PID

Question 1

Indications for inpatient therapy of PID

Answer 1

1. Acute peritoneal signs on exam
2. Pregnant
3. Other surgical emergency not excluded
4. Failure of outpatient management/ no response to oral therapy
5. TOA
6. Inability to comply to follow up
7. Unable to tolerate medications

Question 2

What is the Ddx for a pt with acute pelvic pain presenting with fever

Answer 2

PID
TOA
Septic abortion
Ectopic pregnancy
Appendicitis
Pyelonephritis
Perforation of viscus due to infection (diverticulitis) or peptic ulcer
Cholecystitis
Pancreatitis
Pneumonia
Sepsis

Question 3

How do you evaluate a pt with fever and acute abdominal pain

Answer 3

H&P
CBC, CMP, amylase/lipase, HCG,
Cultures of cervix for STDs, UA/UC, blood cultures
Imaging– TVUS, CT abdomen/pelvis, etc
Chest XR

Question 4

How do you manage pt with acute pelvic pain and fever

Answer 4

Determine if surgical abdomen–> ex lap after IV access, IVFs, IV abx, type and cross

If suspecting TOA/PID:
1. Start with Abx (abscess <7cm)
- Ceftriaxone 1g IV q24hrs, doxycycline 100mg PO/IV q12hrs, metronidazole 500mg PO/IV q12hrs
- Cefotetan 2g IV q12hrs, doxycycline 100mg PO/IV q12hrs
- Clindamycin 900mg IV q8hrs, gentamicin 2mg/kg load then 1.5mg/kg q 8hrs IV, can add ampicillin 2g IV q6hrs

If pt doesn’t respond in 48-72hrs, IR drainage or surgery
Tx failure:
- New onset or persistent fever
- Persistent or worsening abdominal pain
- Enlarging mass
- Persistent or worsening leukocytosis
- Sepsis

Question 5

When do you treat TOA with immediate surgery

Answer 5

Abscess >7cm, failure of initial abx tx, abscess is ruptured, sepsis, or postmenopausal (high rate of malignancy)

Question 6

What is treatment of a ruptured TOA

Answer 6

Immediate surgery esp. if hemodynamic changes, do not delay for abx

Intraoperative management:
1. Consider vertical incision. Drainage of abscess and excision of necrotic tissue
2. Cultures for aerobes and anaerobes
3. Copious irrigation with at least 2-3 liters and serial irrigation
4. Carefully inspect abdomen and evaluate for other possible origins of abscess
5. Unilateral SO if only one TOA, if bilateral the desire to maintain fertility does not supersede the clearance of devitalized tissue. If extremely ill and childbearing is done, TAH/BSO is indicated
6. Place closed suction drains within the pelvis if residual tissue inflammation.
7. Close with delayed absorbable suture (PDS), only close fascia and the skin (no subQ). Consider leaving the wound open with plan for delayed closure or secondary intention.