PID

Question 1

What is PID?

Answer 1

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

Question 2

what does PID result in?

Answer 2

Results in endometritis, salpingitis, oophoritis, pelvic peritonitis, perihepatitis, and/or tubo- ovarian abcess (TOA)

Question 3

Acute PID hard to diagnose because of the wide variation in s/s, which are?

Answer 3

unilateral or bilateral lower abdominal or pelvic pain
fever
vomiting
abnormal vaginal discharge
irregular vaginal bleeding
pain with intercourse

Question 4

*many episodes of PID go undiagnosed and untreated because ??

Answer 4

the patient and/or practitioner fails to recognize the implications of mild or nonspecific signs and symptoms

Question 5

Silent PID

Answer 5

term that can be applied to women with very minimal or no symptoms, represents a large portion of all PID cases

Question 6

what is happening in subclinical PID

Answer 6

mild inflammation is occurring within the reproductive tract at a very low level, yet damage to the fallopian tubes or surrounding structures is occurring

Question 7

important for clinicians to recognize the implication of mild/ non specific findings, especially

Answer 7

in young female patients who might give an incomplete or inaccurate sexual history

Question 8

how can PID occur (less likely)

Answer 8

can be blood- borne, ie. TB or result from an intra- abdominal process or gyn procedures that disrupt the protective cervical barrier

Question 9

how does PID usually occur

Answer 9

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

Question 10

risk factors for PID

Answer 10

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

Question 11

gyn procedures that disrupt the protective cervical barrier

Answer 11

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

Question 12

time course of presentation of PID

Answer 12

typically acute over several days but can be weeks to months

Question 13

clinical diagnosis remains..

Answer 13

the most important practical approach

Question 14

15% of cases of PID are NOT sexually transmitted and instead are associated with..

Answer 14

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

Question 15

what other things can produce a similar clinical picture

Answer 15

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

Question 16

who is at risk?

Answer 16

any sexually active female is at risk for STI associated PID

-those w/ multiple partners at higher risk

Question 17

PID during pregnancy rare because

Answer 17

the mucus plug and decidua seal off the uterus from ascending bacteria.

Question 18

PID rare during pregnancy but possible

Answer 18

• can occur within first 12 weeks of gestation before the mucus plug seals off the uterus

Question 19

our level of suspicion should always be high, especially

Answer 19

in adolescents

Question 20

what is the goal of the initial evaluation of women with suspected PID?

Answer 20

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

Question 21

issues pertaining to high- risk sexual behavior and acquisition of STI are common to both adolescents and adults but

Answer 21

are intensified among adolescents because of both behavioral and biological predispositions

Question 22

behavioral factors that put adolescents and young women at high risk for STI’s and PID are

Answer 22

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

Question 23

what to use to reduce risk of PID

Answer 23

latex condoms

Question 24

use of oral contraceptives

Answer 24

may also reduce risk of PID (associated with a decrease in the severity of inflammation)

Question 25

what will your PID pt possible look like? exam findings vary but may include:

Answer 25

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

Question 26

where does PID come from/ most common pathogens

Answer 26

studies from europe and US from the 80’s found its caused by C trachomatis and N. gonorrhoeae or both about 50% of cases

Question 27

M. genitalium has been associated with

Answer 27

endometritis and PID

Question 28

Actinomyces israelli is a cause of

Answer 28

PID in women with IUDs

Question 29

most common pathogens of PID

Answer 29

neisseria gonorrhoeae and chlamydia trachomatis

Question 30

other organisms from upper genital tract that can cause PID

Answer 30

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

Question 31

genital mycoplasms also associated with PID including

Answer 31

mycoplasma genitalium, mycoplasma hominis, and ureaplasma urealyticum

Question 32

etiology of PID

Answer 32

polymicrobial common, but in more than half the cases, no organism is identified in the specimen

Question 33

complications of PID

Answer 33

perihepatitis (fitz- hugh- curtis syndrome) and tubo- ovarian abscess/ complex formation

Question 34

long term sequelae

Answer 34

tubal scarring that can cause
- infertility in 20% of females
- ectopic pregnancy in 9%
chronic pelvic pain in 18%

Question 35

factors that may increase the likelihood of infertility

Answer 35

delay in diagnosis or initiation of antimicrobial therapy
younger age at time of infection
chlamydial infection
PID determined to be severe by laparoscopic exam

Question 36

*perihepatitis aka fitz- hugh- curtis syndrome

Answer 36

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

Question 37

perihepatitis aka fitz- hugh- curtis syndrome cont

Answer 37

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)

Question 38

ABX of choice for coverage of c. trachomatis

Answer 38

1st choice doxycycline. azithromycin has shown activity against this pathogen too

Question 39

has moderate in vitro activity against n. gonorrhoeae and c. trachomatis

Answer 39

the combo clindamycin and gentamicin

Question 40

have excellent in vitro activity against n. gonorrhoeae and c. trachomatis

Answer 40

second generation cephalosporin (cefoxitin, cefotetan) plus doxy

Question 41

what do you NOT give to treat gonorrhea or associated conditions

Answer 41

fluoroquinolones bc of increased resistance

Question 42

if you suspect PID

Answer 42

you should treat- even if you are not sure

Question 43

CDC recommends initiating treatment of PID in who?

Answer 43

all sexually active young women with adenexal tenderness or cervical motion tenderness (these criteria are sensitive but not specific)

Question 44

treatment against PID directed at what?

Answer 44

c. trachomatis, n. gonorrhoeae, gram negative facultative anaerobes, vaginal anaerobes, and stretococci

Question 45

2 most important sexually transmitted organisms associated with acute PID

Answer 45

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

Question 46

diagnosis of PID difficult to make because

Answer 46

studies have been unable to identify any single clinical finding or constellation of findings that allow accurate identification of women with PID

Question 47

most cases of PID

Answer 47

probably go undiagnosed

Question 48

when PID diagnosis is made clinically

Answer 48

might not be supported by laparoscopic evidence/ surgical findings

Question 49

treatment guidelines from CDC 2015

Answer 49

make chart on paper!