Benha university Hospital, Egypt

ABOUBAKR ELNASHAR

PID is the most important infection in gynecologic

practice

Incidence: decreased in developed countries, still

high in developing countries

Diagnosis: difficult

Complications: serious

ABOUBAKR ELNASHAR

Infection of the upper genital tract i.e above the cervix

ABOUBAKR ELNASHAR

1.Acute

A. Primary (STD, no precipitating cause)

B. Secondary (to precipitating cause;IUCD,abortion or infection

elsewhere in the body; appendicitis)

2. Recurrent acute

After the first episode, due to exogenous organism (STD) or

endogenous organism due to decrease host defense

3. Chronic

Misnomer {chronic problems associated with PID (hydrosalpinx &

adhesions) are bacteriologically sterile}.

The true chronic PID are TB & actinomycosis

ABOUBAKR ELNASHAR

US: 15%

Developed countries: recently decrease due to:

1. Awareness of C. trachomatis & AIDS.

2. Precautions to avoid STD.

Developing countries: No decrease

ABOUBAKR ELNASHAR

1. Age: teenagers

2.Sexual activity:

STD, increse with multiple sexual partners & increased

frequency

(Lee et al,1991)

3. Husband:

Gon., Chlamydia urethritis is an important source of PID

4. Menstrual periods:

2/3 postmenstrual {shedding of the endometrium, retrograde

menstruation}

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5. Iatrogenic:

IUCD (the first 4 mo), HSG, D&C, elective abortion,

laparoscopy & dye test, hysteroscopy, douching

(Scholes et al,1993)

6. Previous PID

(Hills et al,1997)

7. Bacterial vaginosis: change in cervical mucous

leading to ascend of pathogenic bacteria

(Peipert et al,1997)

8. Smooking: by changing cervical mucous

(Scholes et al,1993)

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1. Age:

>45 yr.rarely develop PID

2. Pregnancy:

>10 w (membranes seal the uterus & the tubes)

3. Tubal sterilization:

4. OCP:

not for CT & if PID occur it well be mild (increased

density of cervical mucous & decrease menstrual

bleeding)

5. Barrier contraceptives: diagram, condom, foam

ABOUBAKR ELNASHAR

The oral contraceptive pill& PID

Women taking the oral contraceptive pill who present with

should be screened for genital tract infection, especially C.

trachomatis.

The use of the combined oral contraceptive pill has usually

been regarded as protective against symptomatic PID.

Retrospective case–control and prospective studies have,

however, shown an

association with an increased incidence of asymptomatic

cervical infection with C. trachomatis.

This has led to the suggestion that the oral contraception may

mask endometritis. Women using the oral contraceptive pill

should be warned that its effectiveness may be reduced when

taking antibiotic therapy.

ABOUBAKR ELNASHAR

Polymicrobial

1.C. T:

30-60%. The commonest STD. It is obligate

intracellular organism

2.N. gon:

15-20%. CT & N Gon often are found together in

patients with PID. Gram –ve diplococci.

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3. Endogenous aerobes:

E. coli, proteus, Klebsiella & streptoc

4.Endogenous anaerobes:

60% : bacteroids, p. strep c., pepto c (older recurrent

, long standing).

5.Mycoplasma: 10-15% (parametritis)

6.Actinmycosis (IUCD, unilateral)

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I. Ascending:

Common

from the lower genital tract

Through: sperm, TV

Along surfaces or lymphatics in parametrium

II. Lateral:

Rare

from infected appendix

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No S or S are path gnomonic of PID

(Tuomala & Chen,1999).

CT as well as Gon may be found in asymptomatic

women. Cases of silent PID now outnumber

clinically apparent cases by a ratio of 3:1

(Hare & Foster,1995)

Clinical diagnosis is difficult: non specific

symptoms, exaggerated, sexual history may be

ignored

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1. Pelvic pain: 95% . The commonest & bilateral

2. Cervical movement tenderness: 90%

3. Abdominal tenderness: 90%

4. Purulent cervical discharge: 50%

5. T> 38C: 30% (Gon or anerobe > CT)

6. A.U.bleeding: 35%

7. Dysuria: 20%

8. Nausea & vomiting: late (early in appendicitis)

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1. Pregnancy test: in all cases

2. ESR:

>15 mm/h (75%), not specific

if >40 mm/h: severe PID

3. CRP (Acute phase protein):

75%, >60 mg/L: severe PID

4. Leucocytosis: >10.000 (50%)

5. Genital tract isoamylase: decrease

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6.Pap. Smear:

Ch Tr., not sensitive, IC inclusion bodies

7. Gr stained smear: N. Gon, Gram –ve diplococci

8.Endocervical scrap: Monoclonal I. F stains: Ch. Tr

or ELISA for antigens of CT

9. Transcervical endometrial sampling: microbiology,

histopathology: plasma cell endometritis)

10. Wet mount:

WBC are present in lower genital tract discharge of all women

with PID. Increased WBC in vaginal discharge is the most

sensitive test for PID & serum WBC is the most specific

(Peipert et al,1996)

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Indications:

1. Pelvic mass 2. Suspicion of ectopic

3. Failure of T.T 4. Recurrent PID

Contraindication:

1. Large pelvic mass

2. Adhesions

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Advantages:

1. Confirm diagnosis (65%), no pathology (23%) &

other pathology (12%)

2. Culture

3. Grading (Soper,1991):

Mild:

erythema, edema, exudates, tubes are patent &

mobile,

Moderate: purulent discharge & fixed tubes

Severe: TO abscess, pyosalpinx

ABOUBAKR ELNASHAR

Purulent discharge

Culture: poor correlation

Contraindicated: mass in cul de sac

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Indication: all cases

Value: define adenxal mass,

differentiate between adenxal mass & TO abscess,

exclude IU or ectopic pregnancy,

follow up

TVS:

1. Features of PID: Tubes: Thickened(>5mm) fluid filled in 85%.

Ovaries: Polycystic like, Cog-wheel sign

D pouch: free fluid, incomplete septa (Molander et al,2001)

2. Aspiration of TOA with 16 gauge needle as used in ovum retrieval

3. Follow up

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Indication: Not a routine,

Extreme tenderness,

No response to T.T

ABOUBAKR ELNASHAR

Abdominal pain & tenderness,

Cervical movement tenderness &

Adenxal tenderness + 1 or more of the following

T.> 38 C,

Leucocytosis > 10000,

ESR > 15 mm/h,

Gram –ve intracellular diplcocci,

6 WBC/HPF,

I.F. stain: Ch tr,

U/S: adenxal mass,

culdocentesis: purulent discharge (Hager et al,1983) ABOUBAKR ELNASHAR

1. Ectopic pregnancy

2. Complicated ovarian cyst

3. Endometriosis

4. Septic abortion

5. UTI

6. Acute appendicitis

7. Acute cholycystitis

8. Inflammatory bowel disease

9. Mesenteric lymphadenitis

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Indication: mild PID

(CDC,1998)

Regimen A: Ofloxacin 400 mg po bid X 14 d

plus metronidazole 500 mg po bid for 14 d

Regimen B: Ceftriaxone (Fortum,Rocephin, Cefotrex)

250 mg IM OR Cefoxitin 2 gm plus probencid 1

gm po. PLUS doxycyclin 100 mg po bid for 14 d

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Treatment of CT:

Single dose azithromycin (1 gm) & 7 d doxycyclin

have comparable cure rate & side effects

(Martin et al, 1992)

Actinomycosis

sensitive to doxycyclin, penicillin, & cephalosporin

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IUCD may be left in situ in women with clinically mild

PID but should be removed in cases of severe

disease.

RCOG, 2003

An IUCD only increases the risk of developing PID

in the first few weeks after insertion.

A single small randomised controlled trial suggests

that removing an IUCD does not affect the response

to treatment but the study has suboptimal outcome

measures. An observational study also showed no

benefit in removing an IUCD in this situation.

ABOUBAKR ELNASHAR

Indication:

T > 38 C,

Nausea & vomiting,

Signs of peritoneal irritation,

? pelvic or Tubo-ovarian abscess,

? ectopic preg or appendicitis,

IU CD,

Adolescents,

No follow-up,

Failure of out-patient T.T

ABOUBAKR ELNASHAR

General:

Fowler position,

Fluids, light diet,

Analgesics, antipyretics,

Removal of IUCD (resolution of the disease may be

slower & less complete) & examination for

actinomycosis & culture

ABOUBAKR ELNASHAR

Antibiotics

Combined regimen, covers the 3 major pathogens

Success rate: 85-95%

Failure of improvement:

Tubo-ovarian or pelvic abscess,

Anaerobic infection, Penicillinase producing. N.

gon.,

Recurrent long standing PID.

ABOUBAKR ELNASHAR

Treatment of Chlamydia tachomatis (CDC,1998)

Non-pregnant

Azithromycin 1gm PO X 1 dose or

Doxycycline 100 mg PO BID X 7d or

Erythromycin base 500 mg PO QID 7 d or

Erythromycin ethylsuccinate 800 mg PO QID X 7d

or

Ofloxacin 300 mg PO BID X 7 d

Pregnant

Erythromycin base 500 mg PO QID X 7 d or

Amoxacillin 500 mg PO TID X 7 d ABOUBAKR ELNASHAR

Antibiotics for Gonorrhea (CDC 1998)

Uncomplicated uretheral, cervical or rectal infection

Cefixime 400 mg PO X 1 dose or

Ceftriaxone 125 mg IM X 1 dose or

Ciprofloxacin 500 mg PO x 1 dose or

Ofloxacin 400 mg PO X 1 dose

All single dose regimen should be followed with

azithromycin 1gm PO X 1 dose or doxycyclin 100 mg

PO BID X 7 d to cover possible concomitant infection

with CT

ABOUBAKR ELNASHAR

Antibiotic combinations (CDC,1998)

A.Uncomplicated acute PID

Cefotetan 2gm IV q12 h or cefoxitin 2gm IV q6h

PLUS doxycyclin 100 mg IV or po q 12 h.

Oral therapy may be started 24 h after signs of

clinical improvement & continued for a total of 14 d.

ABOUBAKR ELNASHAR

B.Complicated PID (TOA or inflammatory complex)

Clindamycin 900 mg IV q 8 h plus gentamycin

loading dose of 2 mg /k IV or IM followed by 1.5 mg/k

q 8 h. parentral therapy for at least 4 d.

Subsequent oral therapy of clindamycin 450 mg or

doxycyclin 100 mg bid for a total of 14 d

ABOUBAKR ELNASHAR

Indication:

1. Uncertain diagnosis

2. Multiple recurrent PID

3. Tubo-ovarian abscess

(persistent fever, leucocytosis, Increased ESR,

Increased size)

ABOUBAKR ELNASHAR

Lines:

1. Drainage:

posterior colpotomy or percutaneous

2. Laparotomy:

unilateral salpingo-ovarectomy (fertility is required)

or

total abdominal hysterectomy & bilateral salingo-

ovarectomy (fertility is not required)

ABOUBAKR ELNASHAR

Management of tubo-ovarian abscess

? Ruptured Otherwise

Surgery after antibiotic Antibiotic for 48-72 h

No response Response*

Drainage laparotomy

Posterior-colpotomy percutaneous USO TAH + BSO

*75-80% respond to antibiotics. Most TOA <8cm respond (Reed et al,1991)

ABOUBAKR ELNASHAR

Other modes of treatment

Surgical treatment should be considered in severe

cases or where there is clear evidence of a pelvic

abscess.

Laparotomy/laparoscopy may help early resolution of

the disease by division of adhesions and drainage of

pelvic abscesses.

Ultrasound-guided aspiration of pelvic fluid

collections is less invasive and may be equally

effective.

It is also possible to perform adhesiolysis in cases of

perihepatitis although there is no evidence as to

whether this is superior to antibiotic therapy alone.

ABOUBAKR ELNASHAR

To exclude development of adenxal mass,

Adenxal mass: follow-up until disappear,

Adenxal mass persist: laparoscopy

ABOUBAKR ELNASHAR

1. Recurrent PID: 25%

2. Infertility: 1: 12%, 2: 35%, 3: 75%, TOA: 85%

3. Ectopic pregnancy: 50% of ectopic

4. Chronic pelvic pain & dysparunia: increase 4 fold

5. Mortality: rare

6. Preterm labor: 40%

7. Increased incidence of CIN

(Wilson et al,1990)

ABOUBAKR ELNASHAR

1. Screening & treating asymptomatic females at risk

for CT (young, ectopy,purulent cervical discharge

multiple sexual partners)

2. Doxycyclin 200 mg or azithromycin 500 mg at

insertion of IUCD

(Sinei et al, 1999). Little benefit (Cochrane library,2002)

3. Routine antibiotic prophylaxis before surgical

evacuation of incomplete abortion, No difference in

postabortal infection

(Cochrane libarary,2002)

ABOUBAKR ELNASHAR

4.Treatment of symptomatic & asymptomatic sexual

partners. No sexual intercourse until the husband is

checked & treated

5. Assessment of the partner for CT & Gon

6.Women diagnosed as PID should be evaluated for

other types of STD

ABOUBAKR ELNASHAR

1. PID is the most important infection in gynecology

2. PID is preventable disease & safe sexual practice

can decrease its incidence

3. Accurate diagnosis, appropriate treatment & close

follow-up are required to prevent its serious

complications

ABOUBAKR ELNASHAR

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