PELVIC INFLAMMATORY DISEASE

DEFINITION

INFLAMTION OF UPPER GENITAL TRACT ENVOLVING with ascending infection from lower

genital tract including

endocervix

• Endometris
• Salpingitis
• Oophritis
• Parametritis
• Pelvic peritonitis

Introduction

Delays of only a few days in receiving appropriate treatment markedly increase the risk of sequelae, which include:

1. Infertility,
2. Ectopic pregnancy and
3. Chronic pelvic pain.

AETIOLOGY

While sexually transmitted infections such as :

1. Chlamydia trachomatis and
2. Neisseria gonorrhoeae have been identified as causative agents,
3. Mycoplasma genitalium,
4. Anaerobes and other organisms may also be implicated.

RISK FACTORS

1. Early age of sexual activity
2. Multiple sex partners
3. Sex workers
4. Use of immune suppressant drugs
5. Infection with HIV
6. Drug abuse
7. Alcoholics
8. Gynecological procedures like D/Cs

CLINICAL FEATURES

Symptoms

Pain lower abdomen bilateral

Fever (38.4)

Vaginal discharge

Dyspareunia

Menorrhagia

SIGNS

Increase temperature

Tachycardia

Abdominal tenderness/rebound tenderness

Abnormal discharge per vaginum

Fornicial tenderness

Cervical motion tenderness

INVESTIGATIONS

• Blood :- Hb,TCDC,ESR,Sugar,Urea, grRh,CRP
• Urine
• Endocervical Swab for Gm stain and culture, WBC count.
• Endometrial biopsy
• USG- Abdominal and vaginal
• Laparoscopy, peritoneal fluid culture (Gold standard)
• Laparotomy

CDC CRITERIA

Minimum

1. Cervical motion tenderness
2. Adnexal tenderness and uterine tenderness
3. WBCs on wet mount of discharge

Additional

1. Fever (> 38°4C)
2. Abnormal discharge
3. Raised ESR
4. C reactive protein
5. Culture positive swab

Definitive criteria

• Histopathologic evidence of endometritis on endometrial biopsy

• Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex

• Laparoscopic abnormalities consistent with PID

Classification

• Acute

• Chronic

Clinical diagnosis

Laparoscopy :

Enables specimens to be taken from the fallopian tubes and the pouch of Douglas and

Can provide information on the severity of the condition.

Although Laparoscopy has been considered the gold standard in many studies of treatment regimens, 15–30% of suspected cases may have no laparoscopic evidence of acute infection.

When there is diagnostic doubt, however, laparoscopy may be useful to exclude alternative pathologies.

Transvaginal ultrasound scanning may be helpful where there is diagnostic difficulty.

When supported by power Doppler it can identify inflamed and dilated tubes and tubo -ovarian masses, but there is insufficient evidence to support its routine use.

Laparoscopic view of normal pelvis

Oral treatment

Recommended Regimen A

Levofloxacin 500 mg orally once daily for 14 days* OR Ofloxacin 400 mg orally twice daily for 14 days* WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Regimen B

Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Oral Regimen B

Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

Inpatient treatment

Recommended Parenteral Regimen A

Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours

Alternative parental Inpatient regimens

Levofloxacin 500 mg IV once daily* WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours

OR Ofloxacin 400 mg IV every 12 hours* WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours

OR Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours

Inpatient treatment

Admission to hospital would be appropriate in the following circumstances:

1. Surgical emergency cannot be excluded
2. Clinically severe disease
3. Tuboovarian abscess
4. PID in pregnancy
5. Lack of response to oral therapy
6. Intolerance to oral therapy.

In more severe cases inpatient antibiotic treatment should be based on intravenous therapy, which should be continued until 24 hours after clinical improvement and followed by oral therapy.

Treatment in pregnancy

A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic pregnancy.

Treatment in a woman with an intrauterine contraceptive device

An intrauterine contraceptive device (IUCD) may be left in situ in women with clinically mild PID but should be removed in cases of severe disease.

Other modes of treatment

Surgical treatment should be considered in :

1. Severe cases or
2. Where there is clear evidence of a pelvic abscess.
3. Failure of medical treatment

Laparotomy/laparoscopy may help early resolution of the disease by division of adhesions and drainage of pelvic abscesses.

Culdotomy

Ultrasound-guided aspiration of pelvic fluid collections is less invasive and may be equally effective.

Management of sexual partners of women with PID, which may be sexually acquired

• If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empirical therapy for both gonorrhoea and chlamydia should be given.
• 
  
• Referral of the index patient and her partner to a genitourinary medicine clinic is recommended, to facilitate contact tracing and infection screening.

Women who are infected with HIV

Women with PID who are also infected with HIV should be treated with the same antibiotic regimens as women who are HIV negative.