Pelvic Inflammatory Disease (PID) is an infection and inflammation of the upper female genital tract involving the fallopian tubes and ovaries. It is usually caused by ascending infection from the cervix or vagina, often due to bacteria like Neisseria gonorrhoeae or Chlamydia trachomatis. Risk factors include multiple sexual partners and IUD use. Symptoms include lower abdominal pain and tenderness. Diagnosis involves clinical examination and testing for sexually transmitted infections. Treatment aims to cover common causative bacteria with antibiotic regimens. Without treatment, PID can cause long-term complications like infertility or ectopic pregnancy.

1. Pelvic Inflammatory Disease Dr. Subha Patel Editable Presentation will be available on www.livetalent.org in download area

2. Pelvic Inflammatory Disease Infection & inflammation of the upper genital tract involving fallopian tubes as well as the ovaries. Sometime infection can extend beyond the reproductive tract to cause pelvic peritonitis, generalise peritonitis or pelvic abscess. Usually refer to ascending infection from cervix / vagina.

3. Barrier to spread of infection Natural : Acidic pH of vaginal secretion Closure of Os with cervical plug Down ward ciliary movement of endometrial lining Symbiotic bacterial flora Physiological amenorrhea Artificial : Barrier contraceptive use OCP use

4. How these barriers are impaired 1. During menstruation, after abortion & delivery : Cervical canal is dilated Endothelium sheds Presence of raw surface in the uterine cavity Vaginal pH is increased.

5. How these barriers are impaired (cont...) 2. Intrauterine manipulation: Curettage & evacuation Manual removal of placenta Presence of foreign body (eg. IUCD) 3. Vaginal douching

6. Risk factors Menstruating female Multiple sexual partners Residence in areas with high prevalence of sexually transmitted disease IUCD use Vaginal douching Previous history of PID

7. Etiology Cervical Pathogens : Neisseria gonorrhoeae Chlamydia trachomatis Vaginal Flora Components : Anaerobic bacteria : Prevotella etc Facultative bacteria : Enterobacteriaceae Mycoplasms

8. Etiology Cont... First episode is likely to be due to N. gono -rrhoeae, chlamydia trachomatis, but they are implicated somewhat less often in : Recurrent PID IUCD associated PID HIV associated PID PID associated with intrauterine manipulation

9. Etiology Con.. Difficult to determine exact microbial etiology of PID because of : Frequency of mixed infection Difficulty in sampling the fallopian tube itself Complexity of the microbiological techniques to detect fastidious organisms Implication are Syndromic approach to empirical antimicrobial treatment of PID

10. Pathogenesis Factors possibly contributing to upward spread of microorganisms in susceptible host are : Estrogen dominated (thin) cervical mucus Subendometrial myometrial contractions, which move particulate matter from the cervix to the fundus of the uterus Attachment to sperm that migrate upward into the tubes in rare instance

11. Pathogenesis cont... Gonococci attach to surface pili and taken into secretory cells by endocytosis. Extruded into submucosal connective tissue by exocytosis from the base of the cells. Ciliated cells are sloughed from the mucosa . Increased suceptibility to infection with other organisms.

12. Pathogenesis cont... C.trachomatis also infect columnar cells of the fallopian tube, but produce little damage by itself . May often goes unnoticed. Leads to activation of host immune response Greatest tissue damage due to subacute /chronic nature of inflammation .

13. Pathogenesis cont... Pathogenesis due to mycoplasma & other organisms is less well studied

14. Clinical manifestation Acute onset is more often associated with gonococcal infection. Polymicrobial PID more often have tubal or pelvic abscess formation. Any time 1 st half of menses 1 st half of menses Chronic Sub acute /chronic Acute Symp. Onset Older Young Young Age

15. Clinical manifestation evolves from history Abscess formation Adenexal swelling pelvic abscess Peri appendicitis Right upper quadrant pain Peri appendicitis Symptoms similar to appendicitis Peritonitis Nausea, vomiting, increased abdomen tenderness Endometritis Mildine abdominal pain, abnormal vaginal bleeding Mucopurulent cervicitis/ bacterial vaginosis Yellow / malodorous discharge Clinical manifestation History

16. Physical Examination Evidence of MPC, easily induced endocervical bleeding. Bimanual uterine fundal tenderness. Adenexal tenderness and palpable adnexal mass. Abdominal tenderness. Decreased bowel sounds. Right iliac fossa tenderness. Pleuritic chest pain & friction rub. Palpable mass on Per Abdomen and Vaginal examination.

17. Diagnosis No readily available clinical finding or lab test, short of laparoscopy, definitively identifies salpingitis. Delayed seeking care is 3 times more likely to result in subsequent infertility and ectopic pregnancy. Early diagnosis and initiation of therapy are essential to minimize tubal scarring. It is better to err on the side of over diagnosis and over treatment.

18. Clinical Diagnosis Lower abdominal pain of < 3 weeks duration Pelvic tenderness on bimanual pelvic examination Evidence of lower genital tract infection (e.g., MPC) Identifies approximately 60% of laproscopy proven salpingitis. Additional clinical findings: Rectal temperature > 38oC Palpable adnexal mass ESR > 15 mm/hr

19. Radiological Diagnosis 1. Ultrasonography 2. Magnetic Resonance Imaging Identification of tubo-ovarian or pelvic abscess Increased tubal diameter, intratubal fluid, tubal wall thickening in cases of salpingitis.

20. Laparoscopic Diagnosis - Most specific method for diagnosis of salpingitis. - Indications for laparoscopy are : Unilateral pain / pelvic mass Atypical clinical finding Absence of lower genital tract infection Missed menstrual period Positive pregnancy test Failure to respond to therapy

21. Laparoscopic Diagnosis cont... Laproscopic criteria for diagnosis of salpingitis are : Erythema of the fallopian tube Edema of the fallopian tube Seropurulent exudate or fresh, easily lysed adhesion at the fimbriated end or on the serosal surface of a fallopian tube.

22. Etiologic diagnosis Specimens may be obtained by endocervical swab, endometrial aspiration, culdocentesis,or by laproscopy. Specimens should be subjected to Gram staining . Culture and DNA –PCR based tests for N. gonorrhoeae and chlamydia. Detection in endocervical specimen does not prove presence in upper genital tract, but strongly support the diagnosis in appropriate clinical situations.

23. Treatment Treatment should cover N. Gonorrhoeae, C. trachomatis, Gm-ve facultative bacteria (eg. E.coli, H. influenzae) vaginal anaerobes and group –B streptococci. Sexual partners should be examined for STDs and treated adequately. Clinical follow up after 48-72 hrs of treatment.

24. Regimens for t/t of PID Regimen B Clindamycin 900 mg IV q8h PLUS Gentamycin, loading dose of 2 mg/kg IV Or IM, then maintainence dose of 1.5 mg/kg q8h Regimen B Ceftriaxone 250 mg IM once PLUS Doxicycline 100 mg PO bid for 14 days PLUS Metronidazole 500 mg PO bid for 14 days Regimen A Cefotetan 2 g IV q12h OR Cefoxitin 2 g IV q6h PLUS Doxicycline 100 mg IV or PO q12h Regimen A Ofloxacin 400 mg PO bid for 14 days OR Levofloxacin 500 mg PO once daily for 14 days PLUS Metronidazole 500 mg PO bid for 14 days Parenteral regimens Outpatient regimens

25. Indication for in-hospital treatment If diagnosis is uncertain and surgical emergencies such as appendicitis and ectopic pregnancy cannot be excluded. Pelvic abscess is suspected. Severe illness precluding out patient management. Failure to respond to out patient therapy. Presence of HIV infection. Initiate parenteral therapy with either of the above parenteral regimens & continue until 48h after clinical improvement; then change to outpatient therapy .

26. Role of surgery Drainage of abscess Threatened rupture of tubo ovarian abscess Conservative surgical management is usually adequate.

27. Sequele Infertility Ectopic pregnancy Chronic pelvic pain Recurrent salpingitis

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