Pelvic Inflammatory Disease (PID) Flashcards
Define
The result of ascending infection of the genital tract (endometritis, salpingitis, tuboovarian abscess) o Most common organism = chlamydia trachomatis (other = N. gonorrhoea, M. genitalium, M. hominis)
- Other bacteria – anaerobes, coliforms, mycoplasma genitalium
- Salpingitis is the main concern as risk of ectopic pregnancy and subfertility (if lots of adhesions)
- Chronic PID = 6m+ (this is due to scarring and will result in constant pain worsening when move in certain directions which is NOT linked with periods, and unlikely to have bleeding problems) - will not have discharge/ fever etc as not acute
- CHECK FOR IMPACT ON RELATIONSHIPS
Risk factors
- <25yo
- early age of first coitus
- multiple sexual partners
- recent new partner
- history of STI (partner/woman)
Epidemiology
Often seen in YOUNG, single sexually active women with a history of STIs
Peak incidence between 15-25 yo
Aetiology
PID usually the result of an infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess and/or pelvic peritonitis
It is usually a polymicrobial infection
Sexually transmitted organisms are implicated, especially:
- Neisseria gonorrhoeae
- Chlamydia trachomatis – MOST COMMON
Many organisms that comprise the normal vaginal flora have also been associated with PID e.g.
- Gardnerella vaginalis
- Mycoplasma genitalum
- Mycoplasma hominis
- Other anaerobes e.g. Haemophilus influenzae
Spread to the upper genital tract may have been caused by instrumentation of the cervix e.g.:
- D&C
- Termination of pregnancy
- Insertion of IUD
Symptoms and Signs
ASYMPTOMATIC
- Bilateral lower abdominal pain -> can be longstanding (i.e. weeks)
- Infertility
- Dyspareunia
- Gradual onset
- Like a cramping pain
- Can radiate to the back and vagina
- Abnormal vaginal bleeding- intra-coital, inter-menstrual and/or menorrhagia
- Vaginal discharge
- Abnormal colour
- Different consistency
- Smell
- Irregular periods
- Dysmenorrhoea
- Deep dyspareunia
- Abnormal cervical or vaginal discharge (often purulent)
- Nausea and vomiting
- Fever
- RUQ pain (peri-hepatitis)- Fitz-Hugh-Curtis syndrome (associated with C.trachomatis) – causes inflammation of the liver capsule forming ‘Glisson’s capsule’ (looks like violin strings)
- Urinary symptoms- due to general infection in the pelvis
Signs O/E
- Uterine tenderness
- May have fixed uterus with chronic PID
- Cervical excitation and motion tenderness (pain provoked by moving the cervix)
- Will literally flinch
- Adnexal tenderness
- Fever (usually > 38oC)
- Vaginal discharge
Differentials
ctopic pregnancy – pregnancy should be excluded in all women suspected of having PID
Acute appendicitis – nausea and vomiting occur in most patients with appendicitis but only 50% of those with PID. Cervical movement pain will occur in about a quarter of women with appendicitis
Endometriosis – the relationship between symptoms and the menstrual cycle may be helpful in establishing a diagnosis
Complications of an ovarian cyst e.g. torsion or rupture – symptoms are often of sudden onset
Urinary tract infection – often associated with dysuria and/or urinary frequency
Irritable bowel syndrome – disturbance in bowel habit and persistence of symptoms over a prolonged time period are common. Acute bowel infection or diverticular disease can also cause lower abdominal pain usually in association with other gastrointestinal symptoms
Functional pain (pain of unknown aetiology) – may be associated with longstanding symptoms
STI
Ectropion
Ovarian cyst
Rough sex
Cervical cancer
Investigations
Start ABx before diagnosis
Triple swabs: Endocervical swab + culture (2x endocervical, 1x HVS) – screening for gonorrhoea + chlamydia
- Pus cells absent - can usually rule out PID but the presence of pus cells does not necessarily conclude PID as nonspecific
Examinations- abdominal, bimanual + speculum
Speculum –> looks for signs of inflammation/discharge
Bimanual –> cervical excitation, adnexal masses (tubo-ovarian abscess)
If tubo-ovarian abscess possible or to identify adhesions, confirm with TVUSS
Basic observations
- Urine dipstick- UTI?
- Bloods
- FBC- WCC (infection)
- ESR/ CRP- infection/ inflammation
- LFTs- hepatitis?
- U+Es
- Amylase
- Group and save
- VBG - to see lactate to see how unwell she is
TVUSS
- May see abscess if acute
- May see fluid (hydrosalpinx) in tube if chronic
PREGNANCY TEST- must rule out
Management
ASSESS PATIENT FOR ADMISSION: admit if pyrexial (>38C) or septic otherwise, treat in the community:
If managed as OP, see within 2-3 days to assess response to ABx -> further follow-up in 2-4 weeks
Medical Management
Antibiotics
- IM ceftriaxone- 500mg SINGLE DOSE
Followed by:
- PO Doxycycline(100mg BD) + PO Metronidazole (400mg BD) for 14 days
- Get N+V with it : Blocks met of Et-OH so shouldn’t drink it for 48hrs after
OR
- PO Ofloxacin (400mg BD) + PO Metronidazole (400mg BD) for 14 days
If treating chlamydia infection prophylactically or not complying, can give Azithromycin- SINGLE DOSE
In severe PID/ inpatients:
Admit if:
- Fever > 38oC, N+V, haemodynamic instability
- Suspicion of tubo-ovarian abscess or pelvic peritonitis
- Inability to follow on outpatient antibiotic regime
- Oral tx failed
- Pregnant
- Positive pregnancy test and suspected ectopic
IV ceftriaxone (2g) + IV doxycycline (100mg BD)
Followed by:
- PO doxycycline (100mg BD) + metronidazole(400mg BD) for 14 days (PO is given 24 hours after clinical improvement with IV)
OR
- IV clindamycin + IV gentamycin
Surgical Management
- Laparoscopy
- Abscess drainage (performed if > 5cm)
- Separation of adhesions
- Adhesiolysis for perihepatitis
- Removal of copper IUD- if this is the cause
- The IUD should be removed if significant clinical improvement has not occurred after 48-72 hours.
Sexual health screening
- Male partners should be contacted and offered health advice for screening against gonorrhoeae or chlamydia
- Other recent sexual partners (within the last 6 months) may also be offered screening
- Patient and partners should avoid intercourse until they have completed treatment course
- Discuss contraception
Follow-up
- If managed as outpatients, should be seen within 72 hours to assess response
- If no improvement, admit for IV antibiotics
- Further follow up at 2-4 weeks to:
- Ensure resolution
- Reiterate importance of STIs
- Reassure that if compliant, fertility is NOT impaired
Complications
Early complications
- Peritonitis
- Intestinal obstruction due to adhesions
- Sepsis
- Tubal blockage
- Hydrosalpinx
- Tubo-ovarian abscess
- Fitz-Hugh-Curtis syndrome
Late complications
- Sub/infertility - increases with each episode
- Ectopic pregnancy (paralyses cilia in salpynx)
Prognosis
- Usually patients make a full recovery with appropriate treatment
- Risks of tubal occlusion and infertility depend on severity of infection before treatment
- Clinical improvement may not translate to improved fertility
- Patients with co-existing conditions e.g. HIV, pregnancy, IUD, prior PID or tubo-ovarian abscess) require close monitoring and may require hospitalisation.
Factors that predict poor prognosis:
- Advanced age
- History of previous open gynaecological surgery
- Cystic lesions identified by USS
- High CRP levels
