Welcome to

AHMEDs
presentation
 Pelvic inflammatory
disease
PID

Dr Ahmed Yousif Alobaid Mohammed,

MBBS, NRU batch16
Shendi Teaching Hospital, Obs & Gyne
department, Dr Jihan s Unit
 Case presentation:
A 25-year-old woman presents to ER with
a history of untreated lower abdominal
pain, fever and dysuria. Presents to ER
with a 4-day history of severe lower
abdominal pain, fever, and right upper
quadrant pain. On examination, she has
a temperature of 38.5°C, tachycardia,
and bilateral adnexal tenderness.
Transvaginal ultrasound shows a
complex right adnexal
laproscopy shows this
.
 Case presentation:
A 24-year-old woman presents with a 3-day history of lower
abdominal pain, fever, and purulent vaginal discharge. She
reports having multiple sexual partners and inconsistent condom
use. On examination, her temperature is 38.2°C, and there is
bilateral adnexal tenderness with cervical motion tenderness.
What is the most appropriate initial management?

A) Immediate laparoscopy
B) Empirical broad-spectrum antibiotics
C) Endocervical swabs for culture and await results
D) Pelvic ultrasound
E) Admission for intravenous antibiotics
 Case presentation:
A 28-year-old woman presents with a 4-day history of
severe lower abdominal pain, fever, and right upper
quadrant pain. On examination, she has a temperature of
38.5°C, tachycardia, and bilateral adnexal tenderness.
Transvaginal ultrasound shows a complex right adnexal
mass. What is the most likely diagnosis?
- A) Cholecystitis
- B) Appendicitis
- C) Fitz-Hugh-Curtis Syndrome
- D) Ovarian torsion
Introdution
Introdution:

 Infection of the female “upper genital tract”

 Uterus, fallopian tubes or ovaries
 is usually the result of infection ascending from
the endocervix causing endometritis, salpingitis,
parametritis, oophoritis, tubo-ovarian abscess
and/or pelvic peritonitis.
 Normal vaginal flora: many pathogenic bacteria
 Upper genital tract normally sterile
 Protected by cervical canal
 Disruption of barrier → ascending infection often
due to cervical infection
 Causative organisms:

Neisseria gonorrhoeae
Gram-negative diplococcus
Highly infectious, can cause acute PID
More common in severe cases with tubo-ovarian
abscesses
Less commonly in older women with PID
 Causative organisms:

 Chlamydia trachomatis
Obligate intracellular bacteria
Most common identified cause of PID (14-35% of cases)
Often causes subclinical or mild PID, leading to silent tubal
damage
Less commonly in older women with PID
Causative organisms:
 Mycoplasma genitalium
Emerging cause of PID
Associated with chronic, recurrent, or antibiotic-
resistant cases
Difficult to culture, requires nucleic acid amplification
testing (NAATs)
 Gardnerella vaginalis
Facultative anaerobe, associated with bacterial
vaginosis (BV)
Can ascend into the upper genital tract, contributing
to PID
Causative organisms:

 Anaerobes

(Prevotella, Atopobium,
Leptotrichia spp.)
Common in polymicrobial PID
More likely in post-abortion,
postpartum, or IUD-related PID
 Causative organisms:
 Pathogen-Negative PID
A significant proportion of PID cases (up to 70%)
have no detectable pathogen
 Possible explanations:
Low bacterial load or transient infections
Undetected fastidious organisms
Host immune response clearing pathogens before
detection
Risk Factors
 Sexual Behavior and STI-Related Factors
 Gynecological and Reproductive Factors
 Low socioeconomic status (limited access to
healthcare and STI screening)
 Smoking (reduces immune response in the
reproductive tract)
 Bacterial vaginosis (BV) (associated with
anaerobic overgrowth and increased PID risk)
 Immunosuppression (e.g., HIV, diabetes,
corticosteroid use
diagnosis
Diagnosis
Acute Symptoms:
 Bilaterallower abdominal pain (dull,
aching, or sharp).
 Abnormal vaginal discharge (purulent,
yellow-green, or bloody).
 Dyspareunia (pain during intercourse).
 Irregularvaginal bleeding (post-coital
or intermenstrual).
 Fever >38°C (if systemic).
 Dysuria (due to urethritis).
Diagnosis
 Chronic Symptoms (if
untreated):
Persistent pelvic pain.
Menstrual irregularities.
Infertility.
 Associated Symptoms:
Right upper quadrant pain (suggests Fitz-
Hugh-Curtis syndrome).
Nausea/vomiting (in severe cases).
Violin-string" adhesions of chronic Fitz-Hugh-Curtis
syndrome.
 Key Questions:
Sexual activity: Number of partners, use of condoms.
Past STIs or PID episodes.
Recent gynecological interventions (e.g., IUD
insertion).
Contraceptive use.
Examination
 General Examination:
 Vital Signs: Fever, tachycardia, hypotension (if
septic).
 General Appearance: Assess for distress or systemic
illness.
 Abdominal Examination:
 Lower abdominal tenderness.
 Rebound tenderness or guarding (suggests
peritonitis).
 Palpable masses (suggests tubo-ovarian abscess).
 Pelvic Examination:
 Speculum Examination:
 Cervical discharge: Mucopurulent, yellow-green.
 Cervical friability (bleeding on contact).
 Bimanual Examination:
 Cervical motion tenderness (chandelier sign).
 Uterine tenderness.
 Adnexal tenderness or fullness.
Investigations:
 Bedside Investigations:
Test (urine) : Rule out ectopic pregnancy.
Wet Mount Microscopy: Look for leukocytes and bacterial
vaginosis.
 Laboratory Investigations:
1. NAAT (Nucleic Acid Amplification Test):
Gold standard for detecting Chlamydia trachomatis and
Neisseria gonorrhoeae.
2. Complete Blood Count (CBC): Leukocytosis suggests
infection.
3. C-Reactive Protein (CRP)/ESR: Elevated in inflammatory
states.
4. STI Screening: HIV, syphilis, and hepatitis B/C.
5. High vaginal swap for culture and sensitivity
Imaging
 Pelvic Ultrasound:
Detect tubo-ovarian abscess or hydrosalpinx.
Evaluate for free pelvic fluid.
 CT and MRI :
For unclear diagnoses or complications.
 Invasive Diagnostic Tools:
 Laparoscopy:
Gold standard for direct visualization.
Used for refractory or severe cases
complicati
on
Complications:
Acute Complications (Short-Term)
 Infection spread Leads to inflammation and
adhesions (violin-string adhesions)
 Tubo-ovarian abscess(systemically unwell pt,
severe pelvic pain, palpation of an adnexal mass,
lack of response to therapy)
A pus-filled collection involving the fallopian tube
and ovary, Can rupture, leading to sepsis and
peritonitis.
Complications:
 Pelvic Peritonitis
Infection spreads to the peritoneum, causing
severe abdominal pain, guarding, and
rebound tenderness.
 Sepsis and Septic Shock
Occurs if the infection enters the bloodstream,
leading to multi-organ failure.
Chronic and Long-Term Complications

 Infertility : Up to 20% of women with PID develop

tubal factor infertility due to fallopian tube scarring and
obstruction.
 Ectopic Pregnancy : 6-10 times increased risk
due to tubal damage preventing normal embryo
implantation.
 Chronic Pelvic Pain : Adhesions and fibrosis
cause persistent lower abdominal pain in 18-30% of
cases.
 Dyspareunia (Painful Intercourse) Due to scarring
and adhesions in the pelvis.
 Fitz-Hugh Curtis syndrome: (right upper
quadrant pain, perihepatitis, especially by C.
trachomatis)
differential diagnosis:

 ectopic pregnancy – pregnancy should be

excluded in all women suspected of having PID
 acute appendicitis – nausea and vomiting
occurs in most patients with appendicitis but only 50%
of those with PID. Cervical movement pain will occur
in about a quarter of women with appendicitis29,30.
 endometriosis – the relationship between
symptoms and the menstrual cycle may be helpful in
establishing a diagnosis
 Cervicitis
 adnexal tumors
differential diagnosis:
Completed ovarian cyst e.g. torsion or
rupture – symptoms are often of sudden onset
UTI – often associated with dysuria and/or urinary
frequency
Irritable bowel syndrome – disturbance in
bowel habit and persistence of symptoms over a
prolonged time period are common.
Acute bowel infection or diverticular
disease can also cause lower abdominal pain
usually in association with other gastrointestinal
symptoms.
functional pain (pain of unknown aetiology) –
may be associated with longstanding symptoms
Treatment
Treatment:
 Outpatient Regimens:
IM ceftriaxone* 500mg single dose followed by oral
doxycycline 100mg twice daily plus
metronidazole 400mg twice daily for 14 days
*Clinical trial data support the use of cefoxitin but
not available
Oral ofloxacin 400mg twice daily plus oral
metronidazole 400mg twice daily for 14 days
Grade
( Metronidazole : for anaerobes, severe PID, may be
discontinued in mild or moderate PID if pt don’t
tolerate it.
Oral moxifloxacin 400mg once daily for 14 days
Treatment:
 Outpatient Regimens:
 Alternative Regimens
IM ceftriaxone 500 mg immediately, followed by
azithromycin 1 g/week for 2 weeks.
Treatment:
 Inpatient regimens:
 Indication of Admission
A surgical emergency cannot be excluded
lack of response to oral therapy
clinically severe disease presence of a tubo-
ovarian abscess
intolerance to oral therapy
pregnancy
Treatment:
 Inpatient Regimens:

I.v. ceftriaxone 2g daily plus i.v. doxycycline 100mg

twice daily (oral doxycycline may be used if tolerated)
followed by oral doxycycline 100mg twice daily plus oral
metronidazole 400mg twice daily for a total of 14 days

i.v. clindamycin 900mg 3 times daily plus i.v.

gentamicin (2mg/kg loading dose) followed by 1.5mg/kg
3 times daily [a single daily dose of 7mg/kg may be
substituted]) followed by either oral clindamycin 450mg
4 times daily or oral doxycycline 100mg twice daily plus
oral metronidazole 400mg twice daily to complete 14
days.
Treatment:

 Alternative Regimens
 Clinical trial evidence for the following regimens
is more limited but they may be used when the
treatments above are not appropriate e.g. allergy,
intolerance:
 i.v. ofloxacin 400mg BD plus i.v. metronidazole
500mg TID for 14 days.
 i.v. ciprofloxacin 200mg BD plus i.v. (or oral)
doxycycline 100mg BD plus i.v. metronidazole
500mg TID for 14 days.
 Pregnancy and
Breastfeeding
PID in pregnancy is uncommon but associated
with an increase in both maternal and fetal
morbidity,
 Should be considered taking into account local
antibiotic sensitivity patterns (e.g. i.v. Ceftriaxone,
i.v. erythromycin and i.v. metronidazole switching
to oral therapy following clinical response and
completing 2 weeks of treatment
 Use of the recommended antibiotic regimens
(listed above for non pregnant women) in very
early pregnancy (prior to a pregnancy test
becoming positive).
Treatment:
Surgical Management:
 laparoscopy ( adhesions and draining pelvic
abscesses, to assess and treat clinically
sever PID,adhesiolysis in cases of
perihepatitis )

 ultrasound guided aspiration of pelvic

fluid collections is less invasive and
may be equally effective
 Follow Up:

Review at 72 h(moderate or severe)

Failure to improve ( further investigation,
parenteral therapy and/or surgical intervention) .
If initial testing for
gonorrhoeae positive, (repeat routinely after 2 to
4 weeks) .
C. trachomatis positive (repeat after 3 to 5 weeks)
M. genitalium is positive: treatment with
moxifloxacin. Repeat testing,
Follow up
Follow Up:

 Further review ( 2-4 weeks after therapy is

recommended to ensure:
adequate clinical response to treatment
compliance with oral antibiotics
screening and treatment of sexual contacts
awareness of the significance of PID and its sequelae
repeat pregnancy test, if clinically indicated
Treatment of Sexual
Partners
Even if asymptomatic
Recommended Empiric Treatment for Male Partners
If gonorrhea is suspected or confirmed:
Ceftriaxone 500 mg IM (or 1g if ≥150 kg) + Doxycycline
100 mg PO BID for 7 days
If chlamydia-only PID is diagnosed (gonorrhea ruled out):
Doxycycline 100 mg PO BID for 7 days
Azithromycin 1g PO single dose (alternative if
doxycycline is contraindicated)
If Mycoplasma genitalium is suspected:
Moxifloxacin 400 mg PO daily for 7-14 days
Notification

 Who Needs to Be Notified?

All sexual partners in the past 6 months from
symptom onset ( BASHH guideline)
 Safe Sexual Practices:
Consistent and correct use of condoms during
sexual activity to reduce the risk of sexually
transmitted infections (STIs).
Limiting the number of sexual partners and
engaging in mutually monogamous
relationships.
Regular Screening and Early Detection:
Routine screening for STIs, especially in
sexually active individuals under 25 or
those with new or multiple partners.
Prompt treatment of identified STIs to prevent
the progression to PID.
 Partner Notification and Treatment:
all recent sexual partners of individuals diagnosed
with PID to prevent reinfection and further
transmission.
Avoidance of Risky Gynecological Procedures:
Maintaining strict aseptic techniques during
gynecological interventions to prevent
introducing infections.
Ensuring screening and treatment for STIs before
procedures like intrauterine device (IUD)
insertion.
Public Health Education:
For comprehensive guidance, please refer to the
BASHH guidelines on PID management.