Pelvic Inflammatory Disease and Endometritis Flashcards
Definition of PID
A spectrum of inflammatory disease of the upper genital tract. Infection spreads upwards from the endocervix causing one or more of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and pelvic peritonitis.
Causes of PID
Almost always caused by an STI.
* Chlamydia trachomatis (14-35% of cases) and Neisseria gonorrhoeae (2-3% of cases) are causative organisms for PID
* Mycoplasma genitalium has been associated with upper genital tract infection in women and is a common cause of PID.
* Organisms in normal vaginal flora (such as anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) have also been implicated.
* Pathogen-negative PID is common
Risk factors for PID include
- Young age (younger than 25), early age of first coitus, multiple sexual partners, recent new partner (within previous 3 months), not using barrier contraception, history of STI
- Recent instrumentation of the uterus: TOP, insertion of an IUD, hysterosalpingography, IVF and intrauterine insemination
Complications of PID
Sepsis, tubal infertility, ectopic pregnancy, chronic pelvic pain, tubo-ovarian abscess, Fitz-Hugh-Curtis syndrome
Presentation of PID
- Pelvic or lower abdominal pain (usually bilateral but can be unilateral)
- Deep dyspareunia, particularly of recent onset
- Abnormal vaginal bleeding (intermenstrual, postcoital, ‘breakthrough’) which may be secondary to associated cervicitis and endometritis
- Abnormal vaginal or cervical discharge (usually slight and transient, especially with chlamydia infection)
- RUQ pain due to peri-hepatitis, secondary dysmenorrhoea
- O/E: Lower abdominal tenderness (usually bilateral), adnexal tenderness (with or without palpable mass), cervical motion tenderness on bimanual, abnormal cervical discharge on speculum, fever>38 degrees
Investigations for PID
- The diagnosis should be made on clinical grounds and should NOT be delayed whilst waiting for investigation results (negative swabs do not rule out diagnosis of PID)
- Consider referral to a Genito-urinary medicine (GUM) clinic for screening and contact tracing
- Offer pregnancy test
- Consider taking a high vaginal swab (to rule out bacteriosis and candidiasis)
- Test for Chlamydia, Gonorrhoea, Mycoplasma genitalium.
- Look for endocervical or vaginal pus cells under a microscope on a wet-mount vaginal smear (if absent, PID is unlikely)
- ESR, CRP, WCC
- Offer chlamydia screening to all sexually active people younger than 25 years of age, annually, or more frequently if they have changed their partner
- Imaging is of limited use
When should a patient be admitted with PID
Admit urgently if:
* Ectopic pregnancy cannot be rules out, or if the woman is pregnant
* Symptoms and signs are severe (such as nausea, vomiting and a fever greater than 38 degrees)
* There are signs of pelvic peritonitis
* Surgical emergency (acute appendicitis), tubo-ovarian abscess is suspected
Where is PID best managed
Ideally the woman should be referred to a GUM clinic or other local specialist sexual health service to facilitate screening for infections and for contact tracing.
Does PID require contact tracing
Yes, Ensure that sexual partners of the woman with PID (current and recent partners [within the last 6 months]) are traced and managed appropriately
* Screen for chlamydia and gonorrhoea. Screen for m.genitalium if the woman has a confirmed case
* Advise sexual abstinence until both the woman with PID and her partner(s) have completed the course of treatment
Pharmacological management of PID
Provide pain relief with ibuprofen or paracetamol
Start empirical antibiotics as soon as presumptive diagnosis of PID is made clinically (ideally should be screened for other STIs before commencing antibiotics, but starting is a priority and should not be delayed)
If risk of gonococcal infection is low: prescribe any of the following:
* Ceftriaxone as a single intramuscular (IM) dose, followed by oral doxycycline twice daily plus oral metronidazole twice daily for 14 days.
* Oral ofloxacin twice daily plus oral metronidazole twice daily for 14 days.
* Oral moxifloxacin once daily for 14 day
If test for mycoplasma genitalium is positive- treat with moxifloxacin
If risk of gonococcal infection is high (e.g partner has gonorrhoea)
* Give ceftriaxone as a single IM dose, followed by oral azithromycin for 2 weeks
If pyrexial or oral management has failed (hospital tx):
* 1st line: IV cefoxitin + doxycycline - covers other bacteria including H.influenzae and E.coli
* 2nd line: IV clindamycin + gentamicin
How should PID be managed in the context of HIV
For women with HIV, offer the same treatment as women who are not infected (PID should be managed in conjunction with HIV physician)
How should a women with an IUD or LNG-IUS and PID be managed
- Discuss with the woman and consider removing the device if she wants and symptoms have not resolved within 72 hours
- If a decision is made to remove the device, consider the need for emergency hormonal contraception
What advice should be given about fertility and contraception following PID
- Explain the importance of completing the course of Abx to avoid long-term consequence including infertility, ectopic pregnancy and chronic pelvic pain
- That after treatment, fertility is usually maintained but there is still a risk of long-term complications such as infertility, ectopic pregnancy, and chronic pelvic pain
- The importance of screening for STIs and need for contact tracing
- The need to use barrier methods of contraception
When should patients with PID be followed up
- Review the woman within 72 hours
- There should be demonstrable clinical improvement (if not, consider admitting for further investigation)
- Further follow up at 2-4 weeks to ensure resolution
What is FItz-Hugh-Curtis syndrome
A complication of PID. It is caused by inflammation and infection of the liver capsule (‘Glisson’s capsule’), leading to ‘violin string’ adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
Fitz-Hugh-Curtis syndrome results in right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic involvement. Laparoscopy can be used to visualise and treat the adhesions by adhesiolysis
