Pelvic inflammatory disease (PID) is caused by ascending infections from the cervix by bacteria like Neisseria gonorrhoeae and Chlamydia trachomatis. It causes inflammation of the female reproductive organs within the pelvis. Symptoms include pelvic pain and abnormal vaginal bleeding or discharge. Diagnosis is based on clinical features and confirmed through tests and imaging. Treatment involves antibiotics and sometimes surgery to drain abscesses. Untreated PID can lead to serious long-term complications like infertility.

1. PELVIC INFLAMMATORY
DISEASE
Nimesha Dinusanka Jayawardana

2.  Inflammation of the uterus fallopian tubes and
ovaries as it progress to scar formation with adhesion
to near by tissue and organs
Definition

3.  Infection and Inflammation ascending from
endocervix leading to inflammation in
 endometrium – Endometritis
 Fallopian tubes – Salphyngitis
 Ovaries – Oophoritis
 Parametrium – Parametritis
 Pelvic peritoneum – Pelvic peritonitis
 Tubo-ovarian abscess

4.  Neisseria gonorrhoeae
 Chlamydia trachomatis
 Anaerobes
 Gardnerella vaginalis
 Mycoplasma genitalium
Common Causative Organisms

5. Neisseria Gonorrhoea
 Gram negative diplococci
 Infect cuboidal and columnar epithelium
 Co-infection with trichomonas
 Investigations
 Endo-cervical swab(rectum and Pharynx)
 Gram stain
 Culture- Agar medium
 Nucleic acid amplification test

6. Chlamydia trachomatis
 Obligate intra-cellular bacteria
 Affect columnar epithelium
 Cause PID, Conjunctivitis, Perihepatitis
 Diagnostic test-
 Nucleic acid amplification test,
 PCR
 Culture

7.  Fever
 Vaginal discharge
 Mucopurulent offensive
 Heavy/Inter-menstrual bleeding, Dysmenorrhea
 Pain
 Pelvic pain
 Bilateral Lower abdominal Pain
 Deep dyspareunia
 Pelvic masses
Clinical Features - Symptoms

8.  Pyrexia - >380C
 Abdominal Examination:
 Bilateral lower abdominal and Pelvic tenderness
 Palpable pelvic mass
 Speculum Examination:
 Cervicitis
 Bimanual VE:
 Cervical excitation/Cervical motion tenderness
(Chandelier sign)
 Tender adnexal mass/ Adnexal tenderness
Signs

9.  Damage to Fallopian tubes
 Peritoneal inflammation
 Adhesion formation –
 Between pelvic structures
 Omental
 Perihepatic – Fitz-Hugh-Curtis syndrome
 Abscess formation –
 Tubo -ovarian abscess
 Hydrosalpinx
 Pyosalpinx
 Subfertility
 Sepsis
Complications

10. Tubo-ovarian abscess Bilateral Pyosalpinx

11.  Ectopic Pregnancy
 Acute Appendicitis
 Endometriosis
 Torsion or rupture of an ovarian cyst
 UTI
 Functional pain
Differential Diagnosis

12.  Full blood count
 Raised WBC – Neutrophilia
 Reduced WBC - Neutropenia
 CRP & ESR
 Elevated
 USS
 Tubo-ovarian mass
 Pelvic mass
 Endocervical Swab microscopy and Culture
 Test for Chlamydia & Gonorrhoea
 Laparoscopy
 Urine hCG
Investigations

13. Minimal Criteria
1. Pelvic Tenderness
2. Adnexal Tenderness
3. Cervical Tenderness
Supportive Criteria
1. Temperature > 38.3
2. Elevated ESR,CRP and WBC
3. Offensive Vaginal discharge
4. Positive N. Gonorrhoea and Chlamydia
Diagnosis

14. Definitive Criteria
1. Histological evidence of endometritis
2. Tubo-ovarian mass on ultra sound
3. Laparoscopic evidence

15.  Depends on severity of disease
 Out patient treatment
 Mild/moderate disease
 Inward treatment
 Severe infection
 Adnexal masses suspicious of abscess
 Generalized sepsis
 Poor/inadequate response to oral treatment
 Severe pelvic/abdominal pain requiring strong analgesics
 IUCD if present has to removed
 Pregnancy test in all cases to exclude ectopic
Management

16.  Adequate supportive care:
 Rest and analgesics
 Fluid balance
 Antibiotics
 Surgical Treatment
 Patient Counseling
Principles of Management

17.  Triple antibiotic therapy – Directed towards
Chlamydia, Gonorrhoea and anaerobes
 Single IM Ceftriaxone 500mg
 Oral Doxycycline 100mg bd – 14 days
 Metronidazole 400mg bd – 14 days
 Non- gonococcal infections
 Oral ofloxacin 400mg bd/ Levofloxacin 500mg daily - 14
days
 Metronidazole 400mg bd – 14 days
Antibiotic Treatment

18.  In patients with pelvic abscess or not responding to
therapy
 Laparoscopy done
 Can exclude other DDx – Appendicitis, endometriosis,
ovarian pathology
 Drainage of abscess done
 Adhesiolysis in chronic cases
 Affected tube/ovary may have to be removed
Surgical Treatment

19.  Screening of Partner and other sexual contacts for
Gonococcus, Chlamydia, HIV & Other STDs
 Treat them early to prevent reinfection
 Barrier contraception use until treatment completed
 Explain the possibility of ectopic pregnancy, chronic
pelvic pain and subfertility as sequelae of reinfection
 Prompt and early treatment reduce risk of subfertility
 Seek early medical advise if pregnant, due to risk of
ectopic pregnancy
Patient Counseling