PID and abdominal pain Flashcards
What are the common causes of lower abdominal pain in younger women?
- Menstruation/dysmennorhea
- Appendicits
- Miscarriage
- Ectopic Pregnancy
- UTI/Pyelonephritis, cystitis
- Constipation
- PID, adhesions, endometriosis
- IBS/IBD
- Ruptured ovarian cysts
What specific things do you want to know in a history of a young women with lower abdominal pain
- Pain - SOCRATES
- Associated features
- Nausea and vomiting, anorexia
- Bowel changes (diarrhoea, constipation), Urinary symptoms
- Fevers, unwell contacts, unusual food
- Bleeding, discharge
- Gynaecological history
- Menstrual history, LMP
- Sexual history - and partner’s symptoms. Dyspareunia.
- Previous STI’s, Contraception - including recent IUD insertion history
- Cervical smear history
- Obstetric history, PMH, Medications, allergies, FH, SH
What specific examinations do you want to do on a young women with lower abdominal pain
- General: evidence of sepsis or haemodynamic instability?
- Vitals: BMI, high temp
- Abdo exam
- Pelvic examination
- speculum: discharge, bleeding, get swabs
- Bimanual: uterine position, size, tenderness (uterine, cervical motion or adnexal)
What is the classical history and examination of a patient with pelvic inflammatory disease?
Classical History
- Asymptomatic (85% of women)
- Bilateral lower abdominal pain
- Fever/chills
- Nausea and vomiting
- Back pain
- Dysuria
- Dyspareunia (deep)
- Cervical or vaginal discharge
- Abnormal vaginal odour, bleeding, or discharge
- Abnormal vaginal bleeding, including post-coital, inter-menstrual, and menorrhagia
Classical Exam
- Vitals: fever
- Abdominal: bilateral tenderness
- Speculum: mucopurulent discharge
- Bimanual: unterine, cervical motion and adnexal tenderness
PID is usually a result of?
What are the responsible organsims?
an ascending polymicrobial infection, which causes epithelial damage, disruption of protective cervical barrier allows entry of other micro-organisms which leads to ascending polymicrobial infection. Spread to the upper genital tract may also occur by insertion of instrumentations to the cervix such as D&C, termination of pregnancy, or insertion of an IUD. with the usual culprits being
STI’s: common
- Chlamydia trachomatis
- Neisseria gonnorrhoea
Other organisms:
- Mycoplasma genitalium
- Mycoplasma hominis
- CMV
Classical hx and examination of a ruptured ovarian cyst?
Classical History:
- dyspareunia
- Unilateral pelvic pain
- Can be spontaneous or hx of trauma
- N+V
Classical Exam:
- Hypotension
- Abdo: may show signs of peritonism
Classical history and examination of ovarian torsion?
Classical History:
- sudden acute unilateral pain that radiates to the groin
- N+V
Classical Examination:
- Abdominal tenderness
- Palpable adnexal mass
Classical history and examination of ectopic pregnancy
Classical history
- Unilateral abdominal pain
- PV bleeding
- maybe N+V
Exam
- Fever
- Adnexal tenderness
***test for hcg and USS patient!!
What investigations are appropriate tot do in this young women with abdominal pain?
Bloods:
- hcg: excludes ectopic preg + miscarriage
- if pregnant check Rh to consider anti-D
- FBC, CRP, ESR: indicates inflammatory or infective causes
- monitor Hb if suspcious of haemorrhagic cyst
MSU/Urine culture
Swabs:
- NAAT VVS swab for chlamydia and gonorrhea
- HVS for BV and thrush
- Endocervical swab for gonorrhea culture
- HIV and syphyilis serology
Imaging:
- TVUSS for ?pregnant ?appendicitis
- Pelvic CT: not particularly helpful
- Pelvic MRI: superior to USS but rarely used due to cost
Potential Complications of PID
- Recurrence
- Chronic Pelvic pain consequence of scarring/adhesions
- Tubo-ovarian abscess usually later, can cause death if ruptures
- Infertility 10% are after 1 episode, 50% after 3x
- hydrosalpinx
- Ectopic pregnancy: scarring and obstruction
- Fitz Hugh Curtis Syndrome
How does a hydrosalpinx occur from PID
Following an acute episode of PID, damage to the fallopian tubes can result in fluid filling the tube and potentially causeing infertility
main way to avoid PID
To avoid STI’s!!
Barrier protection in the form of contraceptions is first line
it is important to note that PID is not one specific issue, but rather……
It is a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis.
What is Fitz Hugh Curtis Syndrome
A rare disorder usually only seen in women, which is often a complication of PID
Perihepatitis of the liver capsule (not the parenchyma) with thin adhesion formulation
Inflammation of the peritoneum, and of the tissues surrounding the liver (perihepatitis) and potentially diaphragmatic tissues can be affected
Will result in fever, malaise, severe RUQ pain that radiates to the R shoulder, N+V
Treatment of PID
Empirical treatment of PID should be initiated in women high risk and physical findings suggestive of PID. This is to prevent long term complication of PID.
- Ceftriaxone 250 to 500mg IM STAT
- Doxycycline 100mg bd for 14days OR azithromycin 1g per week for two weeks
- Metronidazole 400mg bd for 14days
- Sexual partners who have had sexual contact with a woman diagnosed with PID 60 days prior to her onset of symptoms should be consulted and treated also
- Analgesia
- Avoid sexual intercourse until completion of treatment
