Pelvic Inflammatory disease (PID)

Question 1

How does PID occur?

Answer 1

Ascending infection/organism from endocervix

Question 2

What comprises PID?

Answer 2

Endometritis
Salpingitis
Parametritis
Oophoritis
Tubo-ovarian abscess
Pelvic peritonitis

Question 3

What organisms are implicated in PID?

Answer 3

Chlamydia trachomatis
Neisseria gonorrhoea
Gardnerella vaginalis
Anaerobes - prevotella, atopobium, leptotrichia
Mycoplasma genitalium

Question 4

What is the most common organism implicated in PID?

Answer 4

Chlamydia

Question 5

What proportion of PID is due to chlamydia?

Answer 5

14-35%

Question 6

How long is there increased risk of PID following IUD insertion?

Answer 6

4-6 weeks

Question 7

What increases the risk of PID following IUD insertion?

Answer 7

gonorrhoea or C. trachomatis infection

Question 8

PID - SYMPTOMS?

Answer 8

lower abdominal pain - BILATERAL (can be unilateral)
Abnormal vaginal/cervical discharge
DEEP dyspareunia
Abnormal vaginal bleed - post coital, intermenstrual, menorrhagia
secondary dysmenorrhoea

Question 9

PID - SIGNS?

Answer 9

lower abdominal tenderness
Adnexal tenderness on bimanual
cervical motion tenderness
Fever (moderat/severe disease)

Question 10

When should a diagnosis of PID be considered?

Answer 10

Sexually active female
RECENT onset lower abdominal pain
ASSOCIATED with local tenderness on bimanual

Question 11

What should be excluded in women who present with PID type symptoms?

Answer 11

PREGNANCY

Question 12

What factors increase the risk of PID?

Answer 12

Women <25 yrs
NO barrier protection
NEW sexual partner

Question 13

Fitz-Hugh Curtis syndrome - describe?

Answer 13

RIGHT UPPER QUADRANT pain

associated with PERIHEPATITIS

Question 14

Which STI is most associated with Fitz-Hugh Curtis?

Answer 14

Chlamydia

Question 15

When should tubo-ovarian abscess be suspected in PID?

Answer 15

Systemically UNWELL

SEVERE pelvic pain

Question 16

When should abdominal imaging take place in PID?

Answer 16

Adnexal mass

Lack of response to treatment

Question 17

What imaging modalities can be used in PID?

Answer 17

US
CT
MRI

Question 18

PID + IUD - mild/moderate symptoms - management?

Answer 18

Leave in

Review 48-72 hours to ensure clinical improvement

Question 19

What other factors should be considered prior to removing a IUD for PID?

Answer 19

Risk of PREGNANCY

Timing of last unprotected sex

Question 20

What is the positive predictive value of clinical diagnosis vs laparoscopic?

Answer 20

65-90%

Question 21

What benefit are CRP and FBC in PID?

Answer 21

if raised support diagnosis

Question 22

When is CRP or WCC typically raised in PID?

Answer 22

Moderate or severe PID

Question 23

How does looking for endocervical or vaginal pus cells help in diagnosis of PID?

Answer 23

ABSENCE of pus cells good negative predictive value for PID

Question 24

What is US useful for in PID?

Answer 24

To identify abscess or hydrosalpinx

Question 25

Between CT & MRI what is preferred for imaging in PID? Why?

Answer 25

MRI Good high resolution images No radiation exposure for women of reproductive age

Question 26

What is the differential diagnosis for PID (6)?

Answer 26

``` Ectopic pregnancy Acute appendicitis Endometriosis Ovarian cyst - rupture or torsion UTI Irritable bowel syndrome ```

Question 27

What feature in clinical presentation makes appendicitis more likely than PID?

Answer 27

Nausea and vomiting

Question 28

What might help differentiate endometriosis from PID?

Answer 28

relationship between symptoms and menstrual cycle

Question 29

What feature in clinical presentation makes UTI more likely than PID?

Answer 29

dysuria | urinary frequency

Question 30

Why is a LOW threshold for treatment of PID indicated?

Answer 30

Significant complications if delayed treatment | lack of definitive diagnostic criteria

Question 31

Following treatment for PID what impact is there on pregnancy rate?

Answer 31

Similar or higher than general population

Question 32

When should IV therapy and hospital admission be considered for PID?

Answer 32

Fever Clinical sign of tubo-ovarian abscess Pelvic peritonitis Lack of response to oral therapy

Question 33

What increases the risk of infertility with PID?

Answer 33

Repeat episodes of PID

Question 34

PID - first line treatment?

Answer 34

CEFTRIAXONE 1gram IM + DOXYCYCLINE 100mg twice daily oral 14 days + METRONIDAZOLE 400MG twice daily oral 14 days

Question 35

PID - what is an alternative treatment?

Answer 35

OFLOXACIN 400mg twice daily oral 14 days + Metronidazole 400mg twice daily oral 14 days

Question 36

Why is metronidazole used on PID?

Answer 36

To improve anaerobic cover

Question 37

When can metronidazole be discontinued? Why?

Answer 37

If NOT tolerated in MILD/MODERATE disease | anaerobes greater importance in severe PID

Question 38

When should ofloxacin or moxifloxacin be avoided in patients?

Answer 38

those high risk of GONOCOCCAL PID

Question 39

In the UK, what proportion of PID is due to gonorrhoea?

Answer 39

less than 3%

Question 40

What is the benefit of levofloxacin over ofloxacin?

Answer 40

L isomer of ofloxacin | once daily dosing

Question 41

What inpatient regimens are used in PID?

Answer 41

``` IV ceftriaxone TWO gram IV doxycycline if oral not tolerated oral metronidazole OR IV clindamycin 900mg three times daily IV gentamicin ```

Question 42

When can IV therapy be switched to oral for PID?

Answer 42

After 24 hours of clinical improvement

Question 43

If PID occurs in pregnancy, how should it be managed?

Answer 43

With IV therapy and hospital admission

Question 44

How should pelvic fluid collections may managed in PID?

Answer 44

US guided aspiration OR laparascopic division adhesions and drainage of collections