Pelvic Inflammatory Disease diagnosis and criteria ( without managements ). by dr. Ali Kareem final year medical student Al Mustansiriyah University College of Medicine \ Baghdad \ IRAQ \ 2018

1. Pelvic inflammatory disease (PID)
how to diagnose ?
presented by final year
medical student
Ali Kareem

2. Definition
• Pelvic Inflammatory Disease (PID) comprises a
spectrum of inflammatory disorders of the upper
female genital tract, including any combination of
endometritis, salpingitis, oophoritis, pelvic peritonitis
and subsequently leading to tubo-ovarian and pelvic
abscess.
• Sexually transmitted organisms, especially N.
gonorrhoea and C. trachomatis, are implicated in
many cases.
• Others , : bacterial vaginosis may be identified.

3. Epidemiology
• PID is commonly associated with Sexually
Transmitted Diseases (STDs).
• Occur in 2% of sexually active females.
• About 85% are spontaneous infection in sexually
active females of reproductive age.
• Remaining 15% follow procedures, which favors the
organism to ascend up.

4. Etiology & Pathophysiology
❖Ascending: common, from the LGT.
⮚1. Through sperm, TV, along surfaces traveling
from the cervix to the endometrium, through the
tubes into the peritoneal cavity.
⮚2. Through the lymphatic systems: infection of the
parametrium from IUCD.
❖Lateral: Rare, from infected appendix
❖Through hematogenous routes

6. • Iatrogenic procedures: favor organism to
ascend
1. Endometrial biopsy
2. Uterine curettage
3. Insertion of IUD
4. Hysterosalpingography.

7. Mode of transmission
• Ascend of gonococcal & chlamydial
organisms by surface extension from the
lower genital tract through the cervical canal
by way of the endometrium to the fallopian
tubes
• Facilitated by the sexually transmitted
vectors such as sperms & trichomonads
• Or Reflux of menstrual blood along with
gonococci into the fallopian tubes may be
the other possibility.

8. • Through uterine lymphatic & blood vessels
across parametrium. Like
⮚Mycoplasma hominis
⮚Secondary organisms

9. risk factors
❖I. Factors related to sexual behavior:-
⮚young age
⮚multiple partners
⮚recent new partner (within previous 3 months)
⮚past history of (STIs) in the patient or their partner
❖II. Instrumentation of the uterus / interruption of
the cervical barrier
⮚termination of pregnancy
⮚insertion of IUCD for the 1st 3 wks of insertion.
⮚HSG
⮚IVF &IUI .

10. Acute PID
• Signs and symptoms vary in women who are
symptomatic.
• Symptoms develop during or following menstruation.
• The clinical criteria :
1. Pelvic tenderness and cervical excitation
2. Uterine tenderness
3. Tender adnexal or palpable ovarian mass.
• Additional criteria
ξ Mucopurulent vaginal discharge
ξ Elevated C- reactive protein or ESR
ξ Tempreature >> 38*C

11. Acute PID presentation & Hx
History
✔ location, intensity, radiation, timing, duration, and
exacerbating and mitigating factors of the pelvic pain:
Bilateral lower abdominal & pelvic dull aching pain is
characteristic of acute PID
✔ H/O Fever (Oral temperature > 38.3˚C/101F)
✔ H/O Abnormal vaginal discharge
✔ H/O symptoms suggestive of dysuria
✔ Previous H/O abdominal or gynecological surgeries
✔ H/O previous gynecological problem
✔ H/O IUD insertion (6 times higher risk within 20 days)
✔ Social history: Should include patient’s sexual and
✔ STDs history & partner’s history in terms of STDs

12. ❖Fitz Hugh & Curtis Syndrome
• Consists of rt. upper quadrant pain resulting
from ascending pelvic infection and
inflammation of the liver capsule or diaphragm
{adhesion}.
❖Physical examination
• Bilateral abdominal tenderness
• Adnexal mass & adnexal tenderness
• Cervical motion tenderness
• Uterine tenderness
• Vaginal mucopurulent discharge

13. Dx criteria
• US ⮚ tubo-ovarian abscess
• Laparoscopy: visually confirming salpingitis
• Screening for STI (specially those who +
gonorrhea, chlamydia )
– Microscope and or culture for T. vaginalis
– HIV AB test
– Syphilis serology
– Urine culture & analysis to exclude UTI.

14. Most common DD of acute PID
1. Appendicitis.
2. Ectopic pregnancy.
3. Endometritis.
4. Ovarian cyst.
5. Ovarian torsion.

17. PID chronic complication
• This diagnosis is given to women who describe a history of acute PID and
who have pelvic pain.
• Hydrosalpinx might qualify as criterion for it.
• Histologically diagnosed >> pyogenic infection
❖ complication
⮚ Dyspareunia
⮚ Infertility : due to tubal factor
✔ 12 % after single episode
✔ 25 % after two episodes
✔ 50 % after three episodes
⮚ Increased risk of ectopic pregnancy
✔ 6-10 % increase in risk following H/O PID
⮚ Formation of adhesion or hydrosalpinx or pyosalpinx & tubo -ovarian
abscess
⮚ Chronic pelvic inflammation
✔ Due to recurrent or associated pyogenic infection/ T.B.
⮚ Chronic pelvic pain and ill health

18. ❑Symptoms
• Chronic pelvic pain
• Dyspareunia
• dysmenorrhea
• Lower abdominal pain
• Menorrhagia
• Vaginal discharge
• Infertility
❑Signs
o Tenderness on one or both iliac fossa
o An irregular tender pelvic mass
o PR Involvement of parametrium & uterosacral
ligament