Pelvic Pain and PID

Question 1

The cervix functions as

Answer 1

A protective barrier to ascending infection. It has a protective mucous plug

Question 2

Pelvic Inflammatory Disease (PID)

Answer 2

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

Question 3

Which infections cause PID?

Answer 3

Chlamydia (40%) –> untreated will lead to PID in 10-30% of cases, Gonorrhoea (14%), Mycoplasma genitalium (8-12%), Anaerobes (60%)

Question 4

PID related changes in the Fallopian tubes

Answer 4

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

Question 5

Risk factors for PID

Answer 5

Behavioural –> unprotected sex, multiple sexual partners, previous PID
Mechanical –> IUD insertion, instrumentation, surgical procedures (TOP), child birth, menstruation or high estrogen levels

Question 6

PID changes in the fallopian tubes

Answer 6

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

Question 7

Severity of PID

Answer 7

60% of PID is sub-clinical
mild to moderate accounts for 36%
4% is severe PID

Question 8

Symptoms of PID

Answer 8

Very variable--> bilateral lower abdo pain
Vaginal discharge, deep dyspareunia
abnormal bleeding (post-coital, intermenstral, menorrhagia)
Systemic symptoms-->fever, nausea, vomiting

Question 9

Differential of PID

Answer 9

Ectopic pregnancy –> should always be excluded. Acute appendicitis. Endometriosis. Ovarian cyst rupture or torsion. Functional pain (Mittelschmerz)

Question 10

Signs of PID

Answer 10

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

Question 11

Indications for Hospital admission

Answer 11

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

Question 12

Diagnosis of PID

Answer 12

Mainly on clinical signs –> low index of suspicion
STI screen –> chlamydia, gonorrhoea, anaerobes
Normal OBs–> Temp, ESR/CRP
USS. investigative laparoscopy

Question 13

IUD removal in PID

Answer 13

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

Question 14

Treatment of PID

Answer 14

Must be polymicrobial–>
Chlamydia -> doycycline 100mg BD 2 weeks
Gonorrhoea-> Ceftriaxone 500mg IM stat
Anaerobes-> metronidazole 400mg BD 5 days

Question 15

Supportive management of PID

Answer 15

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

Question 16

Follow up of PID

Answer 16

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

Question 17

Complications of PID - Ectopic pregnancy

Answer 17

Higher risk of ectopic (12-15% higher, 9.5x more likely)–> particularly with multiple episodes

Question 18

Complications of PID - Infertility

Answer 18

tubal occlusion (8% after first episode, 20% after 2nd, 40% with 3rd)
chlamydia is responsible for 70% of tubal infertility

Question 19

Complications of PID - Chronic pelvic pain

Answer 19

Chronic pelvic pain due to adhesions –> 18% after a single episode. 6x risk of endometriosis, 8x risk of hysterectomy

Question 20

Fitz-Hugh-Curtis syndrome

Answer 20

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

Question 21

Prevention of PID

Answer 21

Mainly safe sex promotion and chlamydia screening

every 83 women screened will prevent 1 case of PID

Question 22

Cause of Fitz-Hugh-Curtis syndrome

Answer 22

Classically part of the triad of disseminated gonorrhoea infection but now found to be 5x more commonly due to chlamydia.

Question 23

Triad of disseminated Gonorrhoea infection

Answer 23

Dermatitis, migrating septic arthritis and tenosynovitis. Can also cause endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)

Question 24

Pelvic pain with pustules on the hands and feet

Answer 24

Gonnorrhoea. May only have mild symptoms but severe inflammation

Question 25

PID with an IUD

Answer 25

Actinomyces israelii - may have mild abdominal pain and irregular bleeding