Pelvic Inflammatory Disease Flashcards
What is pelvic inflammatory disease (PID)?
- inflammation + infection of the organs of the pelvis
- caused by infection spreading up through the cervix
What organs can become inflamed in PID?
endometritis:
- inflammation of the endometrium
salpingitis:
- inflammation of the fallopian tubes
oophoritis:
- inflammation of the ovaries
parametritis:
- inflammation of the parametrium
peritonitis:
- inflammation of the peritoneal membrane
parametrium = connective tissue around the uterus
What are the 3 most common causes of PID?
- Neisseria gonorrhoeae produces a more severe PID
- Chlamydia trachomatis
- Mycoplasma genitalium
- as most cases of PID are caused by an STI, always treat as an STI
What are the less common causes of PID?
Gardnerella vaginalis:
- associated with bacterial vaginosis
Haemophilus influenzae:
- often associated with RTIs
Escherichia coli:
- commonly associated with UTIs
Mycobacterium tuberculosis
it is also possible to get pathogen negative PID
- this is where the swabs do not pick up the pathogen
- there is a pathogen present, it is just not picked up
What are the less common causes of PID?
Gardnerella vaginalis:
- associated with bacterial vaginosis
Haemophilus influenzae:
- often associated with RTIs
Escherichia coli:
- commonly associated with UTIs
Mycobacterium tuberculosis
it is also possible to get pathogen negative PID
- this is where the swabs do not pick up the pathogen
- there is a pathogen present, it is just not picked up
What are the RFs for PID?
- unprotected sex
- younger age
- multiple sexual partners
- existing STI
- previous PID
- presence of an IUD
(the same as for any other STI)
What are the typical symptoms associated with PID?
- fever
- dysuria
- deep dyspareunia (pain during sex)
- abnormal bleeding (IMB / PCB / menorrhagia)
- abnormal vaginal discharge (often purulent)
- pelvic / lower abdominal pain that is BILATERAL
- secondary dysmenorrhoea
pain can be unilateral
What is the difference between superficial and deep dyspareunia?
superficial:
- pain when the penis inserts into the vagina
- associated with vulval conditions / thrush
deep:
- pain is deep within the abdomen
How can the nature of the dyspareunia be used to distinguish PID from other conditions?
- there is deep dyspareunia in PID
- it is constant
- deep pelvic pain is intermittent in IBS and cyclical in endometriosis
- the pain is a menstrual type pain
ectopic pregnancy / cysts produce a similar pattern of pain
What are the 3 areas to cover in history of presenting complaint?
- pain
- bleeding
- other (incl. sexual health)
What features need to be covered in the pain HPC?
- SOCRATES to describe the pain
- presence of dysuria
- presence of DEEP dyspareunia
What features need to be covered in the bleeding HPC?
- last menstrual period (LMP) to consider chance of ectopic pregnancy
- presence of postcoital bleeding (PCB)
- presence of intermenstrual bleeding (IMB)
- recent onset menorrhagia (heavy menstrual bleeding)
- dysmenorrhoea (painful menstrual bleeding)
What other questions need to be asked in the HPC?
- change in vaginal discharge
- change in bowel habit
- presence of a fever
- sexual history - including recent change in sexual partner
- current contraception (can explain some of the bleeding)
if fever:
* consider UTI, appendicitis + severe PID
if change in BH:
* consider IBS, IBD and endometriosis
What is the onset of symptoms like in PID?
recent onset of symptoms (< 30 days)
What examinations would be performed in PID?
abdominal examination:
- including examination of inguinal LNs
bimanual examination
- also check temperature as fever can occur in moderate-severe disease
What are the typical findings on examination?
abdominal examination:
- lower abdominal / pelvic tenderness that is usually bilateral
bimanual examination:
- adnexal tenderness
- cervical motion tenderness / uterine tenderness
- may note the presence of purulent discharge
What is the first-line investigation in PID?
!! PREGNANCY TEST !!
- should be performed in ALL sexually active women with lower abdominal pain
- rules out ectopic pregnancy
What other investigations are performed in suspected PID?
- urine dipstick + MSU (if positive)
- temperature
- NAAT from a vulvovaginal swab (VVS)
- endocervical swab
- blood tests for HIV + syphilis
- consider FBC, CRP/ESR, LFTs
What is tested for on the NAAT VVS?
- NAAT swabs for gonorrhoea + chlamydia
- NAAT swabs for trichomonas if SYMPTOMATIC (itching / discharge / soreness around vulva)
- NAAT swab for Mycoplasma genitalium (if available)
NAAT = nucleic acid amplification test
Why is an endocervical swab performed?
gonorrhoea culture
- this looks at sensitivities to ensure correct antibiotics are given
If a microscope is available, what additional tests may be performed?
- microscopy for the presence of bacterial vaginosis / endocervical pus cells
- swabs taken from vagina or endocervix
- the absence of pus cells excludes PID
What are the potential complications of PID?
- tubal factor infertility
- chronic dyspareunia + pelvic pain (18%)
- Fitz Hugh Curtis syndrome
- tubo-ovarian abscess
- ectopic pregnancy
How is the risk of infertility related to PID?
- the risk of tubal factor infertility increases with number of episodes of PID
- the risk also increases if treatment is delayed
How might someone present if they have a tubo-ovarian abscess as a result of PID?
- systemically unwell
- fever
- palpable mass
- lack of response to treatment
- this is an abscess within the adnexa
- adnexa = region adjoining the uterus containing the ovary, fallopian tube + vessels, ligaments, connective tissue
When is treatment started in PID?
- antibiotics are started immediately before swab results
- this avoids a delay (which increases risk of infertility)
What advice is given to patients about management of PID?
- rest and analgesia
- NO SEX until both they and their partner(s) have completed treatment + follow up
What is involved in the antibiotic management of PID?
ceftriaxone:
- 1g IM stat - given as an injection into the buttocks
- covers for gonorrhoea
doxycycline:
- 100mg PO BD for 14 days
- covers for chlamydia
metronidazole:
- 400mg PO BD for 14 days
- covers for anaerobes (e.g. Gardnerella vaginalis)
What is not covered for in the antibiotic management of PID?
Mycoplasma genitalium
- this requires moxifloxacin 400mg OD for 14 days
When might hospital admission be required in PID?
- if no improvement 72 hours after antibiotics started
- signs of sepsis
- patient is pregnant
- development of pelvic abscess
admission for IV abx / drainage of abscess is required
What is the treatment for a partner of someone with PID?
- a full sexual health screen should be performed
- they are given doxycycline 100mg PO BD for 7 days
When should empirical antibiotic treatment for suspected PID be offered?
- any sexually active patient with bilateral lower abdominal pain
- this is associated with tenderness on bimanual exam
AND
- pregnancy has been excluded
the risk of PID is highest in women < 25 not using barrier contraception and with a history of a new sexual partner
What is Fitz-Hugh-Curtis syndrome?
- inflammation + infection of the liver capsule (Glisson’s capsule)
- resulting in adhesions between the liver and peritoneum
How does Fitz-Hugh-Curtis syndrome present?
- RUQ pain
- the pain is referred to the right shoulder tip if there is diaphragmatic irritation
- this is typically related to chlamydia infection
What is the management for Fitz-Hugh-Curtis syndrome?
laparoscopy:
- can be used to visualise the adhesions and treat them via adhesiolysis
