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gynecological 3

Introduction to Pelvic Inflammatory Disease (PID)

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  • PID is defined as an infection of the upper female reproductive system, notably affecting the uterus, fallopian tubes, and ovaries.

  • PID can lead to serious complications, including infertility.

Anatomy of the Female Reproductive System

Internal Organs

  • Ovaries: The female gonads responsible for producing eggs and hormones.

  • Fallopian Tubes: Two muscular tubes connecting the ovaries to the uterus.

  • Uterus: A strong muscular sac where a fetus develops.

  • Cervix: The neck of the uterus that protrudes into the vagina.

External Organs

  • Vulva: Encompasses the external sex organs, including labia, clitoris, and mons pubis.

  • Urethra: Located at the opening of the vagina; it is important to note that this does not obstruct urinary flow even during menstrual hygiene management (e.g., using tampons).

Pathophysiology of PID

  • PID usually arises from a bacterial infection in the vagina or cervix, resulting in inflammation of the mucosal lining of the reproductive tract.

  • Approximately 60% of PID cases lead to a change in the vaginal bacterial flora, termed bacterial vaginosis.

  • The reproductive tract is described as a continuous pathway from the ovaries to the external genitalia, allowing infections to ascend easily.

  • Factors that facilitate this infection include:

    • Changes in cervical mucus that reduce its barrier function due to hormonal cycles or bacterial vaginosis.

    • Retrograde Menstruation: Menstrual blood flowing backward through the fallopian tubes into the pelvic cavity.

    • Sexual Intercourse: A potential route for introducing bacteria.

Complications of PID

Salpingitis

  • If PID extends to the fallopian tubes, it is classified as salpingitis.

Oophoritis

  • Involvement of the ovaries leads to salpingo-oophoritis.

Immune Response

  • The human body responds to PID with an influx of neutrophils, plasma cells, and lymphocytes, which can cause further damage:

    • Neutrophils, the most common type of leukocyte, contribute to inflammation and pus formation.

    • This pus accumulation can lead to blockages in the fallopian tubes when scar tissue forms, enhancing the risk of ectopic pregnancies.

Other Complications

  • Tubo-Ovarian Abscess: Pus accumulation can create life-threatening situations if ruptured.

  • Hydrosalpinx: Fluid-filled pockets from scar tissue can create swelling and complications.

  • Infertility & Chronic Pain: Scar tissue can hinder pregnancy and lead to chronic pelvic pain.

  • Fitzhugh-Curtis Syndrome: Inflammation can spread to the peritoneum and Glisson's capsule of the liver, leading to adhesion-like strings of scar tissue (violin string adhesions). Symptoms include right upper quadrant pain, attributed to liver involvement.

Risk Factors and Symptoms of PID

Most Common Pathogens

  • The primary bacterial pathogens associated with PID are:

    • Neisseria gonorrhoeae

    • Chlamydia trachomatis

  • Other bacteria may contribute in 30-40% of cases, leading to polymicrobial infections.

Transmission and Risk Factors

  • PID is commonly associated with sexually transmitted infections (STIs) such as gonorrhea and chlamydia.

  • Factors increasing risk include:

    • Multiple sexual partners and lack of condom use.

Symptomatology

Common Symptoms

  • Some individuals may be asymptomatic, but when symptoms occur, they typically include:

    • Pelvic Pain: Primarily in the lower abdomen.

    • Tenderness: Localized around the ovaries and fallopian tubes.

    • Fever: An important clinical indicator.

    • Abnormal Vaginal Discharge: Varying in nature, indicating inflammation.

    • Cervical Motion Tenderness: Pain upon movement of the cervix during examination, historically referred to as the "chandelier sign" due to the pain level encountered.

Other Symptoms

  • Possible bleeding and dysuria (though dysuria is not a classic symptom, it may occur if the urinary tract is affected).

Diagnosis of PID

  • Clinical Findings: The primary diagnosis is made based on the presentation of pelvic pain, tender cervical motion, and abnormal discharge.

  • Supporting Tests:

    • Testing vaginal discharge for bacterial vaginosis.

    • Nucleic Acid Amplification Tests (NAATs) to identify chlamydia and gonorrhea DNA.

    • Laparoscopy to visualize the fallopian tubes and assess for complications.

    • Ultrasound, particularly transvaginal ultrasound, to check for fluid or abscesses.

Treatment Strategies for PID

  • Antibiotic Treatment:

    • Initial treatment often includes injections of ceftriaxone or cefoxitin, followed by a fourteen-day course of oral doxycycline and metronidazole.

  • Pain Management: Acetaminophen can alleviate discomfort during treatment.

  • Surgical Intervention: Required in some cases to manage complicating factors like tubo-ovarian abscesses or persistent pain due to adhesions.

Recap of Key Findings

  • PID hallmark symptoms include:

    • Lower abdominal pain,

    • Fever,

    • Abnormal vaginal discharge,

    • Right upper quadrant pain indicating potential liver involvement due to Fitzhugh-Curtis syndrome.

  • Importance of managing risk factors to prevent the occurrence of PID and its associated complications, highlighting the correlation between untreated STIs and PID developments.

Understanding Associated Conditions

Ectopic Pregnancy and Ovarian Cysts

  • Differentiating PID from Ectopic Pregnancy:

    • Ectopic pregnancies will typically present with sudden severe pain and possibly shock symptoms.

    • PID generally presents with persistent symptoms related to inflammation, without the rapid onset of severe pain.

    • PID is associated with fever, cervical motion tenderness, and discharge, which are generally absent in ectopic pregnancies.

  • Ovarian Cysts:

    • Cysts may present with similar symptoms like abdominal pain, but often lack fever and tenderness on cervical motion.

Attention to Sexual Assault Situations

  • Recognizing that sexual assault occurs frequently in society.

  • When treating potential sexual assault victims, empathy and support are crucial in communication; acknowledging their trauma is important.

  • Documenting evidence accurately and sensitively is vital in any suspected sexual assault case, minimizing interference with potential evidence gathering.

Conclusion

  • PID is a significant condition with the potential for long-lasting consequences on a woman's reproductive health. Understanding its presentation, implications, and the interconnectedness of STIs is crucial for effective diagnosis and management. The information shared reinforces the essential nature of preventive measures and appropriate physician referrals when assessing symptoms of PID and associated reproductive health concerns.