Infection of the upper genital tract

1. PELVIC INFLAMMATORY
DISEASE
PRESENTER: MAGWALI SIMONPETER
SUPERVISOR: DR. ZIMULA JOHN
DATE: 09/05/2025

2. INTRODUCTION
DEFINITION
 Pelvic inflammatory disease (PID) of the upper genital
tract, 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(parametrium).
 It is attributed to the ascending spread of
microorganisms from the cervicovaginal canal to the
contiguous pelvic structures.

3. Cont…
 This occurs when there is ascending infection from
the endocervix to the higher reproductive tract.
 It is a recognized complication of chlamydia and less
frequently of gonorrhea, but they are often not
isolated and other implicated organisms include
Mycoplasma genitalium as well as those in the
vaginal microflora.

4. Cont…
 This infection may include any or all of the following
anatomic sites and it is described as endometritis,
salpingitis, pelvic peritonitis, tuboovarian abscess or
parametritis.
 Cervicitis is not included in the list.

5. Epidemiology
 The ready availability of contraception together with
increased permissive sexual attitude has resulted in
increased incidence of sexually transmitted diseases
and correspondingly, acute PID.
 The incidence varies from 1–2% per year among
sexually active women.
 About 85% are spontaneous infection in sexually
active females of reproductive age.
 The remaining 15% follow procedures, which favors
the organisms to ascend up.

6. Cont…
 Such iatrogenic procedures include endometrial
biopsy, uterine curettage, insertion of IUD and
hystero-salpingography.
 Two-thirds are restricted to young women of less than
25 years and the remaining one-third limited among
30 years or older.
 Pelvic inflammatory disease is a major problem to the
reproductive health of young women

7. Etiology
 Acute PID is usually a poly-microbial 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% and Mycoplasma hominis in 10%.
 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, pepto-streptococcus and peptococcus.

8. Responsible organisms
1.Pyogenic (50%): This is the commonest type – the
organisms responsible are:
 Aerobes
The gram-positive organisms are staphylococcus.
The gram-negatives are E. coli, pseudomonas,
Klebsiella, N. gonorrhoeae, etc.
 Anaerobes.
Gram-positives : e.g. Clostridium welchii, C.
tetani, etc.
Gram-negatives : bacteroides group of which
Bacteroides fragilis is the commonest.

9. Cont…
1.Sexually transmitted disease (STD): e.g. N. gonorrhoeae,
Chlamydia trachomatis, Treponema pallidum, Herpes
simplex virus type II, Human papilloma virus,
Gardnerella vaginalis (Haemophilus vaginalis),
Haemophilus ducreyi, HIV I or II, etc.
2.Parasitic: Trichomonas vaginalis
3.Fungal: Candida albicans
4.Viral: Herpes simplex virus type II, Human papilloma
virus, HIV, Condylomata accuminata, etc
5.Tubercular: Mycobacterium tuberculosis.

10. Risk factors for PID
 Sexually active teenagers
 Younger age (<19 years)
 Multiple sexual partners
 Absence of contraceptive pill use
 Previous history of acute PID
 IUD users (not with LNG-IUS)
 Lower socioeconomic status
 Husband/sexual partner with urethritis or STI
 Genetic predisposition

11. Protective Factors
 Contraceptive practice
 Barrier methods, especially condom, diaphragm
with spermicides.
 Oral steroidal contraceptives have got two
preventive aspects.
 Produce thick mucus plug preventing ascent of
sperm and bacterial penetration.
 Decrease in duration of menstruation, creates a shorter
interval of bacterial colonization of the upper tract.

12. Cont…
 Monogamy or having a partner who had vasectomy.
 Others
„„
 Pregnancy
 Menopause
 Vaccines: Hepatitis B, HPV
 Post-coital washing (urethra, genital skin)

13. Pathology
 The involvement of the tube is almost always bilateral
and usually following menses due to loss of genital
defense.
 The pathological process is initiated primarily in the
endosalpinx.
 There is gross destruction of the epithelial cells, cilia
and microvilli. In severe infection, it invades all the
layers of the tube and produces acute inflammatory
reaction; becomes edematous and hyperemic.

14. Cont…
 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 in drawing 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.

16. Pathology
 Depending upon the virulence, the exudate may be
watery producing hydrosalpinx or purulent producing
pyosalpinx.
 The purulent exudate then changes the
microenvironment of the tube which favors growth of
other pyogenic and anaerobic organisms resulting in
deeper penetration and more tissue destruction.
 The organisms spontaneously die within 2–3 weeks.

17. Cont…
 As the serous coat is not much affected, the resulting
adhesions of the tube with the surrounding structures
are not so dense, in fact flimsy, unlike pyogenic or
tubercular infection.
 On occasions, the exudate pours through the abdominal
ostium to produce pelvic peritonitis and pelvic abscess
or may affect the ovary (the organisms gain access
through the ovulation rent) producing ovarian abscess.
 A tubo-ovarian abscess is thus formed

18. MODE OF SPREAD OF INFECTION
Through continuity and contiguity—gonococcal
infection
Through lymphatics and pelvic veins—postabortal
and puerperal infection—by pyogenic organisms
other than gonococcus
Through blood stream—tubercular
From adjacent infected extra-genital organs like
intestine.

19. Clinical Features
 Symptoms
1. Patients with acute PID present with a wide range
of nonspecific clinical symptoms. Symptoms
usually appear at the time and immediately after
the menstruation.
2. Bilateral lower abdominal and pelvic pain which
„„
is dull in nature.
3. The onset of pain is more rapid and acute in
gonococcal infection (3 days) than in chlamydial
infection (5–7 days)
4. There is fever, lassitude and headache
„„
„„

20. Cont…
5. Irregular and excessive vaginal bleeding is usually due to
associated endometritis
6. Abnormal vaginal discharge which becomes purulent and
„„
or copious
7. Dyspareunia
„„
8. Pain and discomfort in the right hypochondrium due to
„„
concomitant peri-hepatitis (Fitz-Hugh-Curtis syndrome)
may occur in 5–10% of cases of acute salpingitis.
9. The liver is involved due to trans-peritoneal or vascular
dissemination of either gonococcal or chlamydial
infection.

21. 10. Laparoscopic examination reveals inflamed liver
capsule with classic violin string adhesions to the
parietal peritoneum and beneath the diaphragm.
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 (perihepatitis).
 „„

22. Fitz-Hugh-Curtis syndrome violin string like
adhesions

23.  Vaginal examination reveals:
a) Abnormal vaginal discharge which may be of purulent;
b) Congested external urethral meatus or openings of Bartholin’s
ducts through which pus may be seen escaping out on pressure;
c) Speculum examination shows congested cervix with purulent
discharge from the canal and
d) Bimanual examination reveals bilateral tenderness on fornix
palpation, which increases more with movement of the
cervix(cervical motion tenderness).
 There may be thickening or a definite mass felt through the
fornices.

24. ACUTE PELVIC INFECTIONS
 Pelvic inflammatory disease (PID).
 Following delivery and abortion.
 Following gynecological procedures.
 Following IUD.
 Secondary to other infections—appendicitis

25. Clinical features of acute PID.
 Fever >38°C
„„
 Bilateral lower abdominal tenderness with radiation to the
legs
 Abnormal vaginal discharge
„„
 Abnormal uterine bleeding
„„
 Deep dyspareunia
„„
 Cervical motion tenderness
„„
 Adnexal tenderness/mass
„„
 Raised ESR
„„
On bimanual
examination

26. Clinical Diagnostic Criteria of Acute PID
 Minimum criteria
 Lower abdominal tenderness or
 Adnexal tenderness or
 Cervical motion tenderness
 Additional criteria for diagnosing PID
 Oral temperature >38°C
 Mucopurulent cervical or vaginal discharge
 Abundant WBCs on saline microscopy of cervical secretions
 Raised C-reactive protein
 Elevated ESR
 Laboratory documentation of positive cervical infection with
Gonorrhea or C. trachomatis

27. Cont…
 Definitive criteria
 Histopathologic evidence of endometritis on biopsy
 Imaging study (TVS/MRI) showing evidence of thickened
fluid filled tubes, ± free pelvic fluid or tubo-ovarian
complex.
 Laparoscopic evidence of PID
 Although initial treatment can be made before bacteriologic
diagnosis of C. trachomatis or N. gonorrhoeae infection,
such a diagnosis emphasizes the need to treat sex partners.

29. Investigations
„„ Identification of organisms: The materials are collected from the following
available sources:
 Discharge from the urethra or Bartholin’s gland
 Cervical canal
 Collected pus from the fallopian tubes during laparoscopy or laparotomy.
 The material so collected is subjected to Gram stain and culture (aerobic and
anaerobic).
 The findings of gram negative diplococci is very much suggestive of
gonococcal infection.
 Except in highly sophisticated centers, the detection of C. trachomatis is
difficult
 . The process of investigation is not specific and is time consuming, treatment
for C.trachomatis should be started from the clinical diagnosis

30. Cont…
 A positive Gram stain smear from endocervical
mucus is nonspecific and a negative smear does not
rule out upper genital tract infection
 „„Blood: leukocytosis of more than 10,000 per cubic
mm and an elevated ESR value of more than 15 mm
per hour.
 The results correlate with the severity of the
inflammatory reactions of the fallopian tubes as seen
on laparoscopy.
 Serological test for syphilis should be carried out for
both the partners in all cases.
 .

31.  Laparoscopy: 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.
 Non-responding pelvic mass needs laparoscopic clarification.
 Laparoscopic Findings and Grading of PID
 Mild: Tubes—edema, erythema, no spontaneous purulent exudates and tubes
are freely mobile
 Moderate: Gross purulent material present, erythema and edema, marked;
tubes may not be freely movable, and fimbria stroma may not be patent
 Severe: Pyosalpinx or inflammatory complex, abscess ‘Violin string’ like
adhesions in the pelvis and around the liver suggests chlamydial infection .

32. Cont…
 Sonography: Dilated and fluid filled tubes, fluid in the
pouch of Douglas or adnexal mass are suggestive of PID.
It may be employed where clinical examination is difficult
or is not informative because of acute tenderness or
obesity.
 MRI
 Culdocentesis:
„„ Aspiration of peritoneal fluid and its
white cell count, if exceeds 30,000/ml is significant in
acute PID.
 Investigations are also to be extended to male partner and
smear and culture are made from urethral secretion.

33. Diagnosis
 The anatomic diagnosis of infection to the upper genital tract
is made from the following clinical features
 One should not wait for the report, instead treatment should
be started empirically.
 The materials for identification of organisms are from the
cervical and urethral discharge and secretion from the
Bartholin’s gland, and laparoscopic or laparotomy collection
of pus from the fallopian tubes.
 The materials are to be subjected to Gram stain and culture
(aerobic and anaerobic).
 Gram stain of the discharge may be positive for gram
negative intracellular diplococci of N. gonorrhoeae

34. Differential Diagnosis
 Appendicitis
 Disturbed ectopic pregnancy
„„
 Torsion of ovarian pedicle, hemorrhage or rupture of
„„
 Ovarian cyst
 Endometriosis
„„
 Diverticulitis
„„
 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.

35. Complications of PID
 Immediate
 Pelvic peritonitis or even generalized peritonitis
„„
 Septicemia—producing arthritis or myocarditis.
„„
 Late
 Dyspareunia
„„
 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.
 Chronic pelvic inflammation is due to recurrent or associated pyogenic
„„
infection.
 Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian
„„
abscess.
 Chronic pelvic pain and ill health
„„
 Increased risk of ectopic pregnancy (6-10 fold).
„„

36. Management
 Essential steps in the prevention are:
 Community-based approach to increase public health awareness.
„„
 Prevention of sexually transmitted infections with the knowledge of
„„
healthy and safer sex.
 Liberal use of contraceptives.
„„
 Routine screening of high-risk population.
„„
 The principles of therapy are:
 To control the infection
„„
 To prevent infertility and late sequelae
„„
 To prevent reinfection.
„„
 Follow up examination of women within 48 to 72 hours for evaluation
„„
of response.

37. Outpatient Therapy
 Apart from adequate rest and analgesic, antibiotics are to be
prescribed even before the microbiological report is available.
 Combination of antibiotics should be prescribed as the
infection is polymicrobial in nature,
 Antimicrobial coverage includes: N. gonorrhoeae, C.
trachomatis, streptococci, E. coli and anaerobes.
 All patients treated in the outpatients are evaluated after 48
hours and if no response, are to be hospitalized.

38. Cont…
Outpatient antibiotic treatment of PID
1. Ceftriaxone 250 mg IM single dose
Or
Cefoxitin, 2g IM single dose and probenecid, 1 g PO single dose
Or
Injection Cefotaxime IV
Plus
2. Doxycycline 100 mg PO, BID for 14 days with or without Metronidazole
500 mg PO BID for 14 days
3. Minimum criteria: Empirical treatment of PID should be initiated.

39. Treatment
 Treat sexual partners as for urethral discharge syndrome to avoid re-
infection
 In pregnancy, use erythromycin 500 mg every 6 hours for 14 days instead
of doxycycline
 Ceftriaxone 1 g IV daily plus metronidazole 500mg IV every 8 hours until
clinical improvement, then continue oral regimen as above. (Do not take
alcohol when taking metronidazole)
 All women with PID should be tested for HIV
 Abstain from sex or use barrier methods during the course of treatment
ƒ
 Avoid sex during menstrual period and for 6 weeks after an abortion
ƒ
 In IUD users with PID, the IUD need not be removed.
ƒ
 However, if there is no clinical improvement within 48–72hours of
initiating treatment, consider removing the IUD and help patient choose an
alternative contraceptive method

40. Inpatient Therapy
 The patients are to be hospitalized for antibiotic therapy in the conditions
 The patient is urged to take bed rest.
 Oral feeding is restricted.
 Dehydration and acidosis are to be corrected by intravenous fluid.
 Intravenous antibiotic therapy is recommended for atleast 48 hours but
may be extended to 4 days, if necessary.
 Suggested Indications for Parenteral
 Treatment of PIO
 Pregnancy
 High fever
 Suspected abscess
 Uncertain diagnosis
 Generalized peritonitis
 Failed outpatient therapy
 Noncompliant with medications
 White blood cell count > 15,000/mm3
 Nausea/vomiting precluding oral therapy

41. Inpatient antibiotic therapy
 „„ Parenteral regimen A
 Cefoxitin 2 g IV every 6 hours for 7 days
Plus
 Doxycycline 100 mg PO BID for 14 days
 „„ Parenteral regimen B
 Clindamycin 900 mg IV every 8 hours
Plus
 Gentamicin 2mg/kg IV (loading dose), followed by 1.5 mg/kg IV (maintenance dose)
every 8 hours
 Aztreonam (2 g IV slowly) is similar to aminoglycoside and can be used. It has no renal
toxicity and but is more expensive.
 Alternative parenteral regimen
 Ampicillin-salbactum 3 g IV every 6 hours 3–5 days
Plus
 Doxycycline 100 mg orally BID for 14 days

42. Indications of Surgery
 Generalized peritonitis
„„
 Pelvic abscess
„„
 Tubo-ovarian abscess which does not respond (48–72hours) to
„„
antimicrobial therapy/or there is rupture
 Life-threatening infections.
„„
 To prevent reinfection: 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.
unequivocal indications are:

43. 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(s) have been
treated and cured, the patient must be prohibited from
intercourse.

46. Chronic Pelvic Inflammatory Disease
 This is defined as PID lasting longer than 30 days.
 One cause is Actinomyces israelii - a gram-positive, slow-growing, anaerobic
bacterium found to be part of the indigenous genital flora of healthy women.
 Some have found Actinomyces species more frequently in the vaginal flora
of IUD users, and rates of colonization rise with duration of IUD use.
Chronic Pelvic Inflammatory disease results:
 Following acute pelvic infection—the initial treatment was delayed or
inadequate.
 Following low grade recurrent infection.
 Tubercular infection. The first two types are predominantly due to pyogenic
organisms.
 Tubercular infection is chronic from the beginning and is described as a separate
entity.

47. Symptoms
 Chronic pelvic pain of varying magnitude and the pain aggravates prior to
menstruation due to congestion.
• Dyspareunia, which is deep and may be located unilaterally or bilaterally.
• Congestive dysmenorrhea.
• Lower abdominal pain.
• Menorrhagia or polymenorrhagia are due to congestion.
• Vaginal discharge is almost a constant manifestation and may be
mucoid or mucopurulent.
• Infertility, which may be primary or more commonly secondary
 Actinomyces isreali causes chronic endometritis. Always associated with
IUCD esp non copper devices.

48. Cont…
 Important factors for infertility are—cornual block , loss of
cilia, loss of peristalsis due to thickening of the tubal wall,
closure of the abdominal ostium and distortion of the tube
due to peritubal adhesions.
 On examination
 Per abdomen: There may be tenderness on one or both iliac
fossa. An irregular tender pelvic mass may be felt.
 Per vagina: cervical motion tenderness
 Rectal examination corroborates the findings of vaginal
examination and should not be omitted . The involvement of the
parametrium and uterosacral ligaments are better assessed rectally

49. Cont…
Investigations
 Blood examination for evidences of leucocytosis, Hb
estimation and ESR.
 Urine examination— routine and, if necessary,
culture sensitivity.
 Laparoscopy: This is helpful to confirm the diagnosis
and to know the extent of the lesion specially in
cases of infertility. However, in cases where too
much adhesions are anticipated, diagnostic
laparotomy is a safer substitute.

50. Management
General management
-Improvement of general health and anemia.
-Analgesics as required, may be prescribed.
 Specific
-IUCD is removed if it is still inside.
 -Antibiotic therapy has got little benefit unless there is recent
acute exacerbation.
 The longterm broad spectrum antibiotics to be administered
include doxycycline or tetracycline or cephalosporin for three
weeks.
 Actinomyces is sensitive to penicillins.
 Prolonged parenteral antibiotic administration is required for 4
to 6 weeks followed by oral antibiotics for 6 to 12 months.

51. Surgery.
 Indications:
Persistence of symptoms in spite of adequate conservative
treatment
Recurrence of acute attacks
Increase in size of the pelvic mass despite treatment
Infertility for restorative tubal surgery or for adhesiolysis.
Laparoscopy
 Adhesiolysis, tubal restorative and reconstructive surgery
are commonly done. Few cases may need salpingectomy or
salpingo-oophore-ctomy.
 In general, the ideal surgery should be total hysterectomy
with bilateral salpingo-oophorectomy for women that they
have completed their family.

52. Genital tuberculosis
Etiology ; Mycobacterium tuberculosis
MODE OF SPREAD
1. Heamatogenous 90%
2. Lymphatic
3. Direct to other organs
AFFECTION RATES OF OTHER ORGANS WITH TB %
Fallopian tubes 100%
Endometrium 50-60
Cervix 5-15%
Ovaries 30%
Pelvic peritoneum 40-50%
Vulva, Vagina 1%
SYMPTOMS: History of past pulmonary TB, infertility, menstrual abnormalities,
chronic pelvic pain, fever , anorexia, night sweats, weakness
SIGNS.
 P/A. may be negative findings , irregular tender mass , doughy abdomen due to
mated intestines
 V/E. Vulvular or vaginal ulcers with undermined edges

53. Cont…
Investigation
CBC, ESR, CXR, Diagnostic Uterine Curettage, First Day Menstrual Blood
(subjected to nucleic acid amplification tests/GeneXpert), biopsy from the
lesions (in the cervix , vagina,vulva), Abdoninal ultra sound in case of pelvic
masses.
DDX.
Pyogenic tubo ovarian mass , Pelvic endometriosis, adherent ovarian cyst
RX.
New cases . 2(HRZE) Initial phase 4(HRE) Continuatin phase
Previously treated ( acertain resistance patterns if sensitive repeat above)
Rx. Doxy, FQNS, for 12 wks followed with a PAP smear after 3month

54. References
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edition,
by Prof DC Dutta - MBBS DGO MO (Cal). Edited by Prof Hiralal Konar
(Hons; Gold Medalist) MBBS (Cal) MD (PGI) DNB (India) MNAMS
FACS (USA) FRCOG (London). Published in 2020, ISBN: 978-93-89587-
88-3 by JAYPEE Brothers Medical Publishers (P) Ltd, New Delhi London.
2. Williams GYNECOLOGY FOURTH EDITION. Edited by Barbara L.
Hoffman, MD John 0. Schorge, MD Lisa M. Halvorson, MD Cherine A.
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Published in 2020 by McGraw-Hill Education, ISBN: 978-1-26-045687-5.
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EDITION by Ten Teachers edition ISBN-13: 978-
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MD, MRCOG and Louise C. Kenny MBChB (Hons), MRCOG, PhD.
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of Taylor & Francis Group, an Informa business.
4. UCG 2023