PELVIC INFLAMMATORY
DISEASE
Anand
ROLL NO 71
CONTENTS
● Introduction
● Epidemiology
● Aetiopathology
● Diagnosis
● Management
● Prevention
INTRODUCTION
● It is defined as infection of the uterus, fallopian
tubes and adjacent pelvic structures, not
associated with surgery or pregnancy.
● Usually ascending- endometritis, salpingitis,
tuboovarian abscess, pelvic peritonitis.
● Serious sequelae - tubal factor infertility,
ectopic gestation (preventable).
● PID is the preventable cause of infertility.
EPIDEMIOLOGY
● Iud increases risk in women with risk-taking sexual
behaviour.
● Barriers and oral contraception protects against PID.
● Vagina have acidic ph(lactobacilli), increased risk
immediately after menses (alkaline ph- blood)
● Risk factors are- young age, multiple sexual partners, recent
new sexual partner, substance abuse and smoking, lower
socioeconomic status, gonococcal and chlamydial cervicitis
and vaginitis, other STI, IUD insertion
AETIOPATHOLOGY
● Chlamydia trachomatis, Neisseria gonorrhea( most important
pathogens)
● Gardnerella, Mobiluncus, Mycoplasma (less common - bacterial
vaginosis )
● E.coli, group b streptococci, enterococci ( aerobic)
● Actinomyces (rare, associated with iud insertion)
● Tuberculosis(bloodstrem spread not ascending infection)
1. Ascending infection
2. Earliest manifestation = endometritis
3. In 1-10% case (Fitz-Hugh-Curtis syndrome / perihepatitis)
4. Clinical features
● Right upper quadrant pain, pleuritic pain, tenderness
● Mistaken for cholecystitis / pneumonia
● Perihepatic inflammation due to vascular or transperitoneal
dissemination of Neisserhia or Chlamydia
Route of transmission
1. Endocervix
2. Endometrium(endometritis)
3. Fallopian tube(endosalpingitis)
4. Tuboovarian abscess
5. General peritonitis
6. Pelvic abscess
DIAGNOSIS
-Symptoms
Silent PID (no symptoms, seen in Chlamydial infection, leads to tubal damage)
Active PID:-
● B/L lower abdominal pain(most common symptom)
● Abnormal vaginal discharge
● Menometrorrhagia
● Postcoital bleeding
● Fever
● Nausea
● Right upper quadrant pain in perihepatitis
Differential diagnosis
● Acute appendicitis
● Ectopic gestation
● Twisted ovarian cyst
● Septic abortion
Syndromic approach:
● Treatment based on signs and symptoms rather than laboratory tests.
● Increases diagnostic sensitivity, earlier treatment, reduce long term sequelae
like tubal factor infertility and ectopic.
● Specificity is low, may lead to unnecessary antimicrobial treatment.
● CDC recommends- empirical treatment for PID be intitiated in sexually active
young women and other women at risk for STD, if they experience pelvic or
lower abdominal pain, if no other cause can be identified and if one or more of
the minimum criteria specified below are present on pelvic examination.
● Additional criterias:
Other diagnostic modalities
LAPROSCOPY: golden standard, advantage- direct visualisation of fallopian tube and surrounding structures,
microbiological sampling from the fallopian tube, ovary or peritoneal fluid.
Rules out ectopic and acute appendicitis, surgical interventions also possible.
Findings :- peritubal and periovarian adhesions, fimbrial occlusion or phimosis, hydrosalpinx, pyosalpinx,
tubovarian disease, perihepatic adhesions(violin string appearance).
TVS WITH POWER DOPPLER
Distinguishing an adnexal mass ( patients who do not show a response to antimicrobial therapy)
Not very useful in mild or moderate PID
1. HYDROSALPINX: Clear adnexal cystic mass with incomplete sepatation, cog wheel sign, fluid in cul-de -
sac
2. TUBOOVARIAN mass also may be seen
3. COLOUR DOPPLER- hyperemia( a/c PID), low velocity flow, low pulasility indices are seen.
4. TVS+DOPPLER = useful in lower abdominal pain
MRI: not commonly used, equally or more accurate
than TVS.
● Tubal enlargement, fluid filled tubes, tuboovarian
abscess, free fluid in cul-de-sac visualised.
LABORATORY STUDIES
Isolation of concerned organism(diagnostic)
1. Neisseria gonorrhea :
Endocervical or urethral smear
Gram negative intracellular diplococci
Culture, DNA probes, enzyme immunoassay
possible
Chlamydia trachomatis:
cell culture ( historically gold standard )
Antigen tests and Elisa available
PCR and LCR -
have largely replaced cell culture.
First void urine PCR and LCR is highly effective in
detecting symptomatic and asymptomatic
infection.
Useful in screening also.
OTHERS:
Act as ancillary aids.
Also helps in assessment of severity and deciding
whether outpatient treatment will suffice.
They are ESR, C- reactive protein and total WBC
count.
Useful in combination, individually lack sensitivity
and specificity.
Test for infections like HIV and Syphilis is also
important.
MANAGEMENT
Broad spectrum regimen is recommended for the treatment( as it have complex and polymicrobial
aetiology).
It should include agents active against C.trachomatis, N.gonorrhea, all aerobic and anaerobic bacteria
commonly detected in the genital tractof women with PID.
CDC in 2006 published recommended traatment guidelines for inpatient and outpatient management of
a/c PID.
Updated in 2015 - do not support the use of quinolones.
Decision regarding inpatient or outaptient therapy taken based on clinical criteria.
All women after inititiation of therapy followed up at 48-72 hours to assess response.
If necessary hospitalisation is done.
Principles of management:
● Treatment of the acute infection and
symptoms
● Treatment of partner
● Follow up to prevent sequelae
● Counselling
● Family planning advice
Definite indication for hospitalisation:
● Surgical emergencies like appendicitis
● Pregnant patient
● Adolescents
● Do not respond clinically to oral antimicrobials
● Unable to follow or tolerate an outpatient
regimen
● Severe illness, high fever, nausea, vomiting
● Generalised peritonitis
● Tuboovarian abscess
Other measures:
● Male partner- should recieve prophylatic treatment
for chlamydial and gonococcal infection.
● Male partners should be counselled regarding
condom use to prevent further contact.
● PID patient and partner should be counselled
regarding HIV and STDs and should be offered
confidential HIV testing.
● If IUD present, it must be removed once treatment
starts
● Contraceptive counselling must be provided
Surgery in PID:
Ranges from laparoscopy to laprotomy.
Usually abscess drainage and irrigation done.
Drainage of abscess by colpotomy also done.
Indications for surgery:
● No response to treatment and worsening of
condition
● Ruptured tubooovarian abscess
● Drainage of a pelvic abscess
● Severe peritonitis
● Diagnosis is in doubt
Outcome of PID:
● Tubal factor infertility: main long term sequelae
After one episode of PID risk of 7%, on further
episodes risk doubles or triples.
Leading indication for IVF
● Ectopic gestation : Also a main sequelae.
Even without obvious tubal occlusin
endosalpingitis can
lead to ectopic gestation.
With a previous episode risk increases ten fold.
● Chronic PID
● Chronic pelvic pain
● Increased chance of hysterectomy later
PREVENTION
Primary:
● Life style counselling and health education.
● Risk factors should be evualated and risk taking sexual behaviour
assessed.
● Screening tests can be encouraged, male partners are to be evaluated and
treated and safe sex practices should be encouraged.
● Counselling should be given priority.
Secondary prevention:
● Screening for C.trachomatis - critical in
preventing PID in future.
● Screening test - PCR on first voided urine.
● It is the most effective method to prevent
PID.
Tertiary Prevention:
● Treatment of lower genital tract infection to
prevent tubal damage.
● Early diagnosis based upon syndromic
approach and prompt treatment is very
effective.
CHRONIC PID
Sequelae of a/c PID due to inadequate treatment.
It can result in tuboovarian adhesions, hydrosalpinx, pyosalpinx and tuboovarian masses.
Symptoms:
● Deep seated chronic pelvic pain
● Congestive dysmenorrhoea
● Deep dyspareunia
● Abnormal uterine bleeding
● Infertility
Differential diagnosis:
● Endometriosis
● Chronic ectopic gestation
Management:
Chiefly surgical.
In case of chronic pelvic pain- affected tube and
ovary have to be removed.
Sometimes in deblitating pain and badly
damaged adnexa- hysterectomy with b/l
salpingo oopherectomy indicated.
In case of infertility before IVF if a hydrosalpinx
visualised on ultrasound removed by laproscopy.
THANK YOU
