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
Definition
PID is a disease of the upper genital tract.
It 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.
Epidemiology
Occurs both in the developed and developing
countries.
85 per cent are spontaneous infection in sexually active females of reproductive age.
The remaining 15 per cent follow procedures, which favors the organisms to ascend up.
Two-thirds are restricted to young women of less than 25 years and the remaining one-third limited among 30 years or older.
Risk factors
Menstruating teenagers.
Multiple sexual partners.
Absence of contraceptive pill use.
Previous history of acute PID.
IUD users.
Area with high prevalence of sexually transmitted diseases.
Protective factors
Contraceptive practice
Barrier methods
Oral steroidal contraceptives
Monogamy / Vasectomy
Others
Pregnancy
Menopause
Vaccines
CLINICAL FEATURES
Bilateral lower abdominal and pelvic pain dull in nature.
Fever, lassitude and headache.
Irregular and excessive vaginal bleeding .
Abnormal vaginal discharge (purulent or copious)
Nausea and vomiting.
Dyspareunia.
Pain and discomfort in the right hypochondrium.
Signs
Temperature >38.3°C.
Abdominal palpation
(1) Tenderness on both the quadrants of lower abdomen.
(2) The liver may be enlarged and tender.
Vaginal examination
(1) Abnormal vaginal discharge (purulent).
(2) Congested external urethral meatus or openings of Bartholin’s ducts through which pus may be seen escaping out on pressure.
(3) Speculum examination shows congested cervix with purulent discharge from the canal.
Clinical diagnostic criteria of PID (CDC-2006)
Minimum Criteria
Lower abdominal tenderness.
Adnexal tenderness.
Cervical motion tenderness.
Additional Criteria
Oral temperature > 38.3°C.
Mucopurulent cervical or vaginal discharge.
Raised C-reactive protein and/or ESR.
Definitive Criteria
Histopathologic evidence of endometritis on biopsy.
Imaging study (TVS/MRI) evidence of tubo-ovarian complex.
Laparoscopic evidence of PID
Investigations
Identification of organisms
Blood: Leucocyte count shows leucocytosis to more than 10,000 per cu mm and an elevated ESR value of more than 15 mm per hour.
Laparoscopy
Complications Of Pid
Immediate
Pelvic peritonitis or even generalized
Septicemia
Late
Dyspareunia
Infertility
Chronic pelvic inflammation
Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian abscess.
Chronic pelvic pain and ill health.
Ambulatory Management Of Acute PID (CDC-2006)
Patient should have oral therapy for 14 days
Regimen A
Levofloxacin 500 mg (or, ofloxacin 400 mg) PO
Metronidazole 500 PO bid
Regimen B
Ceftriaxone 250 mg IM single dose
Doxycycline 100 mg PO BID with or without
Metronidazole 500 mg PO BID for 14
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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
Definition
PID is a disease of the upper genital tract.
It 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.
Epidemiology
Occurs both in the developed and developing
countries.
85 per cent are spontaneous infection in sexually active females of reproductive age.
The remaining 15 per cent follow procedures, which favors the organisms to ascend up.
Two-thirds are restricted to young women of less than 25 years and the remaining one-third limited among 30 years or older.
Risk factors
Menstruating teenagers.
Multiple sexual partners.
Absence of contraceptive pill use.
Previous history of acute PID.
IUD users.
Area with high prevalence of sexually transmitted diseases.
Protective factors
Contraceptive practice
Barrier methods
Oral steroidal contraceptives
Monogamy / Vasectomy
Others
Pregnancy
Menopause
Vaccines
CLINICAL FEATURES
Bilateral lower abdominal and pelvic pain dull in nature.
Fever, lassitude and headache.
Irregular and excessive vaginal bleeding .
Abnormal vaginal discharge (purulent or copious)
Nausea and vomiting.
Dyspareunia.
Pain and discomfort in the right hypochondrium.
Signs
Temperature >38.3°C.
Abdominal palpation
(1) Tenderness on both the quadrants of lower abdomen.
(2) The liver may be enlarged and tender.
Vaginal examination
(1) Abnormal vaginal discharge (purulent).
(2) Congested external urethral meatus or openings of Bartholin’s ducts through which pus may be seen escaping out on pressure.
(3) Speculum examination shows congested cervix with purulent discharge from the canal.
Clinical diagnostic criteria of PID (CDC-2006)
Minimum Criteria
Lower abdominal tenderness.
Adnexal tenderness.
Cervical motion tenderness.
Additional Criteria
Oral temperature > 38.3°C.
Mucopurulent cervical or vaginal discharge.
Raised C-reactive protein and/or ESR.
Definitive Criteria
Histopathologic evidence of endometritis on biopsy.
Imaging study (TVS/MRI) evidence of tubo-ovarian complex.
Laparoscopic evidence of PID
Investigations
Identification of organisms
Blood: Leucocyte count shows leucocytosis to more than 10,000 per cu mm and an elevated ESR value of more than 15 mm per hour.
Laparoscopy
Complications Of Pid
Immediate
Pelvic peritonitis or even generalized
Septicemia
Late
Dyspareunia
Infertility
Chronic pelvic inflammation
Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian abscess.
Chronic pelvic pain and ill health.
Ambulatory Management Of Acute PID (CDC-2006)
Patient should have oral therapy for 14 days
Regimen A
Levofloxacin 500 mg (or, ofloxacin 400 mg) PO
Metronidazole 500 PO bid
Regimen B
Ceftriaxone 250 mg IM single dose
Doxycycline 100 mg PO BID with or without
Metronidazole 500 mg PO BID for 14
Tata Group Dials Taiwan for Its Chipmaking Ambition in Gujarat’s DholeraAvirahi City Dholera
The Tata Group, a titan of Indian industry, is making waves with its advanced talks with Taiwanese chipmakers Powerchip Semiconductor Manufacturing Corporation (PSMC) and UMC Group. The goal? Establishing a cutting-edge semiconductor fabrication unit (fab) in Dholera, Gujarat. This isn’t just any project; it’s a potential game changer for India’s chipmaking aspirations and a boon for investors seeking promising residential projects in dholera sir.
Visit : https://www.avirahi.com/blog/tata-group-dials-taiwan-for-its-chipmaking-ambition-in-gujarats-dholera/
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2. www.publichealth.columbus.gov
What is PID
Pelvic inflammatory disease (PID) is a clinical syndrome that results
from the ascension of microorganisms from the cervix and vagina to
the upper genital tract.
Approximately one million women are diagnosed yearly
It is the most common serious STD complication
.
Acute PID is commonly caused by Chlamydia and Gonorrhea
Most women with acute PID have BacterialVaginosis (BV)
3. www.publichealth.columbus.gov
Center for Disease Control
The CDC states it is an inflammatory disorder of the upper female
genital tract, including any combination of fallopian tubes, uterine
lining, ovaries, upper genital tract, uterus, throughout the pelvic
area.
Difficult to diagnose due to wide variation in symptoms
6. www.publichealth.columbus.gov
Clinical Manifestations
• Subclinical disease (asymptomatic), which is thought to be present 60% of the time, is
notable because it lacks symptoms. This makes diagnosis and treatment problematic. Women may
experience dyspareunia, irregular bleeding, dysuria, or gastrointestinal symptoms, which they may
not link to PID, and therefore, may not seek care. C. trachomatis is particularly implicated in
subclinical PID.
• Mild to moderate PID, women may complain of lower abdominal pain or pelvic pain,
cramping, or dysuria. They may also exhibit signs such as intermittent or post-coital bleeding,
vaginal discharge, or fever. Uterine tenderness or cervical motion pain or adnexal tenderness is
most often present on pelvic exam in most cases of moderate PID.
• Severe PID, women appear very ill with fever, chills, purulent vaginal discharge, nausea,
vomiting, and elevated white blood cell count (WBC). Other laboratory indicators, such as
erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), may also be elevated.
7. www.publichealth.columbus.gov
Sequelae
• Approximately 25% of women with a single episode of symptomatic PID
will experience ectopic pregnancy, infertility, or chronic pelvic pain.
• The risk of ectopic pregnancy is increased six- to ten-fold after PID.
• Tubal infertility occurs in 8% of women after one episode of PID, in
20% of women after two episodes, and in 50% of women after three
episodes.
9. www.publichealth.columbus.gov
Empiric treatment should be initiated in sexually active young
women & women at risk if there is pelvic or lower abdominal pain,
if no cause for the illness other than PID is identified and if one or
more of the following minimum criteria are present on pelvic exam:
1) cervical motion tenderness
2) Uterine tenderness
3) adnexal tenderness
10. www.publichealth.columbus.gov
Requiring all three minimum criteria be present before treating can result
in insufficient diagnosis of PID
Most women with PID have either mucopurulent cervical discharge or
increaseWBC;s under microscope = infection
The presence of signs of lower genital tract infection plus one of the
three minimum diagnosis increases the specificity of the diagnosis
If cervical discharge is normal and noWBC’s are present the diagnosis is
unlikely and alternative causes of pain should be considered.
12. www.publichealth.columbus.gov
Risk Factors
PID is elevated in sexually active teens partially due to the immature
cervical cells and frequently changing sex partners.
Having multiple sex partners
Women who douche
Women with IUD’s
Previous STD infections may elevate PID risk due to damage of
reproductive organs from the initial infection
13. www.publichealth.columbus.gov
Epidemology
Diagnosed in 1-5% of women in STD clinics in US
Declining rates since the 1990’s
Overt or subclinical PID is the most common cause of ectopic
pregnancy and tubal infertility
Incubation Period:
Varies from 10 days to several months follow acquisition of Chlamydia
or Gonorrhea
15. www.publichealth.columbus.gov
Symptoms
Abnormal or unusual vaginal discharge (yellow/green/malodorous)
Abnormal vaginal bleeding
Dull pain and tenderness in stomach
Lower abdominal or pelvic pain nearly universal in symptomatic cases
Pain with urination
Pain with intercourse (dyspareunia)
Pain in back
Elevated temperature and fever
Irregular menses
Spotting and cramping with prolonged painful menses.(menorrhagia)
16. www.publichealth.columbus.gov
Physical Exam
• Pelvic adnexal tenderness usually bilaterally
• Uterine fundal and cervical motion tenderness
• Signs of MPC or BV
• Fever is common but often absent
• Lower quadrant abdominal tenderness, sometimes rebound tenderness
present
• Adnexal mass may be present
• R upper quadrant tenderness may be present
17. www.publichealth.columbus.gov
Diagnostic Criteria
• In sexually active women, low abdominal pain with adnexal or
cervical motion tenderness
• Fever may be present
• Mucopurulent cervicitis and discharge
• Abundant WBC’s in cervical or vaginal discharge
• Cervical infection with Chlamydia or Gonorrhea
18. www.publichealth.columbus.gov
Lab diagnosis
• Lab evidence of BV or MCP
• Other tests:
Pelvic ultrasound
Laparoscopy may be indicated if diagnosis is uncertain
Endometrial Biopsy helpful with endometritis
19. www.publichealth.columbus.gov
Differential diagnosis
• Appendicitis
• Ectopic pregnancy
• Septic abortion/miscarriage (associated with a serious uterine infection)
• Hemorrhagic, ruptured or twisted ovarian cysts
• Tumors
• Degeneration of a myoma
• Acute enteritis (inflammation small intestine)
20. www.publichealth.columbus.gov
Treatment
• Treat on symptoms prior to lab results
• Outpatient:
Ceftriaxone 250 mg IM x 1
Doxycycline 100 mg PO BID x 14 days
Metronidazole 500 mg PO BID x 14 days
25. www.publichealth.columbus.gov
Bibliography
• CDC. Pelvic Inflammatory Disease. Morbidity and Mortality Weekly
Report 2010; 59 :63-67
• Handsfield, Hunter. H. Sexually Transmitted Diseases Third Edition.
2011;267-277
• Klausner, Jeffrey D., Hook, Edward W III, Current Diagnosis and
Treatment Sexually Transmitted Diseases.2007;46-51