PELVIC

INFLAMMATOR
Y DISEASE
 OVERVIEW
INTRODUCION
ETIOLOGY
PATHOGENESIS
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
TREATMENT
SYNDROMIC MANAGEMENT
SUMMARY
 INTRODUCION
Definition
Pelvic inflammatory disease is a spectrum of infection and
inflammation of the upper genital tract organs typically involving

Uterus(endometrium),
Fallopian tubes,
Ovaries,
Pelvic peritoneum
Surrounding structures
(parametrium).
NATURAL DEFENCE MECHANISMS

Vulva- opposition of labia

-compound racemose type bartholin glands
-apocrine glands is rich in undecylenic acid
(fungicidal)
Vagina -apposition of its anterior and posterior walls.
-Stratified squamous epithelium of vaginal skin
-Low pH( 4 to 4.5)
Cervix-Functional closure of the cervix .
- mucus is said to be bacteriolytic
Uterus -Periodic shedding of surface endometrium
-Closure of uterine ostium of the fallopian tube
Fallopian tubes-Peristalsis of the tube
-movement of the cilia are towards uterus
This protective mechanism is impaired :

During menstruation - Dilated cervical canal

Post abortion - Protective endometrium is shed
Post delivery - Raw surfaces exposed
- Increased vaginal pH
 ETIOLOGY
1.Most common cause of PID is STD (85%)
-Gonococci & Chlamydia are most common organisms
Iatroge
nic
15%
2.Following Iatrogenic procedures (15%)
-Dilatation & curettage 85
-Dilatation & evacuation %

-Post tubectomy STD’s

-Hysterosalpingogram
-Manual removal of placenta
-IUCD insertion(aseptic conditions)
3.Following major surgical procedures
4.Post abortal infection
5.Puerperal infection
 Risk factors Protective factors

AGE: Younger age – estrogen Barrier methods: condom

with spermicidal chemicals
more columnar epithelium.
Oral steroidal
Low socio-economic status contraceptives:
Multiple sex partners (4- 6 fold -Thick mucus plug
risk)
-Decrease in duration of
Early onset of sexual activity menstruation
High frequency of coitus. Progesterone only pills --
Prior H/O PID Thick mucus plug
Sexually Transmitted Infection Women with monogamous
partner with vasectomy
Non-use of barrier
contraceptive Pregnancy
IUCD insertion(aseptic Menopause
conditions) Husband who is azoospermic
Cigarette smoking, substance
abuse
Douching
ORGANISMS RESPONSIBLE FOR PID
Acute PID is usually polymicrobial
Primary organisms:- sexually transmitted
Gonococcus
Chlamydia
Mycoplasma
Others

Secondary organisms: normally found in vagina

Aerobes
Staphylococci
Non hemolytic Streptococci
E. coli
Anaerobes:
Bacteroides fragilis, Peptococcus, Clostrididium
Actinomyces (IUD)
Tubercular salpingitis
Gonococci Chlamydia
Gram negative Obligate intracellular microbe
diplococcus
Invades the columnar Invades the columnar
epithelium becomes epithelium ,transitional
intracellular epithelium
Incubation period 3-5 Incubation period 6-14 days
days
Travel up the genital tract Lesion is limited
along the motile sperms superficially,no deeper
in piggyback manner. penetration
Symptoms-aymptomatic Symptoms-usually
-cerivovaginal purulent asymptomatic,
discharge silent salpingitis is the
-dysuria hallmark
- increased frequency of -dysuria,dyspareunia,
micturition -post coital beeding
Diagnosis-NAAT,ELISA Diagnosis- NAAT, ELISA, PCR
-Microscopy of gram -can be demonstrated in
stained discharge from tissue culture (McCoy cell
endocervix monolayers)
-culture in Thayer martin
medium
 MODES OF TRANSMISSION
Ascending infection (STD’s)

Lymphatic (post abortal, puerperal)

Haematogenous (genital TB)

Direct (Appendicitis, Diverticulitis)

Ascend of organisms by surface extension from
the lower genital tract.
cervical canal

endometrium

fallopian tubes

tuboovarian involvement

peritonitis
Facilitated by  sperms & trichomonads
Reflux of menstrual blood along with gonococci
into the fallopian tubes may be the other
possibility
 POST ABORTAL OR PUERPERIUM
Through uterine lymphatic & blood vessels across
parametrium
Infection localized to the cervix - cervicitis
placental site -endometritis.
Myometrium - endomyometritis .
Directly through cervical tear
- broad ligament.
Lymphatic spreads to the parametrium,

the fallopian tube affected from outside

perisalpingitis
The ovary - tubo-ovarian mass.
TYPES:- PID

Silent PID PID

ACUTE CHRONIC
PID PID

Patient has acute Patient may have no

generalised symptoms symptoms
Lasts a few days Occurs over months and
May recur in episodes years
Very infectious in this Progressive organ damage
stage
 SILENT PID
Follow multiple or continuous low-grade infection in
asymptomatic women.
Women with tubal- factor infertility without h/o prior upper
tract infection.
At laparoscopy or laparotomy
-- Adhesions ,
-- hydrosalpinx
-- Adhesions between the liver capsule and anterior
abdominal wall may be seen.
Internally -tubes show attenued mucosal folds,
- extensive deciliation of the epithelium, and
- secretory epithelial cell degeneration
ACUTE PID : PATHOLOGY
Cervicitis

Endometritis

Salpingitis
Oophoritis
Tubo-ovarian abscess

Peritonitis
 ACUTE SALPINGITIS
1. Involvement of the fallopian tubes is almost bilateral
It usually follows menses due to loss of genital defence

Gross destruction of epithelial cells,

cilia & microvilli

Acute inflammatory reaction ( WBC , Plasma cells)

all layers are involved : Mucosa  serosa)

Tubes become edematous & hyperemic;

exfoliated cells & exudate pour into lumen &
agglutinate the mucosal folds

Abdominal ostium: closed by edema & inflammation

Uterine end: closed by congestion
 Depending on the virulence: watery or purulent exudate
from fimbrial end

Hydrosalpinx or Pyosalpinx

Secondary infections
Deeper penetration & more destruction

Possibilities :-
Oophoritis
Tubo-ovarian abscess
Peritonitis, paralytic ileus
Pelvic abscess
Resolution in 2-3 weeks
with/without chronic sequelae
2.PID following postabortal and puerperal infection,
spreads from cervix via lymphatics

cellular tissue in the broad ligament, causing cellulitis.

The fallopian tube is affected from serosa  mucosa.

The wall of the tube is thickened , hardly any distension of

the lumen.

Eventual involvement of mucosa ends up in blockage of the

fallopian tube by multiple adhesions.
 FITZ HUGH & CURTIS
SYNDROME
Consists of rt. upper quadrant pain.
May be associated with pleuritic pain.
Cause: vascular / transperitoneal dissemination of organisms
( N.gonorrhoea, C. trachomatis.)

Perihepatic inflamation

Violin string
adhesions.
Although it is typically associated with acute salpingitis (1-10%),
it can exist without signs of acute pelvic inflammatory disease
(PID).
Differential diagnosis: cholecystitis, pneumonia.
 STAGES OF PID
STAGE 1: Acute salpingitis without peritonitis- no
adhesions

STAGE 2: Acute salpingitis with peritonitis-purulent

discharge from tubal ostia

STAGE 3: Acute salpingitis with superimposed tubal

occlusion or tuboovarian complex

STAGE 4 : Ruptured tuboovarian abscess

STAGE 5: Tubercular salpingitis

 ACUTE PID : PRESENTATION &
DIAGNOSIS
History:
PAIN : 90% CASES. Bilateral lower abdominal & pelvic dull aching
pain is characteristic of acute PID
Fever (Oral temperature > 38.3˚C/101F).
Abnormal vaginal discharge
Intermenstrual bleeding ,postcoital bleeding
Dysuria
Past history: -H/O abdominal or gynecological surgeries
-H/O IUD insertion (6 times higher risk within 20 days)
-Patient’s sexual and STD history

Signs:
High temperature
Tachycardia
Signs of dehydration
PHYSICAL EXAMINATION
Abdominal & pelvic examination is most important
Per abdomen:
-Bilateral lower abdominal tenderness.
-Rt upper quadrant pain , tenderness.

Per speculum:
-Abnormal vaginal discharge - mucopurulent discharge
-Congested external urethral meatus .
-Congested cervix with purulent discharge from the canal.

Per vaginal:
-Bilateral fornicial tenderness,
-Cervical motion tenderness
-Adnexal mass & adnexal tenderness
CLINICAL DIAGNOSIS CRITERIA OF
ACUTE PID (CDC-2015)
-cervical motion tenderness
Minimu -uterine tenderness
m
criteria -adnexal tenderness
-oral temperature >101°F (>38.3°C);

Addition abnormal cervical mucopurulent discharge or cervical friability;

presence of abundant numbers of WBC on saline microscopy of
al vaginal fluid;
criteria elevated erythrocyte sedimentation rate;
elevated C-reactive protein
laboratory documentation of cervical infection with
N.Gonorrhoeae or C. trachomatis.

-Endometrial biopsy with histopathologic evidence of

endometritis
-TVS or MRI techniques showing thickened, fluid-filled
Specific/ tubes with or without free pelvic fluid or tubo-ovarian
complex
Definitiv -laparoscopic findings consistent with PID.
 INVESTIGATIONS
HB, BGT
Complete blood count: > 10,000 cells /mm3
ESR
CRP
Urine Pregnancy Test (UPT), serum beta HCG testing.
Urinalysis,urine culture
Cervical & high Vaginal swabs and smears:
1. WBCs suggest PID.
2. Cervical chlamydia and gonorrhea testing
3. Nucleic acid amplification tests (NAATs) for organisms
4. culture and sensitivity
Tests for tuberculosis , syphilis , HIV and other STD’s.
Imaging

USG:
Transvaginal ultrasonography is the imaging modality of
choice
Not much helpful in mild & moderate cases
Trans abdominal ultrasonography for D/D
Abdominal CT or MRI : When USG indeterminate.
Diagnostic procedures
Culdocentesis: With acute PID,
WBC count of peritoneal fluid > 30,000 cells/mL,
Endometrial biopsy: Endometritis

Diagnostic laparoscopy
Important and most accurate.
Laparoscopic findings of PID:
Tubal serosal hyperemia,edema
Purulent exudate from the fimbriated ends of
the fallopian tubes, pooling in the cul-de-sac
Tuboovarian mass
Fitz Hugh Curtis syndrome.
Advantages:
1. When diagnosis is inaccurate
2. To obtain cultures from cul-de-sac or fallopian tube.
3. Assess future fertility prognosis
DIFFERENTIAL DIAGNOSIS OF ACUTE
PID
Acute appendicitis :-Pain is initially around umbilicus,
then localized to right iliac fossa (Mc Burney’s point).
-Vaginal discharge and menstrual irregularities are
absent.
Ectopic pregnancy:-Amenorrhea,irregular uterine
bleeding &abdominal pain-
-Pregnancy test,USG will help in diagnosis
Diverticulitis: : Usually seen after the age of 50 yrs,the
signs of infection are confined to left iliac fossa.
Twisted ovarian cyst:Sudden pain in abdomen with
vomiting, vaginal discharge and menstrual irregularities
are absent
Septic abortion
Cholecystitis
Ruptured endometrial cyst.
 MANAGE
AIM OF MANAGEMENT:
MENT
To relieve symptoms
To control the infection efficiently
To prevent infertility & late sequelae
To prevent reinfection

TREATMENT MODALITIES
Prevention
The mild cases of acute PID are treated at home with
antibiotics.
Moderate and severe cases of PID need hospitalization
Medical treatment( antimicrobial )
Minimal invasive surgery
Major surgery
Syndromic management
 PID : PREVENTION
Primary prevention
1. Sexual counseling
Practice safe sex
Limit number of sexual partners
Avoid contact with high risk partners
Delay in sexual activity until 16 years of age
2. Barrier methods & oral contraceptives reduce the risk

Secondary prevention
1. Screening for infections in high risk population
2. Rapid diagnosis & effective treatment of STDs & UTI

Tertiary prevention
1. Early intervention & complete treatment
CDC GUIDELINES (2015) : OP REGIMEN

CEFTRIAXONE 250MG IM CEFOXITIN 2gm single

Once dose
OR with
PROBENECID 1gm PO
single

+
DOXYCYCLINE 100mg orally BD for 14 days
With/without
METRONIDAZOLE-500mg orally BD for 14
days
 NEED FOR HOSPITALIZATION:

Suspected TO abscess
Uncertain diagnosis
Generalized peritonitis
Temperature > 38.3°C,severe illness,vomitings
Unresponsive outpatient therapy for 48 hours
Recent intrauterine instrumentation
Into;erance to oral therapy
Coexisting pregnancy
HIV +ve
HOSPITAL MANAGEMENT CONSISTS
OF
Rest
Intravenous fluids - In presence of dehydration or vomiting
and
correction of electrolyte imbalance.
Ryle’s tube aspiration - In peritonitis with distension,
to correct intake–output chart
should be
maintained.
Analgesics
Antibiotics - at the earliest and not wait for the culture
results.
 CDC GUIDELINES – IN PATIENT
REGIMEN(2015)
Regimen A:

CEFOXITIN 2g IV every 6 hours ×7 days

+
T. DOXYCYCLINE 100mg bd PO ×14 days

Regimen B:

CLINDAMYCIN 900mg IV every 8th hourly

+
GENTAMYCIN :- loading dose – 2 mg/kg
maintanace dose - 1.5 mg/kg IV every 8th hrly.

Alternative regimen:

AMPICILLIN-SULBACTUM 3g IV every 6hrs

+
T.DOXYCYCLINE 100mg bd PO×14 days
 SURGICAL TREATMENT
Surgery may be needed in the following conditions: -
Pelvic abscess  > 10 cm - drainage by colpotomy
 Abcess fails to respond to antibiotics in 48-
72 hrs.
Abcess ruptures
Septic products of conception - D&E
Spreading peritonitis - laparotomy
Intestinal obstruction.
Suspected intestinal injury ( criminal abortion)
Ruptured TOA.
Pyoperitoneum
Uncertain diagnosis
Type of surgeries

1. Colpotomy
2. Percutaneous drainage/aspiration
3. Exploratory laparotomy
4. Laparoscopy

Extent of surgeries
1. Conservation - if fertility desired
2. U/L or B/L Sal.-oophorectomy with/without
hysterectomy
3. Drainage of abscess at laparotomy
 COMPLICATIONS
Immediate:
(1) Pelvic peritonitis or even generalized peritonitis.
(2) Septicemia—producing arthritis or myocarditis.
Late:
(1) Dyspareunia.
(2) Infertility : 1 episode – 12%
2 episodes -25 %
3 episodes -50%.
(3) Chronic PID is due to recurrent
or associated pyogenic infection.
( 4) Adhesions or hydrosalpinx or pyosalpinx
and tubo-ovarian abscess.
(5) Chronic pelvic pain and ill health.
(6) Ectopic pregnancy (6-10 fold).
(7) Intestinal obstruction
MANAGEMENT OF PARTNERS

Contact partners within 60 days of onset

of disease.
Screen for gonococcal/chlamydial
infection
If screening not possible, start empirical
therapy.
Avoid intercourse till the partner
completes treatment.
Early treatment reduces the risk of
sequelae but does not eliminate it.
Barrier contraception reduces risk
Recurrence of infection increases the
risk of infertility.
 PID PREGNANCY
Rare to have PID during pregnancy
Occurs in first 12 weeks of pregnancy
Indication for hospitalization and parenteral
therapy
Treatment : IV CEFOXITIN or CEFOTETAN
Tab.AZITHROMYCIN 1g orally
once
 SUBACUTE PID :
Subacute PID results from
- inadequate treatment or
- from reinfection by the infected partner, if it has
been sexually transmitted.
-Tuberculosis also manifests in the form of recurrent
pelvic infection due to secondary infection.
 CHRONIC PID
Definition: Failure of acute PID to
resolve or end result of acute
infection results in chronic tubo-
ovarian masses.

These masses manifest in form

of :-
Hydrosalpinx
Chronic Pyosalpinx
Chronic interstitial salpingitis
Tubo-ovarian cyst and tuboovarian
abscess (TOA)
Tuberculous tubo-ovarian masses
 PATHOGENESIS
HYDROSALPINX
Distension of the fallopian tubes by
collection of fluid in lumen.
Often bilateral.
Retort shaped tube – d/t enormous
dilatation of ampullary region filled with
clear fluid, fimbrial end is closed and
indrawn.
May be as large as 15cms.
The wall is thin and translucent.
At times, the hydrosalpinx is mobile and
can undergo torsion.
Histology : flattening of tubal plicae and
exfoliation of lining epithelium.
CHRONIC PYOSALPINX:
Thick walled with dense adhesions and filled with pus.
Inner wall is replaced by granulation tissue.

CHRONIC INTERSTITIAL SALPINGITIS:

Wall is thickened and fibrotic.
No accumulation of pus in the lumen.

TUBO-OVARIAN CYST:
A hydrosalpinx communicates with the follicular cyst of
ovary, while TOA and pyosalpinx communicate with an
ovarian abscess.
Difficult to identify normal ovarian tissue.
 SIGNS AND SYMPTOMS:
Constant lower abdomianl pain(worse before
menstruation)
Low back ache
Deep dyspareunia
Vaginal discharge (chronic cervicitis)
Menstrual disturbance (chronic pelvic congestion)
Infertility
Pelvic examination: fixed retroversion, frozen pelvis
 DIFFERENTIAL DIAGNOSIS

Ectopic gestation
Uterine fibroids
Pelvic endometriosis
Ovarian tumour
Tubercular tubo-ovarian mass
 MANAGEMENT
Surgery depends on age and parity of patient,
symptoms and pelvic pathology.

When patient is multiparous & older age group – TAH +

BSO
In a young woman -- conservative surgery in the form of
salpingectomy and salpingo-oophorectomy is
performed.
In case of young women with infertility
-Tuboplasty (after laparoscopic salpingoscopy to
assess the extent of damage)
-Hysteroscopic balloon plasty or cannulation.
-Laparoscopic breakage of external adhesions.
-IVF after clipping or removal of both tubes
PROGNOSIS :
Extent of adhesions.
Nature of adhesions, such as flimsy or dense
adhesions.
Size of hydrosalpinx.
Macroscopic condition of hydrosalpinx.
Thickness of the tubal wall.
 SYNDROMIC MANAGEMENT
Many health care centers in developing countries lack the
equipment and trained personnel for diagnosis id STD’s .
To overcome this problem syndromic based approach has been
proposed by WHO in 2003.
Syndromic approach bases treatment on group of signs and
symptoms which can be by more than one possible infection.
It facilitates HCW to start treatment immediately instead of
referring patient to higher center which may not be affordable
or easily accessible.
Flowcharts and accompanying guidance give healthe care
providers step by step instructions about management and
treatment of common sti’s
Clinical Infective Kit Drugs Image
condiction organisms
1.Urethral Gonorrhea , Kit 1 T.Azithromycin1gm (1tab)
discharge Chlamydia Grey T.Cefixime 400mg (1tab)
2.Vaginal Gonorrhea , Kit 2 Tab. Secnidazole 2gm (1tab)
discharge Chlamydia ,t Green Tab. Fluconazole 150mg(1tab)
richomonas,
candidiasis
3.Genital Syphilis , Kit 3 Inj.Benzathin penicillin 2.4 MU
ulcer(non chancroid White T.Azithromycin1gm (1tab)
herpes)
4. Genital Syphilis , Kit 4 T. Doxycycline 100mg bd for 14
ulcer(non chancroid Blue days
herpes) allergic T.Azithromycin1gm (1tab)
to penicillin
5.Genital HSV Kit 5 T. Acyclovir 400mg tid for 7
ulcer(herpetic) Red days
6.Lower Gonorrhea , Kit 6 T.Cefixime 400mg (1tab)
T. Doxycycline 100mg bd × 14 days
abdomen pain Chlamydia , Yellow T.Metronidazole 400mg bd × 14 days
(PID) mixed
anaerobes
7.Inguinal LGV, Kit 7 T. Doxycycline 100mg bd for 14
swelling chancroid black days
T.Azithromycin1gm (1tab)
 NEW CDC GUIDELINES HAVE EMERGED FOR BOTH OP
AND IP REGIMENS CDC GUIDELINES (2021) : OP REGIMEN

CEFTRIAXONE 500mg IM single dose OR

CEFOXITIN 2gm IM single dose and

PROBENECID 1gm PO single dose OR

Single dose IV 3rd generation cephalosporin

(CEFTIZOXIME / CEFOTAXIME)

DOXYCYCLINE 100mg orally BD for 14 days with

METRONIDAZOLE 500mg orally BD for 14 days
If cephalosporin allergy

LEVOFLOXACIN 500mg orally once or

MOXIFLOXACIN 400mg orally once

METRONIDAZOLE 500mg orally BD for 14 days

AZITHROMYCIN 500mg IV OD (1-2 doses) f/b 250 mg orally OD

 CDC GUIDELINES – IN PATIENT
REGIMEN(2021)
CEFOXITIN 2g IV every 6 hours OR
CEFOTETAN 2g IV every 12 hours
+
T. DOXYCYCLINE 100mg IV or PO every 12 hours x 14 days

CEFTRIAXONE 1g IV every 24 hours

+
T. DOXYCYCLINE 100mg IV or PO every 12 hours x 14 days
+
T. METRONIDAZOLE 500mg IV or PO every 12 hours x 14 day

CLINDAMYCIN 900mg IV every 8th hourly

+
GENTAMYCIN :- Loading dose – 2 mg/kg IV
Maintanace dose - 1.5 mg/kg IV every 8th hrly

AMPICILLIN-SULBACTUM 3g IV every 6hrs

+
T.DOXYCYCLINE 100mg bd PO×14 days
 SUMMARY
PID is mainly caused by N.gonorrhoea and chlamydia
trachomatis followed by other aerobic and anaerobic
organisms
Acute or chronic PID cases are to be diagnosed and treated
promptly and completely to minimize complications and late
sequeles.
Triad of lower abdominal pain ,adnexal tenderness and
tender cervical movements are considered to be the most
important clinical features of acute PID.
Rx is according to the guide lines by the centers for disease
control.
Partner should be treated simultaneously.
Surgical Intervention is needed when there is pelvic abscess
or TO ovarian mass, adhesions--- intestinal
obstruction / general peritonitis.
Syndromic management facilitates HCW to start treatment
immediately instead of referring patient to higher center
which may not be affordable or easily accessible
THANK YOU