PID

Question 1

List some DDx for a presentation of:

• 35 yo female
• vaginal discharge
• irregular PV bleeding
• suprapubic pain

Answer 1

PDx. PID
DDx.
• Ectopic pregnancy
• Vaginal- infections (vaginosis), vaginal ca
• Cervix- infection (cervicitis), neoplastic (cervical ca)
• Uterus- endometriosis, endometrial polyp, fibroids, endometrial ca
• Ovarian- ovarian cyst rupture/torsion, ovarian ca
• Non-gynae- UTI (pyelonephritis), appendicitis, diverticulitis

Question 2

What are the common symptoms and signs of PID? 


Answer 2

• Abnormal bleeding- intermenstrual, post-coital, menorrhagia
• Suprapubic pain- dyspareunia, relation to cycle (endometriosis)
• Vaginal discharge- bacterial vaginosis (thin, white, fishy), cervicitis (mucopurulent, bleeding), endometrial or cervical ca
• Urinary frequency (irritation of adjacent bladder)
• Acute cervical motion/uterine/adnexal tenderness on bimanual exam- defining feature PID
• Acute: < 2 weeks duration
• Chronic: days- months duration, low-grade fever, weight loss, abdo pain

Question 3

Describe the pathogenesis of PID?

Answer 3

• Normal protection: endo-cervical canal forms barrier -> protects against entrance of normal vaginal flora
• STI: disrupts barrier -> vaginal microflora entry into upper genital tract -> infecting endometrium -> endosalpinx, ovarian cortex -> pelvic peritoneum -> PID
• Risk: genetic variations in immune response, oestrogen levels (affect cervical mucous viscosity), bacterial load

Question 4

List some causative organisms of PID?

Answer 4

Causative organisms:
o Neisseria gonorrhoea (most severe)
o Chlamydia tachomatis (most common)
o Mycoplasma genitalium 
o E. coli and colonic anaerobes (post-menopausal cases)

Question 5

What investigations would you order?

Answer 5

Diagnostic:
o Vaginal discharge- MCS, PCR
o Cervical swab- cytology, HPV screen, MCS, NAAT
o First catch urine MCS- STI 
o Midstream urine MCS- UTI
o Transvaginal US
Bedside: 
o Urinalysis: nitrites, leukocytes, casts (RBC, WBC in pyelonephritis) 
o bHCG- pregnancy, ectopic
Labs:
o FBC- anaemia, infection
o CRP/ESR- inflammation
o Coag profile
o EUC- kidney function, electrolyte balance
o LFT- liver function
o Blood culture- sepsis
o STI screen - HIV, HCV, syphilis 
Imaging:
o Transvaginal US
o CT- staging 
o Colposcopy

Question 6

Would you treat it and with what? 



Answer 6

Antibiotics (approx. 14 days):
o Mild: Augmentin (Amoxicillin and clauvanic acid/ Penicillin) + Doxycycline (Tetracycline)
o Mild/moderate: Ceftriaxone (3rd gen cephalosporin) + Doxycyline (Tetracycline) + Azithromycin (Macrolide)
o Severe: Ceftriaxone + Doxycycline + Gentamycin (Aminoglycoside)
o Chronic: Clindamycin (Lincosamide) + Gentamycin
o Pregnant: Azithromycin (avoid Doxycylcine)
o PID and pelvic abscess: add Metronidazole (Nitroimidazoles/anaerobic coverage)
• Antiemetics
• Antipyretics
• Analgesia
• Patient monitoring- improvement (within 48-72hrs), compliance, complications
• Counselling and screening- remove IUD, no sexual intercourse during Rx
• Contact tracing (gonorrhoea traced back 2 months, chlamydia traced back 6 months)

Question 7

What are the complications of PID?

Answer 7

Short-term:
o Hydrosalpinx/pyosalpinx- damaged fallopian tube becomes blocked, fluid filled, enlarged -> infertility
o Peritonitis, bacteraemia
o Adhesions -> intestinal obstruction
Long-term:
o Recurrent PID
o Tubal infertility: scar tissue -> tubal blockage
o Ectopic pregnancy
o Chronic pelvic pain- scarring and adhesions
o Ovarian ca (PID increases risk of low parity, nulliparity, infertility -> independent risks)