Pelvic Inflammatory Disease

Question 1

What is PID?

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, Salpingitis, Parametritis and Oophoritis?

Answer 2

Endometritis – inflammation and infection of the endometrium
Salpingitis – inflammation of the fallopian tube
Parametritis – inflammation of the connective tissue surrounding the uterus
Oophoritis – inflammation of an ovary

Question 3

What is a tubo-ovarian abscess?

Answer 3

Ascending infection from the endocervix and vagina, Infection causes inflammation. Inflammation causes damage – Thus damaged tubal epithelium and adhesions form. There is some recovery of the tubal epithelium.

Question 4

What is parametritis?

Answer 4

Inflammation of connective tissue surrounding the uterus

Question 5

What is oophoritis?

Answer 5

Inflammation of the ovaries

Question 6

What are the complications of PID?

Answer 6

• Ectopic pregnancy
• Infertility
• Chronic pelvic pain
• Fitz-Hugh-Curtis Syndrome – RUQ pain and peri-hepatitis following Chlamydial PID

Question 7

What is the aetiology of PID

Answer 7

• Often polymicrobial
• Sexually transmitted infections – C. trachomatis – N. gonorrhoea
• Others – Gardnerella vaginalis, mycoplasma, anaerobes and actinomyosis

Question 8

What age is PID most common at?

Answer 8

Most common between ages 20-30

Question 9

What are the risk factors for PID?

Answer 9

• As for STIs – Young age – Lack of use of barrier contraception – Multiple sexual partners – Low socioeconomic class
• IUCD – intrauterine contraceptive device e.g. coil

Question 10

What are the clinical features of PID in a history?

Answer 10

• Pyrexia
• Pain – Lower abdominal pain – Deep dyspareunia
• Abnormal vaginal/cervical discharge
• Abnormal vaginal bleeding
• Sexual history & prior STI
• Contraceptive history

Question 11

What are the clinical features of PID on examination?

Answer 11

• Fever
• Lower abdominal tenderness which is usually bilateral
• Bimanual examination – adnexal tenderness – Cervical motion tenderness
• Speculum examination – Purulent cervical discharge – Cervicitis

Question 12

What other differential diagnosis could be considered with PID?

Answer 12

• Other – Functional pain
• Gynaecological: Ectopic pregnancy, Endometriosis, Ovarian cyst complications
• Gastrointestinal: IBS or Appendicitis
• Urinary – UTI

Question 13

What kind of investigations are done for PID?

Answer 13

• Urinary and/or serum pregnancy test
• Endocervical and High vaginal (fornixes ) swabs – Presence of NG/CT (gonorrhoea and chlamydia) supports diagnosis – Absence of NG/CT does not exclude diagnosis
• Blood tests – WBC and CRP
• Screening for other STIs including HIV

Question 14

How do we managed PID?

Answer 14

Delayed treatment increases long term sequelae. Symptomatic management with analgesia and rest and management of sepsis. Severe disease requires IV antibiotics and admission for observation and possible surgical intervention – Pyrexia >38, signs of tubo-ovarian abscess, signs of pelvic peritonitis – Increased risk of long term sequelae. Antibiotic therapy for 14 days

Question 15

What is essential to do once a treatment plan is in place?

Answer 15

Contact tracing essential for partners and full screen for woman

Question 16

What surgical options are there for treatment of PID?

Answer 16

Laparoscopy/laparotomy may be considered if: no response to therapy, clinically severe disease, presence of a tubo-ovarian abscess. Ultrasound guided aspiration of pelvic collections is less invasive

Question 17

Why is PID an increased risk of ectopic pregnancy and infertility?

Answer 17

Due to the tubule cilia not functioning properly the risk of an ectopic pregnancy is much higher as is the risk of infertility. Chronic pelvic pain is also common.

Question 18

What is Fitz Hugh Curtis syndrome?

Answer 18

Fitz Hugh Curtis syndrome occurs in many patients with chlamydial PID and is where you get right upper quadrant pain and peri hepatitis.

Question 19

What is Reiter’s Syndrome?

Answer 19

Reiter’s syndrome - can’t see can’t pee can’t bend at the knee, this is also associated with chlamydia. This is immune mediated form of inflammatory arthritis sometimes known as reactive arthritis.