6. Pelvic inflammatory disease (lecture)

Question 1

what is pelvic inflammatory disease?

Answer 1

the result of infection ascending from the endocervix, causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and / or pelvic peritonitis

Question 2

what is endometritis?

Answer 2

inflammation and infection of the endometrium (lining of uterus)

Question 3

what is salpingitis?

Answer 3

inflammation of fallopian tube

Question 4

what is tubo-ovarian abscess?

Answer 4

It consists of an encapsulated or confined ‘pocket of pus’ with defined boundaries that forms during an infection of a fallopian tube AND ovary

Question 5

what can tubo-ovarian abscess lead to?

Answer 5

one of the late complications of pelvic inflammatory disease (PID) and can be life-threatening if the abscess ruptures and results in sepsis

Question 6

what is the pathophysiology of PID?

Answer 6

ascending infection from the endocervix and vagina

infection causes inflammation

Question 7

what can the inflammation from infection cause in PID?

Answer 7

damage to tubal (fallopian) epithelium, therefore adhesions form

Question 8

what are complications of PID?

Answer 8

ectopic pregnancy
infertility
chronic pelvic pain
Fitz-Hugh-Curtis syndrome

Question 9

what is Fitz-Hugh-Curtis syndrome?

Answer 9

RUQ pain and peri-pehatitis (outermost layer of liver)

Question 10

what does Fitz-Hugh-Curtis syndrome normally follow?

Answer 10

chlamydial PID

Question 11

aetiology of PID?

Answer 11

often polymicrobial
sexually transmitted infections: C. trachomatis, N. gonorrhoea
others: Gardnerella vaginalis, mycoplasma, anaerobes

Question 12

epidemiology of PID?

Answer 12

underestimated
sexually active women (peak 20-30 years)
incidence rate in primary care about 280/100,000py

Question 13

risk factors for PID?

Answer 13

STIs: young age, lack of barrier contraception, multiple sex partners, low socioeconomic class
IUCD (Intrauterine Contraceptive Device)

Question 14

what is a typical history of PID?

Answer 14

pyrexia (fever)
pain: lower abdo, deep dyspareunia
abnormal vaginal / cervical discharge
abnormal vaginal bleeding
sexual history + prior STI
contraceptive history

Question 15

clinical features on examination of PID?

Answer 15

fever

lower abdominal tenderness - usually bilateral

Question 16

clinical features on bimanual examination of PID?

Answer 16

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)

Question 17

clinical features on speculum examination of PID?

Answer 17

purulent cervical discharge (pus from cervix)

cervicitis (inflammation of the cervix)

Question 18

what is a urinary differential diagnosis of a PID history?

Answer 18

UTI

Question 19

what are the GI differential diagnosis of a PID history?

Answer 19

IBS (irritable bowel syndrome)

appendicitis

Question 20

what are the Gynaecological differential diagnosis of a PID history?

Answer 20

ectopic pregnancy
endometriosis
ovarian cyst complications

Question 21

what is an ‘other’ differential diagnosis of a PID history?

Answer 21

functional pain

Question 22

what investigations would you carry out for suspected PID?

Answer 22

urinary and or serum pregnancy test
endocervical and high vaginal swabs
blood test
screening for other STIs including HIV

Question 23

what would you test for on a blood test for PID?

Answer 23

WBC

CRP (infections)

Question 24

what would you test for on endocervical and high vaginal swabs for PID?

Answer 24

presence of NG/CT supports diagnosis
absence of NG / CT does NOT exclude diagnosis
(C. trachomatis, N. gonorrhoea - STI causing PID)

Question 25

what is the management for low threshold PID?

Answer 25

empirical treatment

Question 26

what can delayed treatment for low threshold PID lead to?

Answer 26

increases longterm sequelae

Question 27

what is the management of severe PID?

Answer 27

requires IV antibiotics and admission for observation and possible surgical intervention

Question 28

what are signs of tubo-ovarian abscess and pelvic peritonitis?

Answer 28

pyrexia > 38 (degrees)

Question 29

what does severe PID lead to?

Answer 29

increased risk of longterm sequelae

Question 30

how long should patients with PID be on antibiotics for?

Answer 30

14 days

Question 31

what is the OUTpatient antibiotic treatment for PID?

Answer 31

IM Ceftriaxone 500mg STAT (immediate)
\+
Oral Doxycycline 100mg BD (twice daily)
\+
Oral Metronidazole 400mg BD (twice daily)

Question 32

what is the INpatient antibiotic treatment for PID?

Answer 32

IV Ceftriaxone 500mg STAT +
IV/PO Doxycycline 100mg BD +
IV Metronidazole 400mg BD
THEN
PO Doxycycline 100mg BD +
PO Metronidazole 400mg BD

Question 33

what are the different surgical management of PID?

Answer 33

laparoscopy / laparotomy (surgical diagnostic procedure used to examine the organs inside the abdomen)
Ultrasound guided aspiration of pelvic collections

Question 34

when would you consider laparoscopy / laparotomy?

Answer 34

no response to therapy
clinically severe disease
present of a tubo-ovarian abscess

Question 35

why would ultrasound guided aspiration of pelvic collections be chosen over laparoscopy?

Answer 35

ultrasound guided aspiration is less invasive

Question 36

what do you have to tell patients with PID?

Answer 36

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

Question 37

what is the point of contact tracing?

Answer 37

empirical treatment of partners

abstinence until antibiotic course complete