Pelvic Inflammatory Disease (PID)

What is PID?

-an acute infection of the upper female genital tract, including the uterus, fallopian tubes, and ovaries

-infection and inflammation can spead to the abdomen, including perihepatic structures (Fitz-Hugh-Curtis syndrome)

-initiated by infection that ascends from the vagina and cervix

PID is most commonly caused by...

sexually transmitted agents like, Chlamydia trachomatis and Neisseria gonorrhoeae

______ women experience an episode of PID every year

>1 million

PID results in _____ million office visits and _____ hospitalizations yearly

~2.5, 125,000 - 150,000

Each woman with PID costs ~$_____ to treat, which can rise to $______ of she develops chronic pelvic pain

2,000, 6,000

Who is at THE MOST RISK for PID?

-women younger than 25 y/o who have multiple sex partners

-do not use contraception

-live in areas with a high prevalence of STDS

What is the GREATEST risk factor for PID?

prior history of PID

What is the 1st stage of PID?

acquisition of vaginal or cervical infection - often sexually transmitted and may be asymptomatic

What is the 2nd stage of PID?

direct ascent of microorganisms from the vagina or cervix to the upper genital tract with infection and inflammation of those structures

inflammation can spread to parametrial structures, including the bowel

Spread of the infection in PID is facilitated by...

spillage of purulent material from the fallopian tubes or via lymphatic spread which can lead to acute perionitis and perihepatitis (Fitz-Hugh-Curtis syndrome)

PID is rare in pregnancy because of the...

The mucous plug acts as a barrier between the uterus and bacteria; however, infection can occur in the first 12 weeks of gestation and fetal loss may result

Most common organisms that cause PID are...

1. Chlamydia trachomatis

2. Neisseria gonorrhoeae

Additionally, there are usually anaerobes, facultative anaerobes and other bacteria that cause inflammation

What are some risk factors for PID?

-multiple sex partners

-history of prior STDs

-age

How does contraception LOWER the risk of PID?

-barrier protection decreases the risk of acquiring most STDs

-OCPs may decrease the risk of symptomatic PID by increasing cervical mucus viscosity BUT this not proven

-current IUDs carry a much lower risk of PID then older IUDs - the most significant risk within the first month after insertion

Signs and symptoms of PID

-clinical diagnosis of PID is imprecise

-lower abdominal pain - usually bilateral and worsened during sex or with sudden movement

-abnormal uterine bleeding occurs in 1/3 or more of patients with PID

-new vaginal discharge, urtheritis, proctitis (inflammation around anus), fever, and chills can be associated signs

What can you see on PE with someone with PID?

-vitals = only about 1/2 of patients have a fever

-abdomen = diffuse lower abdominal tenderness, rebound tenderness and decreased bowel sounds

-pelvic = purulent endocervical discharge and /or cervical motion tenderness and adnexal tenderness

Different differential diagnoses similar to PID

-ectopic pregnancy = CT, US

-ovarian torsion = CT, US

-appendicitis = CT, US

-cervicitis

-UTI = urinalysis

-endometriosis = CT, US

-adnexal tumors/ovarian cysts = CT, US

What are the suggested labs for diagnosing PID?

-pregnancy test

-CBC

-urinalysis

-microscopic exam of vaginal discharge

-nucleic acid amplification tests for C. trachomatis and N. gonorrhoeae

-C-reactive protein

-HIV testing, syphilis testing

What are the NECESSARY criteria for diagnosing PID?

1. Lower abdominal pain or pelvic pain

2. Adnexal tenderness

3. Cervical motion tenderness

What are the ADDITIONAL criteria for diagnosing PID?

1. Temperature > 101 F (>38 C)

2. Abnormal cervical or vaginal mucopurulent

3. WBC > 10,000

4. Elevated ESR or CRP (c-reactive protein)

5. Laboratory evidence of cervical infection with C. trachomatis and N. gonorrhoeae via culture or DNA probe

6. Imaging that shows thickened fluid-filled tubes/oviducts with or without free pelvic fluid or tuboovarian complex

What are some ultrasound findings when a patient has PID?

-bulky uterus with fluid-distended endometrial cavity = endometrium appears thickened and hyperechoic

-'Cogwheel' sign

What is 'Cogwheel sign'?

refers to thickening loops of the fallopian tube seen on cross-section on an ultrasound

In order to make a definitive diagnosis of PID you need to perform a...

laparoscopy

What are some laprascopic findings consistent with PID?

-tubal erythema

-edema

-adhesions

-purulent exudate or cul-de-sac fluid

Treatment of PID addresses..

-the relief of acute symptoms

-eradication of chronic infection

-minimization of the risk of long-term sequelae

Long-term sequelae of PID include:

-chronic pelvic pain

-ectopic pregnancy

-infertility

-implantation failure with in vitro fertilization attempta

Therapy with antibiotics alone for PID is successful in _______ of cases

33-75%

If surgical treatment is warranted, conservation of reproductive organs is favored by performing...

-simple drainage

-adhesiolysis

-copious irrigation

-unilateral adnexectomy

Insufficient evidence to recommend removal of...

IUDs in women diagnosed with PID; however, they should be closely monitored

Antibiotic therapy should be initiated quickly if suspicious of PID and should include...

empirical broad-spectrum antibiotics

All regimens of antibiotics must be effective against...

C. trachomatis and N. gonorrhoeae, as well as against GRAM-NEGATIVE facultative organisms, anaerobes, and streptococci

Hospitilizations should be considered for patients with the following:

1. Uncertain diagnosis

2. Pelvic abscess

3. Pregnancy

4. Inability to tolerate PO antibiotics

5. Severe illness

6. Immunodeficiency (HIV with low CD4 counts)

7. IUD

8. Low likelihood of compliance with outpatient regimen

9. Failure to improve clinically after 72 hours of outpatient therapy

Most COMMON treatment for INPATIENT treatment of PID

1. Cefoxitin 2g IV q6hrs OR cefotetan 2g IV q12hrs (covers gonorrhea) PLUS

2. Doxycycline 100mg PO or IV q12hrs (covers chlamydia)

Second treatment for INPATIENT treatment of PID

1. Clindamycin 900 mg IV q8hrs PLUS

2. Gentamicin IV in a loading dose of 2mg/kg, followed by a maintenance dose of 1.5mg/kg q8hrs IV or IM

Usually for those with a penicillin allergy to the other treatment

IV therapy may be discontinued after ______ hours after the patient improves clinically

24

improving clinically can be a decrease in inflammation or decrease in WBC count

Oral therapy with 100 mg Doxycycline should be continued for a total of ____ days after being discharged from the hospital

14

What is regimen A for OUTPATIENT treatment of PID?

1. Ceftriaxone 500mg IM PLUS

2. Doxycycline 100mg PO BID x14 days

3. Metronidazole 500mg PO BID x14 days CAN be added if suspicion of vaginitis

What is regimen B for OUTPATIENT treatment of PID?

1. Cefoxitin 2 g IM and Probenecid 1g PO (prolongs half-like of ABX - usually for immunocompromised) PLUS

2. Doxycycline 100mg PO BID x 14 days

3. Metronidazole 500mg PO BIX x14 days can be added if suspicion of vaginitis

How should you follow up with a patient that you diagnosed and treated with PID?

-re-evaluates patients 48-72 hours after starting antibiotic therapy

-patients who do NOT improve in 72 hours should be re-evaluated for possible laparoscopic or surgical intervention

-patients should follow up 3-4 weeks after receiving treatment to receive a pelvic exam, STD and HIV prevention counseling, and contraceptive counseling

-anyone who has had sexual contact with a woman with PID in the 60 days preceding the onset of symptoms should be treated empirically for C. trachomatis and N. gonorrhoeae

What do you suggests to your patients to help them prevent PID?

-improved education, routine screening, diagnosis, and empirical treatment

-education should focus on strategies to prevent PID and STDs, including:

-reducing the number of sexual partners

-avoiding unsafe sexual practices

-using appropriate barrier protection

What are some COMPLICATIONS of PID?

-Tubo-ovarian abscess

-Fitz-Hugh-Curtis syndrome

-Infertility

-Ectopic pregnancy

-Chronic pelvic pain

-Endometritis

What is a tubo-ovarian abscess (TOA)?

an inflammatory mass involving the fallopian tube, ovary, and sometimes adjacent pelvic organs (bladder, bowel, etc.)

serious and potentially life-threatening condition- rupture of an abscess can result in SEPSIS

What are the signs and symptoms of TOA?

-acute lower abdominal pain

-+/- fever

-chills

-vaginal discharge

The most useful and commonly performed study to assess for TOA are...

pelvic ultrasound and pelvic CT

The evaluation of a woman with suspected TOA includes...

making the diagnosis of PID

then pursuing further testing to evaluate for TOA

What are the ultrasound findings of TOA?

transvaginal US image of left adnexa shows the tubo-ovarian abscess is seen as a complex cyst (large arrow) and fluid-filled tube (short arrow)

CT findings of TOA

A definitive diagnosis of TOA can ONLY be made with...

direct visualization of the abscess during an invasive surgical procedure such as laparoscopy or laparotomy

How do you treat TOA?

-hospitalization is recommended

-most women can be treated with IV broad-spectrum antibiotics alone

-removal of the IUD is indicated

-if, after 48-72 hours of treatment with antibiotics alone, a patient does not respond or worsens, surgical intervention is required

What is REGIMEN A for the treatment of TOA?

1) Cefoxitin 2g IV q6hrs OR Cefotetan 2g IV q12hrs PLUS

2) Doxycycline 100mg PO or IV q12hrs

What is REGIMEN B for the treatment of TOA?

1) Clindamycin 900mg IV q8hrs PLUS

2) Gentamicin IV in a loading dose of 2mg/kg, followed by a maintenance dose of 1.5mg/kg q8hrs IV or IM

What should the patient be given after being discharged with TOA?

oral therapy with 100mg Doxycycline BID should be continued for a total of 14 days

Surgical options for TOA include:

1) Minimally invasive abscess drainage with US or CT guidance

2) Open or laparoscopic with conservation of fertility if possible; however, total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) may be indicated if large infection

What does TAH-BSO stand for?

total abdominal hysterectomy and bilateral salpingo-oophorectomy

What is Fitz-Hugh-Curtis syndrome?

-caused by spread of C. trachomatis and N. gonorrhea

-infection of the liver capsule and peritoneal surfaces of the right upper quadrant of the abdomen causing "VIOLIN STRING" adhesions

What symptoms does a patient usually present with Fitz-Hugh-Curtis syndrome?

-severe right upper quadrant pain with a pleuritic component

-pain sometimes radiates to the right shoulder and can be confused for cholecystitis

Both symptomatic and asymptomatic PID can cause permanent injury to the...

the fallopian tube, which can lead to infertility

Tubal damage caused by PID also increases the risk of...

ectopic pregnancy because the egg can't roll down to the uterus

What is chronic pelvic pain?

menstrual or non-menstrual pain of at least 6 months duration that occurs below the umbilicus and is severe enough to cause functional disability

What causes chronic pelvic pain?

-while exact etiology is unknown, the pain most likely results from scarring and adhesions that develop from inflammation during PID

-adhesions never go away

What is endometritis?

inflammation and infection of the endometrium (lining of the uterus)

Women with PID are _______ more likely to have a diagnosis of endometritis than healthy controls

6-10x