PHYSIOTHERAPY in pelvic inflammatory disease

1. PHYSIOTHERAPY
IN PELVIC
INFLAMMATORY
DISEASE
MUSKAN RASTOGI
MPT

2. WHAT IS PID?
• PID, also known as Pelvic Inflammatory Disease 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.
• C. trachomatis is the commonest cause, and N. gonorrhoeae
and Mycoplasma hominis are frequent causes.
• Such infections may occur independently or concurrently, and
are sexually transmitted.
• The infection causes inflammation, and the body’s response in
the highly vascular pelvic area is the production of adhesions
(sometimes profuse) and scarring, which contort structures and
glue or bind them to adjacent ones.
• Chronic PID does not run a predictable course. Some cases even
resolve spontaneously. A broad-spectrum antibiotic is often
given and surgery to remove the uterus, ovaries and fallopian
tubes is often advocated

3. • Chlamydia trachomatis is an important cause
of pelvic inflammatory disease.
• Gelatinous exudates are formed in the pouch
of Douglas, proceeding to multiple adhesions and
tubal occlusion.
• It does not, however, produce a noticeable
discharge.
• Vaginal organisms are transmitted sexually so,
in treatment, partners must also be considered.
• Severe cases may present with cervicitis that
looks like an infected erosion.
• It has also been suggested that Chlamydia may
be an etiological factor in cervical carcinoma.

5. • Neisseria gonorrhoeae is the causative
organism of gonorrhoea.
• This may be asymptomatic or with a
light discharge and can cause pelvic
inflammatory disease.
• It can further affect the urethra, cervix,
rectum and mouth. Transmission to a
fetus at birth can cause neonatal
conjunctivitis, which, if it remains
untreated, can cause blindness.
• It is a notifiable disease and is treated
with penicillin; sexual partners should
always be traced to be tested and treated
if necessary.

6. NEONATAL CONJUNCTIVITIS

7. 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.

8. Protective Factors
Contraceptive practice
• Barrier methods, especially condoms, diaphragm with
spermicides
• Oral steroidal contraceptives have got two preventive
aspects.
1.Produce thick mucus plug preventing ascent of sperm
and bacterial penetration
2. A decrease in duration of menstruation creates a shorter
interval of bacterial colonization of the upper tract.
• Monogamy or having a partner who had a vasectomy.
Others
• Pregnancy
• Menopause
• Vaccines: hepatitis B, HPV

9. Mode of
Affection
• The classic concept is that the gonococcus
ascends up to affect the tubes through
mucosal continuity and contiguity. This
ascent is facilitated by the sexually
transmitted vectors such as sperm and
trichomonads.
• Reflux of menstrual blood and gonococci
into the fallopian tubes is the other possibility.
• Mycoplasma hominis probably spreads
across the parametrium to affect the tube.
• The secondary organisms probably affect the
tube through lymphatics.
• Rarely, organisms from the gut may affect
the tube directly.

10. 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 endo
salpinx.
• There is gross destruction of the epithelial cells, cilia, and
microvilli. In severe infection, it invades all the layers of the
tube and produces an acute inflammatory reaction; it
becomes edematous and hyperemic.
• The exfoliated cells and the exudate pour into the lumen of
the tube and agglutinate the mucosal folds. The abdominal
ostium is closed by the indrawing of the edematous fimbriae
and by inflammatory adhesions.

11. • The uterine end is closed by congestion. The closure of both the ostia results in pent
up of the exudate inside the tube. 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. 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.

13. Clinical Features
• Symptoms usually appear at the time
and immediately after the menstruation.
• Bilateral lower abdominal and pelvic
pain which is dull in nature.
• The onset of pain is more rapid and
acute in gonococcal infection (3 days)
than in chlamydial infection (5–7 days).
• There is fever, lassitude and headache.
• Irregular and excessive vaginal
bleeding is usually due to associated
endometritis.
• Abnormal vaginal discharge which
becomes purulent and or copious.

14. • Nausea and vomiting.
• Dyspareunia.
• Pain and discomfort in the right hypochondrium due to concomitant
perihepatitis (Fitz-Hugh-Curtis syndrome) may occur in 5–10 per cent of
cases of acute salpingitis.
• The liver is involved due to transperitoneal or vascular dissemination of
gonococcal or chlamydial infection.

16. • The temperature is elevated to beyond 38.3°C.
• Abdominal palpation reveals tenderness on both quadrants of the lower abdomen.
• The liver may be enlarged and tender.
• Vaginal examination reveals:
(1)Abnormal vaginal discharge which may be of 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.
(4)Bimanual examination reveals bilateral tenderness on fornix palpation, which
increases more with movement of the cervix.
(5)There may be thickening, or a definite mass felt through the fornices.

17. Investigations
• Identification of organisms: For identification of organisms,
the materials are collected from the following available
sources:
1. Discharge from the urethra or Bartholin’s gland.
2. Cervical canal.
3. Collected pus from the fallopian tubes during laparoscopy or
laparotomy.
• The collected material is subjected to Gram stain and culture
(aerobic and anaerobic).
• 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. The results correlate with the severity of the
inflammatory reactions of the fallopian tubes as seen on
laparoscopy.

18. • Laparoscopy:Laparoscopic findings and severity of PID:
• Mild: Tubes: edema, erythema, no purulent exudates and mobile.
• Mod: Purulent exudates from the fimbrial ends, tubes not freely
movable.
• Severe: Pyosalpinx, inflammatory complex,abscess.
• ‘Violin string’ like adhesions in the pelvis and around the liver
suggests chlamydial infection.
• Sonography: Dilated and fluid-filled tubes, fluid in the pouch of
Douglas or adnexal mass are suggestive of PID.

19. DIFFERENTIAL DIAGNOSIS
Appendicitis
Disturbed ectopic pregnancy
Torsion of the ovarian pedicle, hemorrhage or rupture of ovarian cyst,
Endometriosis
Diverticulitis
Urinary tract infection

20. Medications
• Analgesics
• Anti-biotics- Levofloxacin, Ceftriaxone,
Doxycycline,Metronidazole
• Surgery- done due to pelvic abscess, peritoneal
abscess.

21. Complications of PID
• Immediate: (1) Pelvic peritonitis or even generalized peritonitis.
(2) Septicemia—producing arthritis or myocarditis.
• Late:
(1) Dyspareunia.
(2) Infertility rate is 12 percent, after two episodes increase to 25 per cent and after three raises to 50
per cent. It is due to tubal damage or tubo-ovarian mass.
(3) Chronic pelvic inflammation is due to recurrent or associated pyogenic infection.
(4) Formation of adhesions or hydrosalpinx or pyosalpinx and tubo-ovarian abscess.
(5) Chronic pelvic pain and ill health.
(6) Increased risk of ectopic pregnancy (6-10 fold).

22. ROLE OF PHYSIOTHERAPY
• There is no role for physiotherapy in the acute phase of gynaecological infections.
• These must be promptly and properly diagnosed, and effectively treated with the correct
pharmacotherapy.
• However, in the chronic phase, where the organism is resistant to antibiotics or when adhesions are
causing pain, there may occasionally be a place for physiotherapeutic measures such as
continuous or pulsed short-wave diathermy.
• The women’s health physiotherapist can also offer coping strategies to deal with pain and stress,
and advice on the promotion of good health.
• Iontophoresis
• Salpingotomy
• Oophrectomy