Pelvic Pain and PID Flashcards
The cervix functions as
A protective barrier to ascending infection. It has a protective mucous plug
Pelvic Inflammatory Disease (PID)
An infection which has ascended into the pelvis, allowing a simple infection to become complicated leading to infection of the upper genital tract–>
Endometritis, salpingitis, tubo-ovarian abscesses, peritonitis
Which infections cause PID?
Chlamydia (40%) –> untreated will lead to PID in 10-30% of cases, Gonorrhoea (14%), Mycoplasma genitalium (8-12%), Anaerobes (60%)
PID related changes in the Fallopian tubes
Within days of infection ciliary activity is irreversibly reduced and they slough off.
There is also a delayed hypersensitivity reaction which can cause severe disease. –> worse reaction to subsequent infection
Risk factors for PID
Behavioural –> unprotected sex, multiple sexual partners, previous PID
Mechanical –> IUD insertion, instrumentation, surgical procedures (TOP), child birth, menstruation or high estrogen levels
PID changes in the fallopian tubes
Normal –> 1mm-1cm diameter, lined with cilia, things move one way
PID–> intense inflammation, odema, purulent secretions, vasodilation–> tissue destruction. Fibroblasts are eventually activated leading to tubal scarring, adhesions and tubal occlusion
Severity of PID
60% of PID is sub-clinical
mild to moderate accounts for 36%
4% is severe PID
Symptoms of PID
Very variable--> bilateral lower abdo pain Vaginal discharge, deep dyspareunia abnormal bleeding (post-coital, intermenstral, menorrhagia) Systemic symptoms-->fever, nausea, vomiting
Differential of PID
Ectopic pregnancy –> should always be excluded. Acute appendicitis. Endometriosis. Ovarian cyst rupture or torsion. Functional pain (Mittelschmerz)
Signs of PID
Fever. Lower abdo tenderness +- guarding. O/E –> purulent cervical discharge, cervical motion tenderness, uterine tenderness, bilateral adnexal tenderness
Adnexal mass indicating tuboovarian abscess
peritonitis mimicking an acute surgical abdomen
Indications for Hospital admission
Severe clinical disease. marked systemic symptoms. N&V meaning they cannot take oral antibiotics. risk of surgical emergency. Mass/tubo-ovarian abscess on examination. unresponsive to oral therapy. pregnancy
Diagnosis of PID
Mainly on clinical signs –> low index of suspicion
STI screen –> chlamydia, gonorrhoea, anaerobes
Normal OBs–> Temp, ESR/CRP
USS. investigative laparoscopy
IUD removal in PID
Should be removed in severe disease, as there is a better recovery in coil removed group. In mild to moderate disease leave in situ and monitor clinical response. Having an IUD does not itself increase PID risk, only if there is pre-existing infection
Treatment of PID
Must be polymicrobial–>
Chlamydia -> doycycline 100mg BD 2 weeks
Gonorrhoea-> Ceftriaxone 500mg IM stat
Anaerobes-> metronidazole 400mg BD 5 days
Supportive management of PID
Rest and Analgesia. Health promotion and safe sex education
Contact tracing –> recent male partners must be treated even if no primary organism is identified. no sex till both partners have finished their antibiotics
Follow up of PID
In mild disease review at 2-4 weeks, assess–> clinical response, adherence to antibiotics, adherence to safe sex
In moderate-severe disease review in 2-3 days
Complications of PID - Ectopic pregnancy
Higher risk of ectopic (12-15% higher, 9.5x more likely)–> particularly with multiple episodes
Complications of PID - Infertility
tubal occlusion (8% after first episode, 20% after 2nd, 40% with 3rd) chlamydia is responsible for 70% of tubal infertility
Complications of PID - Chronic pelvic pain
Chronic pelvic pain due to adhesions –> 18% after a single episode. 6x risk of endometriosis, 8x risk of hysterectomy
Fitz-Hugh-Curtis syndrome
Right upper quadrant pain from perihepatitis (worse on coughing/sneezing etc–> 10-20% of young women with PID -
Violin string adhesions in the right paracolic gutter, subphrenic space & hepatic surface
Prevention of PID
Mainly safe sex promotion and chlamydia screening
every 83 women screened will prevent 1 case of PID
Cause of Fitz-Hugh-Curtis syndrome
Classically part of the triad of disseminated gonorrhoea infection but now found to be 5x more commonly due to chlamydia.
Triad of disseminated Gonorrhoea infection
Dermatitis, migrating septic arthritis and tenosynovitis. Can also cause endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
Pelvic pain with pustules on the hands and feet
Gonnorrhoea. May only have mild symptoms but severe inflammation
PID with an IUD
Actinomyces israelii - may have mild abdominal pain and irregular bleeding
