Tutorial 14: Pelvic Inflammatory Disease Flashcards
What is Pelvic Inflammatory Disease?
Pelvic inflammatory disease (PID) is an acute, ascending, polymicrobial infection of the upper female reproductive tract.
PID is frequently associated with Neisseria gonorrhoeae or Chlamydia trachomatis.
It is a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis.
What types of infection is PID and what are the most common causative organisms?
PID is a polymicrobial infection.
- Sexually transmitted organisms (common): Neisseria gonorrhoeae and Chlamydia trachomatis
- Micro-organisms of the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae)
- Other organisms: Cytomegalovirus (CMV), Mycoplasma hominis, Mycoplasma genitalium, and Ureaplasma urealyticum.
What is the epidemiology of Pelvic Inflammatory Disease?
It most commonly affects young, single, sexually active women with a history of sexually transmitted diseases.
No actual prevalence is known. The rate of diagnosed Chlamydia infection is increasing in NZ, having risen by 27.7% from 3363 diagnosed cases in 2002 to 4295 in 2006.
What is the pathophysiology behind pelvic inflammatory disease?
Infection of the cervix, usually caused by Neisseria gonorrhoeae and Chlamydia trachomati, if left untreated, may ascend to the upper genital tract.
Epithelial damage leads to a disruption of protective cervical barrier which allows entry of other micro-organisms, which ultimately leads to an ascending polymicrobial infection.
Spreading to the upper genital tract may also occur by insertion of instrumentations to the cervix such as D&C, TOP termination of pregnancy, or insertion of an IUD.
What are some complications of Pelvic Inflammatory Disease?
Long term complications of untreated or incompletely treated PID may lead to:
- Tuboovarian Abscess (TOA)
- Tubal scarring and obstruction: leading to infertility or ectopic pregnancy
- Chronic pelvic pain
- Reactive arthritis
- Perihepatitis (Fitz-Hugh-Curtis syndrome).
What are some risk factors for Pelvic Inflammatory Disease?
- Prior infection with chlamydia or gonorrhoea
- Prior Hx of PID
- Young age at onset of sexual activity
- Unprotected sexual intercourse with multiple sexual partners
- Instrumentation (eg. IUD insertion, D & C, surgical TOP termination of pregnancy)
- Lifestyle Factors: Smoking, low SES, linked with sex trade and drug use,
- Sexual Habits: intercourse during menstruation, vaginal douching
What are some symptoms of Pelvic Inflammatory disease?
- Asymptomatic (85% of women)
- Unspecific and may vary widely (mild to absent)
- 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
What are some signs of Pelvic Inflammatory Disease?
- Vitals: High temperature
- Abdo exam: Bilateral lower abdominal tenderness
- Speculum: mucopurulent cervical (cloudy or yellow discharge) and vaginal
- Friable cervix : Cervix bleeds easily with friction from a Dacron swab (uncommon)
- Bimanual to reveal: uterine tenderness, cervical motion tenderness, adnexal tenderness
What Investigations would you want to perform if a patient had suspected pelvic inflammatory disease?
- FBC (WBC count), CRP, ESR
- Swabs – NAAT Chlamydia and gonorrhoea from cervix. HVS for trichomonas vaginalis (rectal swab if anal sex)
- Nucleic acid amplification test (NAAT): Polymerase chain reaction, transcription mediated amplification, strand displacement amplification
What investigations would you consider for an uncertain clinical diagnosis of Pelvic Inflammatory disease?
- Transvaginal USS: primary imaging modality and may be normal in early stages or uncomplicated cases to confirm uncertain diagnosis. Use of c_olour or power Doppler_ can improve detection of subtle abnormalities of endometritis, salpingitis, and, oophoritis.
- Pelvic CT: indicated in patients with diffuse pelvic pain, peritonitis, or difficult or equivocal ultrasound. It should be performed with both oral and intravenous contrast, as un-opacified bowel may be mistaken for an abscess.
- Pelvic MRI: considered superior to USS at diagnosing PID when there is a tubo-ovarian abscess, pyosalpinx, fluid-filled tube, and/or enlarged polycystic ovaries with free intrapelvic fluid. Rarely used due to cost effectiveness.
- Laparoscopy: enables specimens to be taken from the fallopian tubes and pouch of Douglas. It will not detect endometritis or subtle inflammation of the fallopian tubes. Not be used as a routine diagnostic tool, especially when symptoms are mild or vague.
- Endometrial biopsy (endometritis) : Endometrial biopsy should not be used as a routine diagnostic test. It is indicated in women undergoing laparoscopy who do not have visual evidence of salpingitis.
What are some differentials for Pelvic Inflammatory Disease?
- Ectopic Pregnancy
- Acute appendiciis
- Ruptured Ovarian cyst
- Ovarian cyst torsion
- Haemorrhagic ovarian cyst
- Endometritis
How do you differentiate between an ectopic pregnancy and PID?
Lower abdominal pain, adnexal tenderness, fever, and other symptoms of acute abdomen (nausea, vomiting, diarrhoea) may be present.
May resemble severe case of PID. PID can exist concurrently with ectopic pregnancy.
A positive pregnancy test: hCG hormone level is high in serum and urine.
USS may reveal an empty uterus and may show a mass in the fallopian tubes.
How do you differentiate between acute appendicitis and PID?
Nausea and vomiting. Cervical motion tenderness will occur in about 25% of women with appendicitis while this sign is usually present in all patients with PID.
Abdominal USS shows aperistalic or non-compresible structure with diameterof >6mm.
Abdominal and pelvic CT may show calcified appendicolith seen in association with periappendiceal inflammation.
Laparoscopy will be diagnostic and therapeutic
How do you differentiate between ruptured ovarian cyst and PID?
Rupture usually spontaneous, can follow history of trauma; mild chronic lower abdominal discomfort may suddenly intensify.
Signs of peritonism (guarding, rebound tenderness, rigid abdomen) may be present in lower abdomen and pelvis; size of the adnexal mass may be unremarkable due to collapsed cyst.
Pelvic ultrasound confirms diagnosis.
How can you differentiate between ovarian cyst torsion and PID?
Sudden, acute, unilateral, lower quadrant abdominal pain, severe and colicky in nature; two thirds of patients have nausea and vomiting.
Lowgrade fever usually correlates with necrosis;
Tender adnexal mass palpated in 90%; localised peritoneal irritation.
Pelvic ultrasound confirms diagnosis.
