PID Flashcards
What is PID?
Pelvic inflammatory disease- acute and subclinical infection of the upper genital tract in women. It comprises a spectrum of inflammatory diseases involving any combo of the uterus, fallopian tubes, ovaries. Often accompanied by involvement of neighboring pelvic organs
what does PID result in?
Results in endometritis, salpingitis, oophoritis, pelvic peritonitis, perihepatitis, and/or tubo- ovarian abcess (TOA)
Acute PID hard to diagnose because of the wide variation in s/s, which are?
unilateral or bilateral lower abdominal or pelvic pain fever vomiting abnormal vaginal discharge irregular vaginal bleeding pain with intercourse
*many episodes of PID go undiagnosed and untreated because ??
the patient and/or practitioner fails to recognize the implications of mild or nonspecific signs and symptoms
Silent PID
term that can be applied to women with very minimal or no symptoms, represents a large portion of all PID cases
what is happening in subclinical PID
mild inflammation is occurring within the reproductive tract at a very low level, yet damage to the fallopian tubes or surrounding structures is occurring
important for clinicians to recognize the implication of mild/ non specific findings, especially
in young female patients who might give an incomplete or inaccurate sexual history
how can PID occur (less likely)
can be blood- borne, ie. TB or result from an intra- abdominal process or gyn procedures that disrupt the protective cervical barrier
how does PID usually occur
most often develops when bacteria ascend from the vagina or cervix into the endometrium, fallopian tubes, and pelvic peritoneum. majority (85%) of cases caused by sexually transmitted pathogen or bacterial vaginosis- associated pathogens
risk factors for PID
a previous h/o of PID higher numbers of lifetime sex partners douching h/o bacterial STD age younger than 25 having a partner with an STI
gyn procedures that disrupt the protective cervical barrier
pregnancy termination IUD insertion dilation and curettage hysterosalpingography - all elevate the risk of PID and may lead to PID in the absence of the classic sexually transmitted pathogen
time course of presentation of PID
typically acute over several days but can be weeks to months
clinical diagnosis remains..
the most important practical approach
15% of cases of PID are NOT sexually transmitted and instead are associated with..
enteric pathogens (E.coli, bacteroides fragilis, group B strep, and campylobacter spp) or respiratory pathogens (h. influenzae, strep pneumoniae, group A strep, and staph aureus) that have colonized in the lower GI tract
what other things can produce a similar clinical picture
post- op pelvic cellulitis and abscess, pregnancy- related pelvic infection, injury or trauma- related pelvic infection, and pelvic infection secondary to spread of another infection
who is at risk?
any sexually active female is at risk for STI associated PID
-those w/ multiple partners at higher risk
PID during pregnancy rare because
the mucus plug and decidua seal off the uterus from ascending bacteria.
PID rare during pregnancy but possible
- can occur within first 12 weeks of gestation before the mucus plug seals off the uterus
our level of suspicion should always be high, especially
in adolescents
what is the goal of the initial evaluation of women with suspected PID?
to establish a presumptive diagnosis of PID
- assess for additional findings that increase the liklihood of that diagnosis
- evaluate for other potential causes of pelvic pain
issues pertaining to high- risk sexual behavior and acquisition of STI are common to both adolescents and adults but
are intensified among adolescents because of both behavioral and biological predispositions
behavioral factors that put adolescents and young women at high risk for STI’s and PID are
inconsistent use of barrier protection
douching
greater number of current/ lifetime sexual partners
use of ETOH and other substances that may impair judgement while engaging in sexual activity
what to use to reduce risk of PID
latex condoms
use of oral contraceptives
may also reduce risk of PID (associated with a decrease in the severity of inflammation)
what will your PID pt possible look like? exam findings vary but may include:
oral temp >101F
lower abdominal tenderness w/ or w/o peritoneal signs
cervical or vaginal discharge
tenderness with lateral motion of the cervix
uterine tenderness
unilateral or bilateral adnexal tenderness and adnexal fullness
pyuria- abundant WBCs on saline microscopy of vaginal fluid
elevated c- reactive protein
and/ or adnexla mass demonstrated by abdominal or transvaginal US
where does PID come from/ most common pathogens
studies from europe and US from the 80’s found its caused by C trachomatis and N. gonorrhoeae or both about 50% of cases
M. genitalium has been associated with
endometritis and PID
Actinomyces israelli is a cause of
PID in women with IUDs
most common pathogens of PID
neisseria gonorrhoeae and chlamydia trachomatis
other organisms from upper genital tract that can cause PID
anaerobes such as bacteroides species and peptostreptococcus species
facultative anaerobes such as gardnerella vaginalis, haemophilus influenzae, strep species, actinomyces
enteric gram negative bacilli and
cytomegalovirus
genital mycoplasms also associated with PID including
mycoplasma genitalium, mycoplasma hominis, and ureaplasma urealyticum
etiology of PID
polymicrobial common, but in more than half the cases, no organism is identified in the specimen
complications of PID
perihepatitis (fitz- hugh- curtis syndrome) and tubo- ovarian abscess/ complex formation
long term sequelae
tubal scarring that can cause
- infertility in 20% of females
- ectopic pregnancy in 9%
chronic pelvic pain in 18%
factors that may increase the likelihood of infertility
delay in diagnosis or initiation of antimicrobial therapy
younger age at time of infection
chlamydial infection
PID determined to be severe by laparoscopic exam
*perihepatitis aka fitz- hugh- curtis syndrome
occurs in setting of PID when there is inflammation of the liver capsule and peritoneal surfaces of the anterior right upper quadrant
- there is generally minimal stromal hepatic involvement
- was first associated with gonococcal salpingitis in 1920 and subsequently C trachomatis
perihepatitis aka fitz- hugh- curtis syndrome cont
occurs in approximately 10% of women with acute PID and is chracterized by RUQ abdominal pain with a distinct pleuritic component, sometimes referred to as the right shoulder
- marked tenderness at RUQ on exam
- the severity of pain in this location may mask PID and lead to concerns of cholecystitis
- aminotransferase are usually normal or only slightly high
- on laparoscopy or visual inspection, it manifests as “violin string”- patchy purulent and fibrinous exudate, most commonly affecting the anterior surfaces of the liver (not the liver parenchyma)
ABX of choice for coverage of c. trachomatis
1st choice doxycycline. azithromycin has shown activity against this pathogen too
has moderate in vitro activity against n. gonorrhoeae and c. trachomatis
the combo clindamycin and gentamicin
have excellent in vitro activity against n. gonorrhoeae and c. trachomatis
second generation cephalosporin (cefoxitin, cefotetan) plus doxy
what do you NOT give to treat gonorrhea or associated conditions
fluoroquinolones bc of increased resistance
if you suspect PID
you should treat- even if you are not sure
CDC recommends initiating treatment of PID in who?
all sexually active young women with adenexal tenderness or cervical motion tenderness (these criteria are sensitive but not specific)
treatment against PID directed at what?
c. trachomatis, n. gonorrhoeae, gram negative facultative anaerobes, vaginal anaerobes, and stretococci
2 most important sexually transmitted organisms associated with acute PID
c. trachomatis, n. gonorrhoeae- these should be the target of tx. However negative endocervical screeening for either of these pathogens does not rule out upper tract infection
diagnosis of PID difficult to make because
studies have been unable to identify any single clinical finding or constellation of findings that allow accurate identification of women with PID
most cases of PID
probably go undiagnosed
when PID diagnosis is made clinically
might not be supported by laparoscopic evidence/ surgical findings
treatment guidelines from CDC 2015
make chart on paper!
