Pelvic Inflammatory disease (PID) Flashcards
How does PID occur?
Ascending infection/organism from endocervix
What comprises PID?
Endometritis Salpingitis Parametritis Oophoritis Tubo-ovarian abscess Pelvic peritonitis
What organisms are implicated in PID?
Chlamydia trachomatis Neisseria gonorrhoea Gardnerella vaginalis Anaerobes - prevotella, atopobium, leptotrichia Mycoplasma genitalium
What is the most common organism implicated in PID?
Chlamydia
What proportion of PID is due to chlamydia?
14-35%
How long is there increased risk of PID following IUD insertion?
4-6 weeks
What increases the risk of PID following IUD insertion?
gonorrhoea or C. trachomatis infection
PID - SYMPTOMS?
lower abdominal pain - BILATERAL (can be unilateral)
Abnormal vaginal/cervical discharge
DEEP dyspareunia
Abnormal vaginal bleed - post coital, intermenstrual, menorrhagia
secondary dysmenorrhoea
PID - SIGNS?
lower abdominal tenderness
Adnexal tenderness on bimanual
cervical motion tenderness
Fever (moderat/severe disease)
When should a diagnosis of PID be considered?
Sexually active female
RECENT onset lower abdominal pain
ASSOCIATED with local tenderness on bimanual
What should be excluded in women who present with PID type symptoms?
PREGNANCY
What factors increase the risk of PID?
Women <25 yrs
NO barrier protection
NEW sexual partner
Fitz-Hugh Curtis syndrome - describe?
RIGHT UPPER QUADRANT pain
associated with PERIHEPATITIS
Which STI is most associated with Fitz-Hugh Curtis?
Chlamydia
When should tubo-ovarian abscess be suspected in PID?
Systemically UNWELL
SEVERE pelvic pain
When should abdominal imaging take place in PID?
Adnexal mass
Lack of response to treatment
What imaging modalities can be used in PID?
US
CT
MRI
PID + IUD - mild/moderate symptoms - management?
Leave in
Review 48-72 hours to ensure clinical improvement
What other factors should be considered prior to removing a IUD for PID?
Risk of PREGNANCY
Timing of last unprotected sex
What is the positive predictive value of clinical diagnosis vs laparoscopic?
65-90%
What benefit are CRP and FBC in PID?
if raised support diagnosis
When is CRP or WCC typically raised in PID?
Moderate or severe PID
How does looking for endocervical or vaginal pus cells help in diagnosis of PID?
ABSENCE of pus cells good negative predictive value for PID
What is US useful for in PID?
To identify abscess or hydrosalpinx
Between CT & MRI what is preferred for imaging in PID? Why?
MRI
Good high resolution images
No radiation exposure for women of reproductive age
What is the differential diagnosis for PID (6)?
Ectopic pregnancy Acute appendicitis Endometriosis Ovarian cyst - rupture or torsion UTI Irritable bowel syndrome
What feature in clinical presentation makes appendicitis more likely than PID?
Nausea and vomiting
What might help differentiate endometriosis from PID?
relationship between symptoms and menstrual cycle
What feature in clinical presentation makes UTI more likely than PID?
dysuria
urinary frequency
Why is a LOW threshold for treatment of PID indicated?
Significant complications if delayed treatment
lack of definitive diagnostic criteria
Following treatment for PID what impact is there on pregnancy rate?
Similar or higher than general population
When should IV therapy and hospital admission be considered for PID?
Fever
Clinical sign of tubo-ovarian abscess
Pelvic peritonitis
Lack of response to oral therapy
What increases the risk of infertility with PID?
Repeat episodes of PID
PID - first line treatment?
CEFTRIAXONE 1gram IM
+
DOXYCYCLINE 100mg twice daily oral 14 days
+
METRONIDAZOLE 400MG twice daily oral 14 days
PID - what is an alternative treatment?
OFLOXACIN 400mg twice daily oral 14 days
+
Metronidazole 400mg twice daily oral 14 days
Why is metronidazole used on PID?
To improve anaerobic cover
When can metronidazole be discontinued? Why?
If NOT tolerated in MILD/MODERATE disease
anaerobes greater importance in severe PID
When should ofloxacin or moxifloxacin be avoided in patients?
those high risk of GONOCOCCAL PID
In the UK, what proportion of PID is due to gonorrhoea?
less than 3%
What is the benefit of levofloxacin over ofloxacin?
L isomer of ofloxacin
once daily dosing
What inpatient regimens are used in PID?
IV ceftriaxone TWO gram IV doxycycline if oral not tolerated oral metronidazole OR IV clindamycin 900mg three times daily IV gentamicin
When can IV therapy be switched to oral for PID?
After 24 hours of clinical improvement
If PID occurs in pregnancy, how should it be managed?
With IV therapy and hospital admission
How should pelvic fluid collections may managed in PID?
US guided aspiration
OR
laparascopic division adhesions and drainage of collections
