Pelvic inflammatory disease (PID) is an infection of the female upper genital tract including the uterus, fallopian tubes, and surrounding pelvic structures. It is usually caused by sexually transmitted infections like chlamydia and gonorrhea spreading from the vagina or cervix. Left untreated, PID can cause long-term complications like infertility, ectopic pregnancy, and chronic pelvic pain. Treatment involves antibiotics to cover the most common causative organisms.

1. PELVIC INFLAMMATORY
DISEASE (PID)
Fahad zakwan

2. What is PID?
•Inflammation of female pelvic structures
•Ascending spread of infection from the
vagina or cervix through the uterus, to
fallopian tubes, ovaries and adjacent
peritoneum.
•Upper genital tract infection
•It is not infection in the vagina or vulva

3. It comprises a spectrum of
inflammatory disorders including any
combination of endometritis,
salpingitis, tubo-ovarian abscess,
and pelvic peritonitis.

4. ANATOMY

5. Why PID is important
•Many hospital admissions
• Sometimes fatal
•Chronic damage causes infertility
•Predisposes to ectopic pregnancy
•Can affect a baby during birth
• Lung inflammation
• Eye infections
•Is a common cause of chronic menstrual problems

6. RISK FACTORS
• Adolescence
• History of PID
• Gonorrhea or chlamydia,
or a history of gonorrhea
or chlamydia
• Male partners with
gonorrhea or chlamydia
• Multiple partners
• Current douching
• Insertion of IUD
• Bacterial vaginosis
• Oral contraceptive use
(in some cases)
• Demographics
(socioeconomic status)

7. • Number of sexual contacts by the sexual partner
• Cultural practices
• Polygamy,
• Prostitutes
• Attitudes to menstruation and pregnancy
• Frequency of intercourse (Age)
• Poor health resources
• Antibiotic exposure (resistance)

9. AETIOLOGY
• Infection can occur after procedures that break cervical
mucous barrier
• The adult vagina is lined by stratified squamous epithelium
like skin
• But the cervix has mucous to receive sperm
• Organisms can access higher when mucous is receptive
• Endometrium sheds regularly so is infrequently a site of
chronic infection
• Fallopian tubes and peritoneum should be sterile

10. Microbial aetiology…
•Most cases of PID are polymicrobial
•85 – 95% is due to specific sexually transmitted
organisms
• Neisseria gonorrhoea
• Chlamydia trachomatis
• Others e.g. Mycoplasma species
•5 – 15% begins after reproductive tract damage
• From pregnancy
• From surgical procedures e.g. D&C
• Includes insertion of IUCD

11. •N. gonorrhoeae: recovered from
cervix in 30%-80% of women with PID
•C. trachomatis: recovered from
cervix in 20%-40% of women with PID
•N. gonorrhoeae and C.
trachomatis are present in
combination in approximately 25%-
patients

12. •Endogenous infection occurs from
commensal organisms
•Anaerobes e.g. Bacteroides
•Aerobes e.g. E Coli, Streptococcus species
•Actinomycosis with IUCD
•A smaller number of PID is due to
Tuberculosis (TB)
•Blood borne spread after primary lung infection

13. Chlamydia trachomatis
• Produces a mild form of salpingitis
• Slow growing in culture (48-72 hr.)
• An intracellular organism
• Insidious onset
• Remain in tubes for months/years after initial colonization of
upper genital tract
• Can cause severe damage/changes over long periods

14. Neisseria gonorrhoea
•Gram negative Diplococcus
•Grows rapidly in culture (doubles every 20-40 min)
•Causes a rapid & intense inflammatory response
•May occur after prior Chlamydia infection
•More likely to be symptomatic in the male partner

15. PATHO-PHYSIOLOGY OF PID:
•Bacterial Chlamydia & gonorrhea enter woman’s
genital tract & move toward the cervix.
•Penetrates cervical mucus which protects against
spread of microorganisms, having access to upper
genital tract of women, infecting uterus, ovaries,
fallopian tubes, & other structures in the pelvic
cavity.

16. Pathway of Ascendant Infection
cervicitis endometritis
Salpingitis/
tubo-ovarian
abscess
peritonitis

17. PATHOLOGY
normal fallopian tube
fallopian tube in PID

18. NORMAL FALLOPIAN TUBES AFTER C. trachomatis INFECTION

19. PID Classification
Subclinical/silent
60%
Mild to moderate symptoms
36%
Severe symptoms
4%
Subclinical/silent
Mild to moderate symptoms
Severe symptoms
Overt
40%

20. PID comes in two forms...
•Acute
• Patient has generalised symptoms
• Lasts a few days
• May recur in episodes
• Very infectious in this stage
•Chronic
• Patient may have no symptoms
• Occurs over months and years
• Progressive organ damage & change
• May burn out (arrest)

21. SYMPTOMS OF PID:
• Pain in lower abdominal region
disassociated with a period.
• Fever
• Can range from subtle &mild to
sudden onset of moderate to
severe pain
• Unusual vaginal discharge that
may have a foul odor
• Pain during intercourse
• Irregular menstrual
bleeding.
• Back pain
• Urinary discomfort
• Pain during a pelvic exam

22. symptoms

23. COMPLICATIONS OF PID
• Can be life threatening
• Chronic Pelvic Pain (15-20 %)
• Causes complications of conception, pregnancy, & fertility
• Infertility (Tubal)
• 10 – 15% after one episode
• 20% ~ 2 episode
• >40% ~ 3 episodes
• Inflammation of fallopian tubes
• Scarring of abdominal cavity tissue

24. • Scarring of fallopian tubes, causing blockage which can
lead to ectopic pregnancy (tubal conception)
• Ectopic pregnancy (6-10 fold ↑Risk)
• At least 50% of tubal pregnancies have histology of PID
• Causes high pregnancy-related deaths among African
American
• Recurrence of acute PID at least 25%
• Male genital disease in 25%

25. DIAGNOSIS
Minimum Criteria in the Diagnosis of PID
1. Uterine tenderness, or
2. Adnexal tenderness, or
3. Cervical motion tenderness

26. Additional Criteria to Increase Specificity of
Diagnosis
• Temperature >38.3°C (101°F)
• Abnormal cervical or vaginal mucopurulent discharge
• Presence of abundant numbers of WBCs on saline
microscopy of vaginal secretions
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated C-reactive protein (CRP)
• Gonorrhea or chlamydia test positive

27. More Specific Criteria
•Endometrial biopsy
•Transvaginal sonography or MRI
•Laparoscopy

28. •The diagnosis requires a high index of
suspicion in a patient “at risk” when
there is:
1. Lower abdominal pain (90%)
2. Fever (sometimes with malaise,
vomiting)
3. Mucopurulent discharge from cervix
4. Pelvic tenderness

29. Differential Diagnosis for PID
• Endometriosis
• Appendicitis & other gastro conditions
• Appendicitis is unilateral and right sided
• PID is bilateral
• Ectopic pregnancy
• Always do a pregnancy test
• Urinary tract infection or stone
• “Ovarian cysts”
• Lower genital tract infection

30. INVESTIGATIONS
•FBP
•Raised WCC
• Elevated erythrocyte sedimentation rate (ESR)
• Elevated C-reactive protein (CRP)
•Endocervical swab for organisms or PCR
•Ultrasound evidence of pelvic fluid collections
•Laparoscopy

31. FBP

32. Mucopurulent Cervical Discharge
(Positive swab test)

33. LAPARASCOPY
ULTRASONOGRAPHY

34. MANAGEMENT
GENERAL PID CONSIDERATIONS
•Regimens must provide coverage of N.
gonorrhoeae, C. trachomatis, anaerobes, Gram-
negative bacteria, and streptococci
•Treatment should be instituted as early as
possible to prevent long term sequelae

35. treatment options include…….
• Antibiotics
• Needs appropriate spectrum of activity
• Specific or broad spectrum
• Surgical
• Drain abscess
• Selective or radical removal
• Rest and analgesia
• NSAID’s useful

36. Antibiotic Therapy
• Gonorrhea : Cephalosporins, Quinolones
• Chlamydia: Doxycycline, Erythromycin &
Quinolones (Not cephalosporins)
• Anaerobic organisms: Metronidazole,
Clindamycin and, in some cases, Doxycycline.
• Beta hemolytic Streptococcus and E. Coli Penicillin
derivatives, Tetracyclines, and Cephalosporins ,
Gentamicin.

37. Oral Regimens
CDC-recommended oral regimen A
• Ceftriaxone 250 mg IM in a single dose,
PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days

38. CDC-recommended oral regimen B
• Cefoxitin 2 g IM in a single dose and Probenecid 1 g
orally in a single dose,
PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days

39. CDC-recommended oral regimen C
• Other parenteral third-generation cephalosporin (e.g.,
Ceftizoxime, Cefotaxime),
PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days

40. Parenteral Regimens
CDC-recommended parenteral regimen A
• Cefotetan 2 g IV every 12 hours, OR
• Cefoxitin 2 g IV every 6 hours, PLUS
• Doxycycline 100 mg orally or IV every 12 hours
CDC-recommended parenteral regimen B
• Clindamycin 900 mg IV every 8 hours, PLUS
• Gentamicin loading dose IV or IM (2 mg/kg), followed by maintenance dose
(1.5 mg/kg) every 8 hours. Single daily gentamicin dosing may be
substituted.

41. alternative regimen
• Ampicillin/ Sulbactam 3 g IV every 6 hours, PLUS
• Doxycycline 100 mg orally or IV every 12 hours.
• It is important to continue either regimen A or B or
alternative regimens for at least 24 hours after substantial
clinical improvement occurs and also to complete a total of
14 days therapy with:
• Doxycycline 100mg orally twice a day OR
• Clindamycin 450mg orally four times a day.

42. Follow-Up
• Patients should demonstrate substantial improvement within
72 hours.
• Patients who do not improve usually require hospitalization,
additional diagnostic tests, and surgical intervention.
• Some experts recommend re-screening for C. trachomatis
and N. gonorrhoeae 4-6 weeks after completion of therapy in
women with documented infection due to these pathogens.
• All women diagnosed clinical acute PID should be offered
HIV testing.

43. •Partner or sexual contact tracing and testing
or treatment
•Look for other STD’s
•STS, Hep B and HIV
•Lower genital tract infections
•Counselling and support
•Pregnancy care

44. CRITERIA FOR HOSPITALIZATION
1. Inability to exclude surgical emergencies
2. Pregnancy
3. Non-response to oral therapy
4. Inability to tolerate an outpatient oral regimen
5. Severe illness, nausea and vomiting, high fever or
tubo-ovarian abscess
6. HIV infection with low CD4 count

45. Pregnancy
- Augmentin or Erythromycin
- Hospitalization
Concomitant HIV infection
- Hospitalization and IV antimicrobials
- More likely to have pelvic abscesses
- Respond more slowly to antimicrobials
- Require changes of antibiotics more often
- Concomitant Candida and HPV infections
Special Situations

46. PREVENTION OF PID
• Screen & treat asymptomatic disease
• Sexual health counselling
• Barrier contraceptives
• Progestin-based contraception
• COC & POP
• Depot and Implanon
• ?Mirena
• Sexual fidelity or abstinence
• Improving the education and status of women

47. Screening
• To reduce the incidence of PID, screen and treat for
chlamydia.
• Annual chlamydia screening is recommended for:
• Sexually active women 25 and under
• Sexually active women >25 at high risk
• Screen pregnant women in the 1st trimester.

48. Partner Management
• Male sex partners of women with PID should be
examined and treated if they had sexual contact with
the patient during the 60 days preceding the patient’s
onset of symptoms.
• Male partners of women who have PID caused by C.
trachomatis or N. gonorrhoeae are often asymptomatic.
• Sex partners should be treated empirically with
regimens effective against both C. trachomatis and N.
gonorrhoeae, regardless of the apparent etiology of PID
or pathogens isolated from the infected woman.

49. Reporting
•Report cases of PID to the local STD
program in states where reporting is
mandated.
•Gonorrhea and chlamydia are reportable
in all states.

50. Patient Counseling and Education
•Nature of the infection
•Transmission
•Risk reduction
• Assess patient's behavior-change potential
• Discuss prevention strategies
• Develop individualized risk-reduction plans