Pelvic Inflammatory Disease

Question 1

Presentation of PID (4)

Answer 1

Triad of lower abdominal pain, cervical excitation tenderness, adnexal and uterine tenderness
PLUS one: fever, mucopurulent cervical discharge, ESR>15, raised CRP
Other: rebound tenderness, tachycardia, palpable masses (abscesses)

Question 2

Gainesville Stage 1 PID (3)

Answer 2

• Acute Early salpingitis and local tenderness
• without peritonitis (no rebound tender or guarding ) but
• 1 or more minimum criteria eg cet, uterine tenderness, adnexal tenderness (lower abdominal / pv pain)

Question 3

Gainesville Stage 2 PID

Answer 3

• Acute Salpingitis
• and pelvic peritonitis of lower abdomen: Tenderness PLUS rebound and guarding

Question 4

Stage 3 PID Gainesville

Answer 4

Acute Salpingitis with superimposed tubal occlusion or tubo- ovarian complex (abscess) (pyosalpinx) + ESR >60
( Inflammatory mass causing tenderness, rebound, guarding )

Question 5

Gainesville Stage 4 PID

Answer 5

Rupture of tubo-ovarian abscess → acute abdomen
( inflammatory mass/pus leaking into abdo and pelvis, causing acute abdo, gen peritonitis, fail respond med rx )

Question 6

Rx stage 1 PID

Answer 6

Out pt: ciprafloxacin (fluoroquinolone G+ and -), doxycycline (tetracycline atypical), metronidazole (anaerobes)

In practice : augmentin (amoxicillin clavulanate) only (1000 Mg 12 hrly 7 days)

Question 7

Rx stage 3+4 PID (6)

Answer 7

• Medical: CDC regimen B (preferred due to drug availability)
→ inpatient: clindamycin 900 mg iv 8 hourly PLUS gentamicin loading dose iv or IM 2mg / kg followed by maintenance 1,5 mg /kg iv 8 hourly (switch to oral after clinical response and treat for 14 days)
Themba protocol: rocephin + gentamicin + flagyl
→ outpatient: third generation cephalosporin ( ceftriaxone 250 mg IM stat ) PLUS doxycycline 100mg po bd 14 days PLUS metronidazole 400 - 500mg po bd 14 days.

• sx: laparotomy if abscesses don’t respond to antibiotics in 48 hours/uncertain Dx / severely ill / after 4-6 weeks still large/symptomatic pelvic mass

Question 8

Define PID (5)

Answer 8

Ascending polymicrobial infection of the upper female genital tract characterised by any of the following

• Endometritis
• Salpingitis
• tubo - ovarian abscesses
• pelvic peritonitis

Question 9

Stage 5 Gainesville PID

Answer 9

Advanced disease with septic shock and ARDS

Question 10

History diagnostic features /risk factors PID? (5)

Answer 10

• <25 years age
• high risk sexual behaviour
• previous pid/sti
• drug use
• vaginal douching

Question 11

Clinical diagnostic features PID? (6)

Answer 11

• mucopurulent discharge
• lower abdominal pain
• abnormal uterine bleeding
• temperature > 38
• one or more minimum criteria!: cervical excitation tenderness, adnexal tenderness, uterine tenderness
• acute abdomen

Must exclude other common causes lap: appendicitis, ovarian cyst, ectopic pregnancy

Question 12

Laboratory diagnostic features PID? (4)

Answer 12

• WBC on saline microscopy of vaginal fluid
• raised CRP + ESR
• raised wCC
• NAAT positive for C trachomatis / N gonorrhoea
• endometrial sample for histology to confirm Endometritis; exclude genital Tb

Also do HIV; urine dipstix to exclude UTI and pregnancy

Question 13

Ultrasound diagnostic features PID? (4)

Answer 13

• Thickened fluid filled tubes (hydrosalpinX)
• free pelvic fluid
• tubo-ovarian complex
• Doppler studies suggesting pelvic infection eg tubal hyperemia

Question 14

How confirm definitive diagnosis PID?

Answer 14

Laparoscopy: see Salpingitis, tubo-ovarian abscess, pelvic abscess

Although impractical so not done

Question 15

Name 5 complications PID

Answer 15

Short term

• Increased morbidity + mortality
• long admission

Long term

• infertility
• increased risk ectopic
• chronic pelvic pain