PELVIC INFLAMMATORY DISEASE

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<p> 1. Benha university Hospital, Egypt ABOUBAKR ELNASHAR 2. 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 3. Infection of the upper genital tract i.e above the cervix ABOUBAKR ELNASHAR 4. 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 &amp; adhesions) are bacteriologically sterile}. The true chronic PID are TB &amp; actinomycosis ABOUBAKR ELNASHAR 5. US: 15% Developed countries: recently decrease due to: 1. Awareness of C. trachomatis &amp; AIDS. 2. Precautions to avoid STD. Developing countries: No decrease ABOUBAKR ELNASHAR 6. 1. Age: teenagers 2.Sexual activity: STD, increse with multiple sexual partners &amp; 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} ABOUBAKR ELNASHAR 7. 5. Iatrogenic: IUCD (the first 4 mo), HSG, D&amp;C, elective abortion, laparoscopy &amp; 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) ABOUBAKR ELNASHAR 8. 1. Age: &gt;45 yr.rarely develop PID 2. Pregnancy: &gt;10 w (membranes seal the uterus &amp; the tubes) 3. Tubal sterilization: 4. OCP: not for CT &amp; if PID occur it well be mild (increased density of cervical mucous &amp; decrease menstrual bleeding) 5. Barrier contraceptives: diagram, condom, foamABOUBAKR ELNASHAR 9. The oral contraceptive pill&amp; 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 casecontrol 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 10. Polymicrobial 1.C. T: 30-60%. The commonest STD. It is obligate intracellular organism 2.N. gon: 15-20%. CT &amp; N Gon often are found together in patients with PID. Gram ve diplococci. ABOUBAKR ELNASHAR 11. 3. Endogenous aerobes: E. coli, proteus, Klebsiella &amp; streptoc 4.Endogenous anaerobes: 60% : bacteroids, p. strep c., pepto c (older recurrent , long standing). 5.Mycoplasma: 10-15% (parametritis) 6.Actinmycosis (IUCD, unilateral) ABOUBAKR ELNASHAR 12. I. Ascending: Common from the lower genital tract Through: sperm, TV Along surfaces or lymphatics in parametrium II. Lateral: Rare from infected appendix ABOUBAKR ELNASHAR 13. No S or S are path gnomonic of PID (Tuomala &amp; 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 &amp; Foster,1995) Clinical diagnosis is difficult: non specific symptoms, exaggerated, sexual history may be ignored ABOUBAKR ELNASHAR 14. 1. Pelvic pain: 95% . The commonest &amp; bilateral 2. Cervical movement tenderness: 90% 3. Abdominal tenderness: 90% 4. Purulent cervical discharge: 50% 5. T&gt; 38C: 30% (Gon or anerobe &gt; CT) 6. A.U.bleeding: 35% 7. Dysuria: 20% 8. Nausea &amp; vomiting: late (early in appendicitis) ABOUBAKR ELNASHAR 15. 1. Pregnancy test: in all cases 2. ESR: &gt;15 mm/h (75%), not specific if &gt;40 mm/h: severe PID 3. CRP (Acute phase protein): 75%, &gt;60 mg/L: severe PID 4. Leucocytosis: &gt;10.000 (50%) 5. Genital tract isoamylase: decrease ABOUBAKR ELNASHAR 16. 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 &amp; serum WBC is the most specific (Peipert et al,1996) ABOUBAKR ELNASHAR 17. Indications: 1. Pelvic mass 2. Suspicion of ectopic 3. Failure of T.T 4. Recurrent PID Contraindication: 1. Large pelvic mass 2. Adhesions ABOUBAKR ELNASHAR 18. Advantages: 1. Confirm diagnosis (65%), no pathology (23%) &amp; other pathology (12%) 2. Culture 3. Grading (Soper,1991): Mild: erythema, edema, exudates, tubes are patent &amp; mobile, Moderate: purulent discharge &amp; fixed tubes Severe: TO abscess, pyosalpinx ABOUBAKR ELNASHAR 19. Purulent discharge Culture: poor correlation Contraindicated: mass in cul de sac ABOUBAKR ELNASHAR 20. Indication: all cases Value: define adenxal mass, differentiate between adenxal mass &amp; TO abscess, exclude IU or ectopic pregnancy, follow up TVS: 1. Features of PID: Tubes: Thickened(&gt;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 ABOUBAKR ELNASHAR 21. Indication: Not a routine, Extreme tenderness, No response to T.T ABOUBAKR ELNASHAR 22. Abdominal pain &amp; tenderness, Cervical movement tenderness &amp; Adenxal tenderness + 1 or more of the following T.&gt; 38 C, Leucocytosis &gt; 10000, ESR &gt; 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 23. 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 lymphadenitisABOUBAKR ELNASHAR 24. 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 ABOUBAKR ELNASHAR 25. Treatment of CT: Single dose azithromycin (1 gm) &amp; 7 d doxycyclin have comparable cure rate &amp; side effects (Martin et al, 1992) Actinomycosis sensitive to doxycyclin, penicillin, &amp; cephalosporin ABOUBAKR ELNASHAR 26. 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 27. Indication: T &gt; 38 C, Nausea &amp; vomiting, Signs of peritoneal irritation, ? pelvic or Tubo-ovarian abscess, ? ectopic preg or appendicitis, IUCD, Adolescents, No follow-up, Failure of out-patient T.T ABOUBAKR ELNASHAR 28. General: Fowler position, Fluids, light diet, Analgesics, antipyretics, Removal of IUCD (resolution of the disease may be slower &amp; less complete) &amp; examination for actinomycosis &amp; culture ABOUBAKR ELNASHAR 29. 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 30. 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 dABOUBAKR ELNASHAR 31. 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 32. 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 &amp; continued for a total of 14 d. ABOUBAKR ELNASHAR 33. 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 34. Indication: 1. Uncertain diagnosis 2. Multiple recurrent PID 3. Tubo-ovarian abscess (persistent fever, leucocytosis, Increased ESR, Increased size) ABOUBAKR ELNASHAR 35. Lines: 1. Drainage: posterior colpotomy or percutaneous 2. Laparotomy: unilateral salpingo-ovarectomy (fertility is required) or total abdominal hysterectomy &amp; bilateral salingo- ovarectomy (fertility is not required) ABOUBAKR ELNASHAR 36. 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</p>

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