6. Pelvic inflammatory disease (lecture) Flashcards
what is pelvic inflammatory disease?
the result of infection ascending from the endocervix, causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and / or pelvic peritonitis
what is endometritis?
inflammation and infection of the endometrium (lining of uterus)
what is salpingitis?
inflammation of fallopian tube
what is tubo-ovarian abscess?
It consists of an encapsulated or confined ‘pocket of pus’ with defined boundaries that forms during an infection of a fallopian tube AND ovary
what can tubo-ovarian abscess lead to?
one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis
what is the pathophysiology of PID?
ascending infection from the endocervix and vagina
infection causes inflammation
what can the inflammation from infection cause in PID?
damage to tubal (fallopian) epithelium, therefore adhesions form
what are complications of PID?
ectopic pregnancy
infertility
chronic pelvic pain
Fitz-Hugh-Curtis syndrome
what is Fitz-Hugh-Curtis syndrome?
RUQ pain and peri-pehatitis (outermost layer of liver)
what does Fitz-Hugh-Curtis syndrome normally follow?
chlamydial PID
aetiology of PID?
often polymicrobial
sexually transmitted infections: C. trachomatis, N. gonorrhoea
others: Gardnerella vaginalis, mycoplasma, anaerobes
epidemiology of PID?
underestimated
sexually active women (peak 20-30 years)
incidence rate in primary care about 280/100,000py
risk factors for PID?
STIs: young age, lack of barrier contraception, multiple sex partners, low socioeconomic class IUCD (Intrauterine Contraceptive Device)
what is a typical history of PID?
pyrexia (fever) pain: lower abdo, deep dyspareunia abnormal vaginal / cervical discharge abnormal vaginal bleeding sexual history + prior STI contraceptive history
clinical features on examination of PID?
fever
lower abdominal tenderness - usually bilateral
clinical features on bimanual examination of PID?
Adnexal tenderness (structures closely related to the uterus e.g. the ovaries, fallopian tubes, or any of the surrounding connective tissue) Cervical motion tenderness (Pain elicited when the uterine cervix is manipulated during pelvic examination)
clinical features on speculum examination of PID?
purulent cervical discharge (pus from cervix)
cervicitis (inflammation of the cervix)
what is a urinary differential diagnosis of a PID history?
UTI
what are the GI differential diagnosis of a PID history?
IBS (irritable bowel syndrome)
appendicitis
what are the Gynaecological differential diagnosis of a PID history?
ectopic pregnancy
endometriosis
ovarian cyst complications
what is an ‘other’ differential diagnosis of a PID history?
functional pain
what investigations would you carry out for suspected PID?
urinary and or serum pregnancy test
endocervical and high vaginal swabs
blood test
screening for other STIs including HIV
what would you test for on a blood test for PID?
WBC
CRP (infections)
what would you test for on endocervical and high vaginal swabs for PID?
presence of NG/CT supports diagnosis
absence of NG / CT does NOT exclude diagnosis
(C. trachomatis, N. gonorrhoea - STI causing PID)
what is the management for low threshold PID?
empirical treatment
what can delayed treatment for low threshold PID lead to?
increases longterm sequelae
what is the management of severe PID?
requires IV antibiotics and admission for observation and possible surgical intervention
what are signs of tubo-ovarian abscess and pelvic peritonitis?
pyrexia > 38 (degrees)
what does severe PID lead to?
increased risk of longterm sequelae
how long should patients with PID be on antibiotics for?
14 days
what is the OUTpatient antibiotic treatment for PID?
IM Ceftriaxone 500mg STAT (immediate) \+ Oral Doxycycline 100mg BD (twice daily) \+ Oral Metronidazole 400mg BD (twice daily)
what is the INpatient antibiotic treatment for PID?
IV Ceftriaxone 500mg STAT + IV/PO Doxycycline 100mg BD + IV Metronidazole 400mg BD THEN PO Doxycycline 100mg BD + PO Metronidazole 400mg BD
what are the different surgical management of PID?
laparoscopy / laparotomy (surgical diagnostic procedure used to examine the organs inside the abdomen)
Ultrasound guided aspiration of pelvic collections
when would you consider laparoscopy / laparotomy?
no response to therapy
clinically severe disease
present of a tubo-ovarian abscess
why would ultrasound guided aspiration of pelvic collections be chosen over laparoscopy?
ultrasound guided aspiration is less invasive
what do you have to tell patients with PID?
what the diagnosis is
what treatment they have: possible side effects, importance of completing antibiotics
Risk of complications: increases with repeat episodes
how to reduce further episode risks
contact tracing
what is the point of contact tracing?
empirical treatment of partners
abstinence until antibiotic course complete
