Pelvic Inflammatory Disease Flashcards
What is pelvic inflammatory disease?
It is a clinical spectrum of infection and inflammation which may involve:
- cervix
- endometrium
- fallopian tubes
- ovaries (rarely)
- broad ligaments
- intraperitoneal cavity
- perihepatic region
Eventually the process may evolve into scar formation and form adhesions.
What causes PID?
It is usually caused by an ascending infection from the endocervix but can also be caused by a descending infection from the appendix.
Usually polymicrobial but it is thought 25% are caused by chlamydia trachomatis and neisseria gonorrhoea.
What is the common natural progression of acute PID?
Cervicitis: thick yellow mucopurulent discharge from an inflamed external os
Endometritis: infected endometrial glands with premature sloughing and irregular bleeding.
Salpingitis: Swollen erythematous fallopian tubes filled with pus (pyosalpinx)
This progression can often happen very quickly.
What are the signs and symptoms of PID?
It is often asymptomatic particularly in PID caused by chlamydia.
Gonorrhoeal PID is more likely to cause symptoms such as:
Symptoms:
- Pelvic pain (may be bi/unilateral, constant/intermittent)
- Deep dyspareunia (painful sex)
-May be vaginal discharge due to concurrent vaginal infection
- Irregular and more painful menstruation
- Intermenustral bleeding/post coital bleeding
- Fever (unusual in mild PID)
Signs: (At least one must be present for a diagnosis)
- Adenexal tenderness (usually bilateral)
- Cervical excitation (tenderness on movement)
- Fever
- Lower abdo peritonism
- A palpable mass on VE
What differentials should you consider alongside PID?
- Ectopic pregnancy
- Ovarian cyst accident (torsion/haemorrhage/rupture)
- Pelvic appendicitis
What are the risk factors for developing PID?
Essentially STI’s and any uterine instrumentation
Age
What factors are protective against PID?
- Premenarchy, postmenopausal and pregnant women (all rarely effected)
- Barrier contraception
- The COCP and IUS (hormonal coil)
What complications are associated with PID? (6)
Tubo-ovarian abscesses (abscess in fallopian tube or ovary) Recurrent PID Scar formation and infertility (10-15%) Ectopic pregnancy (6-10x increased risk) Chronic Pelvic Pain Fitz Hugh Curtis syndrome
What is Fitz Hugh Curtis Syndrome?
It is a rare complication of PID in which there is infection of the hepatic capsule (but not the over) peri-hepatitis.
As the disease progresses then adhesions form between the anterior liver capsule and the anterior abdominal wall and it is said to have ‘violin string appearance’.
How would you investigate a lady that has come in with suspected PID?
Bedside:
Pregnancy test (help rule out ectopic)
Swab for gonorrhoea and chlamydia
Bloods:
FBC + CRP (infection)
Blood cultures if febrile
Imaging:
USS if Tubo-ovarian abscess is suspected, also rules out ovarian cysts
Invasive:
Laparoscopy with fibril biopsy (gold standard for diagnosis)
Only used when diagnosis is uncertain as it is invasive.
How would you decide where to manage someone with suspected PID?
Inpatient if any of the following are present:
- Uncertainty re diagnosis
- Severe illness including high fever
- HIV +ve
- Suspected TOA
- Treatment failure in outpatients
How would you treat a patient with PID as an inpatient?
Cefoxitin IV 2g/6hourly
OR
Cefotetan IV 2g/12hourly + doxycycline 100mg po bd
Continue treatment for 48hours after clinical improvement. Discharge with Doxycycline 100mg bd for 14days
If TOA present needs draining by USS guided aspiration or laparoscopy.
Contact tracing is important.
How would you treat a patient with PID as an outpatient?
Multiple antibiotics are required to cover the possible causative organisms
Ceftriaxone 250mg IM + doxycycline 100mg bd for 14days
+/- metronidazole 500mg bd for 14days
Alternative regimen:
Metronidazole and ofloxacin
Review after 72hrs
Contact tracing is important.
