PID Flashcards
What is PID?
An acute infection that ascends from the vagina and cervix and includes the uterus, fallopian tubes and ovaries
What is Fitz-Hugh-Curtis syndrome?
Infection and inflammation that can spread to the abdomen including perihepatic structures
PID causes this most cases
What agents most commonly caused PID
Chlamydia trachomatis and Neisseria gonorrhea
SEXUALLY TRANSMITTED
Who is at risk of PID?
High risk patients include
women younger than 25 years old who have multiple sex partners, Do not use contraception, and live in areas with a high prevalence of STDs
What is the greatest risk factor of PID?
Prior history of PID
What is the first stage of PID?
Localized
Acquisition of vaginal, or cervical infection, like gonorrhea or chlamydia
Often sexually transmitted, and may be asymptomatic
What is the second stage of PID?
Spreads to other areas
Direct assent of microorganisms from the vagina or cervix to the upper genital tract with infection and inflammation of those structures
What is the spread of infection facilitated by in PID
The spillage of purulent material from the fallopian tubes because they’re hollow
Or via lymphatic spread, which can lead to acute peritonitis and acute perihepatitis (F-H-C)
Is PID common in pregnancies?
Rare because the mucous plug acts as a barrier between the uterus and bacteria
Infection can still occur in the 12 weeks of gestation because the mucous plug has not formed, and it can travel
Fetal loss may result
What other organisms cause inflammation in PID
Anaerobes and other bacteria
Risk factors for PID
Multiple sex partners
History of prior STDs
Age less than 25 years old
Young age at first sex
Non-barrier contraception
Sex during menses
Vaginal douching (excessive)
Bacterial Vaginosis (low unless untreated for months)
What can decrease the risk of PID?
Barrier protection decreases the risk of acquiring most STDs
Oral contraceptives mag decrease the risk of symptomatic PID by increasing cervical mucus viscosity, but this is not proven
Current IUD’s carry a much lower risk of PID than older IUDs- the most significant risk is within the first month after insertion
What are the signs and symptoms of PID?
Lower abdominal pain- usually bilateral and worsened during sex or with sudden movement
Abnormal uterine bleeding occurs in 1/3 or more of patients with PID
New vaginal discharge, urethritis, proctitis, fever, and chills can be associated signs
What are the physical exam findings in a patient with PID?
Vitals- only about half of patients have a fever
Abdomen - diffuse lower abdominal tenderness, rebound tenderness, and decreased bowel sounds
Pelvic- purulent endocervical discharge and or cervical motion tenderness and adnexal tenderness
Need to have a high index of suspicion
Differential diagnosis of PID
Ectopic pregnancy
ovarian torsion
Appendicitis
Cervicitis
Urinary tract infection
Endometriosis
Adnexal tumors or ovarian cysts
Where is adnexal tenderness usually located for PID
On the side of inflammation
Bilateral adnexal tenderness is very rare
Suggested lab tests for PID
Pregnancy test
CBC
Urinalysis
Microscopic exam of vaginal discharge
Nucleic acid amplification tests for gonorrhea and chlamydia
C- reactive-protein
HIV testing syphilis testing
What three are necessary criteria for diagnosis of PID?
Lower abdominal pain or pelvic pain
Adnexal tenderness
Cervical motion tenderness
Additional criteria to support diagnosis of PID
Temperature over 101
Abnormal cervical or vaginal mucopurulent discharge
WBC over 10,000
Elevated ESR or CRP
Laboratory evidence of cervical infection with gonorrhea or chlamydia via culture or DNA probe**
Imaging that shows thickened fluid filled tubes/Oviducts with or without free pelvic fluid or tuboovarian complex
What will you see on an ultrasound of PID?
Bulky uterus with fluid distended endometrial cavity- endometrium appears thickened and hyperechoic
Cogwheel sign - refers to thickening loops of the fallopian tube seen on cross-section
What do you need to do to make a definitive diagnosis of PID?
Perform a laparoscopy
What laparoscopic findings are consistent with PID
Tubal erythema
Edema
Adhesions
Purulent exudate or cul-de-sac fluid
What do adhesions form from?
When there’s a disruption in tissue from trauma infection, etc. the tissue is healing and will form adhesions
What does the treatment of PID address?
The relief of acute symptoms, eradication of current infection, and minimization of the risk of long-term sequelae
What does long-term sequelae include for PID
Chronic pelvic pain due to adhesions
Ectopic pregnancy, because adhesions in the fallopian tube can block the egg
Infertility, depending on the degree can block sperm from getting to egg
Implantation failure with in vitro, fertilization attempts
What is the treatment of PID? General
Therapy with antibiotics alone is successful in 33 to 75% of cases
If surgical treatment is warranted, conservation of reproductive organs is favored by performing simple drainage, adhesiolysis, copious irrigation, or unilateral adnexectomy if possible
Insufficient evidence to recommend removal of IUDs. However, they should be closely followed.
What must all regimens be affective against in PID?
Chlamydia trachomatis and N. Gonorrhea. As well as gram-negative, facultative organisms, anaerobes and streptococci
When should antibiotic therapy be done in PID?
Should be initiated quickly, if suspicious of PID and should include empirical broad-spectrum antibiotics
When should PID patients be managed as hospitalization
Uncertain diagnosis
Pelvic abscess
Pregnancy
Inability to tolerate oral antibiotics
Severe illness
Immunodeficiency (HIV w/ <250 CD4)
IUD
Low likelihood of compliance with outpatient regimen
Failure to improve clinically after 72 hours of outpatient therapy
Inpatient treatment of PID regimen a
- Cefoxitin 2g IV q6hrs OR cefotetan 2g IV q12hrs
- Doxycycline 100mg PO or IV q12hrs
Inpatient treatment of PID regimen b
- Clindamycin 900mg IV q8hrs
- Gentamicin IV in a loading dose of 2mg/kg, followed by a maintenance dose of 1.5mg/kg q8hrs IV or IM
When can IV therapy be discontinued for
PID patients
IV Therapy may be discontinued 24 hours after the patient improves clinically
Decreased fever, less tenderness and labs are improving
What should be continued in a PID patient after IV antibiotics
Oral therapy with 100 mg doxycycline BID x 14d
Outpatient treatment of PID regimen a
- Ceftriaxone 500 mg IM
- Doxycycline 100mg PO BIDx 14d
- Metronidazole 500 mg PO BID x14d
Give all three
Metronidazole can be added, if suspicion of vaginitis
Outpatient treatment of PID regimen b
- Cefoxitin 2g IM and Probenecid 1g PO
- Doxycycline 100mg PO BIDx 14d
- Metronidazole 500 mg PO BID x14d
Probenecid helps antibiotics to stay longer in the blood
What should a follow up look like for a patient with PID?
Reevaluate patients 48 to 72 hours after starting antibiotics
Patients who do not improve in 72 hours, should be reevaluated for possible laparoscopic or surgical intervention
Patient should follow up 3 to 4 weeks after receiving treatment to receive a pelvic exam, STD and HIV prevention counseling, and contraceptive counseling
Should sexual partners be treated for patients with PID
Anyone who has had sexual contact with a woman with PID in the 60 days preceding the onset of symptoms should be treated empirically for Chlamydia trachomatis and gonorrhea
What prevention techniques are there for PID?
Improved education, routine screening, diagnosis and empirical treatment
Education should focus on strategies to prevent PID and STDs, including
Reducing the number of sexual partners
Avoiding unsafe sexual practices
Using appropriate barrier protection
Complications of PID
Tubo ovarian abscess (TOA)
F-H-C syndrome
Infertility
Ectopic pregnancy
Chronic pelvic pain
Endometritis
What is a tubo ovarian abscess?
An inflammatory mass involving the fallopian tube, ovary, and sometimes adjacent pelvic organs( like the bladder, bowel, etc)
What can a tubo ovarian abscess rupture result in?
Serious and potentially life-threatening condition
Can result in sepsis, because pus collects in a pocket and forms an abscess, which is released
Signs and symptoms of TOA
Similar to presentation of patient with PID
Acute lower abdominal pain
+/- fever
Chills
Vaginal discharge
What is the most useful and commonly performed study to assess for TOA
Pelvic ultrasound or pelvic CT
Ultrasound findings of TOA
Transvaginal ultrasound image
Shows a complex cyst (appears walled off and you can see white ISH stripes, indicating fluid )and fluid filled tube
How can a definitive diagnosis of TOA be made?
Only be made with direct visualization of the abscess during an invasive surgical procedure, such as laparoscopy or laparotomy
What is the treatment for TOA?
Hospitalization is recommended
Same treatment as PID regimen A and B for inpatient
Oral therapy with 100 mg doxycycline BID should be continued for a total of 14 days
When is the removal of an IUD indicated?
In treatment of TOA because risk of uterine perforation from inflammation
What happens if a TOA is not better after 48 to 72 hours of treatment?
Surgical intervention is required abscess may have ruptured
What is a telltale sign of Fitz Hugh Curtis syndrome?
Violin string adhesions caused by spread of gonorrhea and chlamydia infection to the liver capsule and peritoneal surfaces of the right upper quadrant
How does a patient with Fitzhugh Curtis syndrome present?
Usually present with severe right upper quadrant pain with a pleuritic component (taking a deep breath, radiation of pain)
Pain can radiate to the right shoulder and be confused with cholecystitis
What is a treatment for Fitz Hugh Curtis syndrome?
Surgical lysis of adhesions, but that could just cause more adhesions
What is chronic pelvic pain?
Defined as menstrual or non-menstrual pain of at least six months duration, that occurs below the umbilicus, and is severe enough to cause functional disability
What is the etiology of chronic pelvic pain?
The exact etiology is unknown, the pain most likely results from scarring and adhesions that develop from inflammation during PID
What is the link between endometritis and PID?
Women with PID are 6 to 10 times more likely to have a diagnosis of endometritis than healthy controls
