infection due to these pathogens.
• All women diagnosed clinical acute PID should be
offered HIV testing.
23

24. TREATMENT...
• Parenteral Regimens:
• CDC-recommended parenteral regimen A
– Cefotetan 2 g IV every 12 hours, OR
– Cefoxitin 2 g IV every 6 hours, PLUS
– Doxycycline 100 mg orally or IV every 12 hours
• CDC-recommended parenteral regimen B
Clindamycin 900 mg IV every 8 hours, PLUS
– Gentamicin loading dose IV or IM (2 mg/kg),
followed by maintenance dose (1.5 mg/kg) every
8 hours. Single daily gentamicin dosing may be
substituted.
24

25. CONCLUSION
• Clinical syndrome associated with ascending
spread of microorganisms from the vagina or
cervix to the endometrium, fallopian tubes, ovaries,
and contiguous structures; comprising a spectrum
of inflammatory disorders including any
combination of endometritis, salpingitis, tubo-
ovarian abscess, and pelvic peritonitis.
• It has debilitating sequellae on the reproductive
health of women.
• Regular screening and safe sexual practices with
monogamous partners are key to its prevention.
25

26. REFERENCES
• Ash Monga and Stephen Dobbs(2011). Gynaecology by
Ten Teachers, Nineteenth edition , Bookpower, India,
pg 55.
• Lareau SM (2008). Pelvic Inflammatory Diseases and
Tubo-Ovarian Abscesses: Infect Dis Clin North Am.
22(4):693-708.
• Ikolina Antonia Domokus(2013). Pelvic Inflammatory
Disease . Power Point Presentation
• Okpere Eugene (2007). Clinical Gynaecology, Revised
edition, Mindex Publishing Company, Nigeria, pg 233.
• Trigg BG(2008). Sexually Transmitted Infections and
Pelvic Inflammatory Diseases in Women. Med Clin
North Am 92(5):1083-1113. 26

27. REFERENCES
Ash M, Stephen D. (2011). Problems of early
pregnancy. Gynaecology by Ten teachers. 19th
edition; 94-98.
Okpere E. (2007). Ectopic Pregnancy. Clinical
gynaecology. Revised edition; 73-78.
1. Edmonds K. (2011). Ectopic pregnancy.
Dewhursts textbook of obstetrics and
gynaecology. 7th edition; 106-117.
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