Dr.
Tahamina Khanum
Associate prof. gynae and obs
EMCH
Pelvic Inflammatory disease
Definition : PID is a clinical syndrome associated with ascending spread
of microorganism from the vagina or cervix to the endometrium,
fallopian tubes and or contagious structures not associated with
pregnancy or surgery.
Risk factors of PID :
• Menstruating teenagers
• Multiple sexual partners.
• Absence of contraceptive pill use.
• Previous history of acute PID
• IUD users
• Area with high prevalence of sexually transmitted diseases.
Causative organisms
Acute PID is usually a polymicrobial infection caused by organisms ascending
upstairs from downstairs.
The primary organisms are sexually transmitted and limited approximately to
N.gonorrhoeae in 30 percent, Chlamydia trachomatis in 30 percent and
Mycoplasma hominis in 10 percent.
The secondary organisms normally found in the vagina are almost always
associated sooner or later. These are :
Aerobic organisms – non-haemolytic streptococcus
E.coli, group B streptococcus and staphylococcus.
Anaerobic organisms – Bacteroids species fragilis and bivius,
pepstreptococcus and peptococcus.
Mode of affections
• The classic concept is that the gonococcus ascends up to affect the tubes
through mucosal continuity and contiguity. However, ascent of the
bacteria from lower to upper genital tract is facilitated by the sexually
transmitted vectors such as sperm and trichomonads.
• Reflux of menstrual blood along with gonococci into the fallopian tubes
may be the other possibility.
• Mycoplasma hominis probably spreads across the parametrium to affect
the tube.
• The secondary to organisms probably affect the tube through lymphatics.
• Rarely, organisms from the gut may affect tube directly.
Pathology :
The involvement of the tube is almost always bilateral and usua;;y
following mens due to loss of genital defence.
The pathological process is initiated primarily in the endosalpinx. There
is gross destruction of the epithelial cells, cilia and microvilli. In severe
infection, it invades all the layers of the tube and produces acute
inflammatory reaction ; becomes oedematous and hyperaemic. The
exfoliated cells along with extudate pour into the lumen of the tube
and agglutinate the mucosal folds. The abdominal ostium is closed by
the indrawing of the oedematous fimbriae and by the inflammatory
adhesions. The uterine end is closed by congestion.
The closure of both the ostia results in pent up of the exudate inside
the tube. Depending upon the virulence, the exudate may be watery
producing hydrosalpinx or purulent producing pyosalpinx. The purylent
exudate then changes the microenvironment of the tube which favours
the growth of other pyogenic and anaerobic organisms resulting in
deeper penetration and more tissue destruction. The organisms
spontaneously die within 2-3 weeks. As the serious coat is not much
affected, the resulting adhesions of the tube with the surrounding structures
are not dense, in fact flimsy , unlike pyogenic or tubercular infection.
Clinical features
Symptoms :
Patients with acute PID present with a wide range of non-specific clinical
symptoms. Symptoms usually appear at and immediately following the mens.
• Bilateral lower abdominal and pelvic pain which is dull in nature. The onset
of pain is more rapid and acute in gonococcal infection (3 days) than in
chlamydial infection (5-7 days).
• There is fever, lassitude and headache.
• Irregular and excessive vaginal bleeding is usually due to associated
endometritis.
• Abnormal vaginal discharge which becomes purulent and or copious.
• Nausea and vomiting.
• Dyspareunia
• Pain and discomfort in the right hypochondrium due to concomitant
perihepatitis (Fitz Hugh Curtis syndrome) may occur in 5-10 percent of cases
of acute salpingitis. The liver is involved due to transperitoneal, or vascular
dissemination of either gonococcal or chlamydial infection.
Signs :
• The temperature is elevated to beyond 38.3 degree c.
• Abdominal palpation reveals tenderness on both the quadrants of lower
abdomen. The liver may be enlarged and tender.
• Vaginal examination reveals –
(1) Abnormal vaginal discharge which may be of purulent.
(2) Congested external urethral meatus or openings of Bartholin’s ducts
through which pus may be seen escaping out on pressure
(3) Speculum examination shows congested cervix with purulent discharge
from the canal.
(4) Bimanual examination reveals bilateral tenderness on fornix
palpation, which increases more with movement of the cervix. There
may be thickening or a definite mass felt through the fornices.
Investigations :
1. USG of the lower abdomen.
2. Urine R/E, C/S
3. HVS
4. CBC
5. Laparoscopy
Treatment :
Preventive treatment –
• Community based approach to increase public health awareness.
• Prevention of sexually transmitted diseases with the knowledge of
healthy and safer sex.
• Liberal use of contraceptives
• Routine screening of high-risk population
Principles of therapy are :
• To control the infection energetically
• To prevent infertility and late sequelae.
• To prevent reinfection by contract tressing and treatment
Out patient therapy :
• Analgesic
• Antibiotic – Doxycycline, Erethromycin, Tetracycline
• Metronidazole
• Cefroaxone
• Ciprofloxacin
In patient therapy :
Indications of in patient therapy
• Suspected pelvic abscess
• Severe illness, temperature > 38 degree C.
• Uncertain , diagnosis – where surgical emergencies , e,g,ectopic pregnancy cannot be
excluded.
• Unresponsive to out-patient therapy for 48 hours
• Intolerance to oral antibiotics.
• Co-existing pregnancy
In patient therapy
• Hospitalization
• Bed rest
• Analgesi
• Restrite oral feeding
• Intravenous fluid to correct dehydration , acidosis
• NG- suction – abd distention ileus
• Anti pyretic
• Intravenous antibiotic according to CDC
1. Doxy 100mg IV plus – cefoxitin 2 gm IV 4 times daily for at least 24 hours. Then orally plus metro
2. Clindamycin 900mg IV 3 times daily plus Gentemycin 2 mg per kg IV then 1.5 mg per kg IV 8 hourly, then
Doxy 100 mg oral b.d for 14 days. Clindamycin 450 mg 6 hourly for 14 days.
Indecations of surgery
• Generalised peritonitis
• Pelvic abscess
• Tubo-ovarian abcess which does not respond (48-72 hours) to antimicrobial therapy
Complications
Immediate :
1. Pelvic peritonitis or even generalized peritonitis.
2. Septicaemia – prodicing arthritis or myocarditis
Late :
3. Dyspareunia
4. Infertility rate is 12 percentm after two episodes increases 25 percent and
after three raises to 50 percent. It is due to tubal damage or tubo-ovarian
mass
5. Chronic pelvic inflammation is due to recurrent or associated pyogenic
infections
6. Formation of adhesions or hydrossalpinx or pyosalpinx and tubo-ovarian
abscess.
7. Chronic penvic pain and ill health.
8. Increased risk of ectopic pregnancy (6-10 fold).
Thanks
