PELVIC INFLAMMATORY DISEASE

1. Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. PID is the most important infection in gynecologic
practice
Incidence: decreased in developed countries, still
high in developing countries
Diagnosis: difficult
Complications: serious
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3. Infection of the upper genital tract i.e above the cervix
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4. 1.Acute
A. Primary (STD, no precipitating cause)
B. Secondary (to precipitating cause;IUCD,abortion or infection
elsewhere in the body; appendicitis)
2. Recurrent acute
After the first episode, due to exogenous organism (STD) or
endogenous organism due to decrease host defense
3. Chronic
Misnomer {chronic problems associated with PID (hydrosalpinx &
adhesions) are bacteriologically sterile}.
The true chronic PID are TB & actinomycosis
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5. US: 15%
Developed countries: recently decrease due to:
1. Awareness of C. trachomatis & AIDS.
2. Precautions to avoid STD.
Developing countries: No decrease
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6. 1. Age: teenagers
2.Sexual activity:
STD, increse with multiple sexual partners & increased
frequency
(Lee et al,1991)
3. Husband:
Gon., Chlamydia urethritis is an important source of PID
4. Menstrual periods:
2/3 postmenstrual {shedding of the endometrium, retrograde
menstruation}
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7. 5. Iatrogenic:
IUCD (the first 4 mo), HSG, D&C, elective abortion,
laparoscopy & dye test, hysteroscopy, douching
(Scholes et al,1993)
6. Previous PID
(Hills et al,1997)
7. Bacterial vaginosis: change in cervical mucous
leading to ascend of pathogenic bacteria
(Peipert et al,1997)
8. Smooking: by changing cervical mucous
(Scholes et al,1993)
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8. 1. Age:
>45 yr.rarely develop PID
2. Pregnancy:
>10 w (membranes seal the uterus & the tubes)
3. Tubal sterilization:
4. OCP:
not for CT & if PID occur it well be mild (increased
density of cervical mucous & decrease menstrual
bleeding)
5. Barrier contraceptives: diagram, condom, foamABOUBAKR ELNASHAR

9. The oral contraceptive pill& PID
Women taking the oral contraceptive pill who present with
should be screened for genital tract infection, especially C.
trachomatis.
The use of the combined oral contraceptive pill has usually
been regarded as protective against symptomatic PID.
Retrospective case–control and prospective studies have,
however, shown an
association with an increased incidence of asymptomatic
cervical infection with C. trachomatis.
This has led to the suggestion that the oral contraception may
mask endometritis. Women using the oral contraceptive pill
should be warned that its effectiveness may be reduced when
taking antibiotic therapy.
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10. Polymicrobial
1.C. T:
30-60%. The commonest STD. It is obligate
intracellular organism
2.N. gon:
15-20%. CT & N Gon often are found together in
patients with PID. Gram –ve diplococci.
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11. 3. Endogenous aerobes:
E. coli, proteus, Klebsiella & streptoc
4.Endogenous anaerobes:
60% : bacteroids, p. strep c., pepto c (older recurrent
, long standing).
5.Mycoplasma: 10-15% (parametritis)
6.Actinmycosis (IUCD, unilateral)
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12. I. Ascending:
Common
from the lower genital tract
Through: sperm, TV
Along surfaces or lymphatics in parametrium
II. Lateral:
Rare
from infected appendix
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13. No S or S are path gnomonic of PID
(Tuomala & Chen,1999).
CT as well as Gon may be found in asymptomatic
women. Cases of silent PID now outnumber
clinically apparent cases by a ratio of 3:1
(Hare & Foster,1995)
Clinical diagnosis is difficult: non specific
symptoms, exaggerated, sexual history may be
ignored
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14. 1. Pelvic pain: 95% . The commonest & bilateral
2. Cervical movement tenderness: 90%
3. Abdominal tenderness: 90%
4. Purulent cervical discharge: 50%
5. T> 38C: 30% (Gon or anerobe > CT)
6. A.U.bleeding: 35%
7. Dysuria: 20%
8. Nausea & vomiting: late (early in appendicitis)
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15. 1. Pregnancy test: in all cases
2. ESR:
>15 mm/h (75%), not specific
if >40 mm/h: severe PID
3. CRP (Acute phase protein):
75%, >60 mg/L: severe PID
4. Leucocytosis: >10.000 (50%)
5. Genital tract isoamylase: decrease
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16. 6.Pap. Smear:
Ch Tr., not sensitive, IC inclusion bodies
7. Gr stained smear: N. Gon, Gram –ve diplococci
8.Endocervical scrap: Monoclonal I. F stains: Ch. Tr
or ELISA for antigens of CT
9. Transcervical endometrial sampling: microbiology,
histopathology: plasma cell endometritis)
10. Wet mount:
WBC are present in lower genital tract discharge of all women
with PID. Increased WBC in vaginal discharge is the most
sensitive test for PID & serum WBC is the most specific
(Peipert et al,1996)
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17. Indications:
1. Pelvic mass 2. Suspicion of ectopic
3. Failure of T.T 4. Recurrent PID
Contraindication:
1. Large pelvic mass
2. Adhesions
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18. Advantages:
1. Confirm diagnosis (65%), no pathology (23%) &
other pathology (12%)
2. Culture
3. Grading (Soper,1991):
Mild:
erythema, edema, exudates, tubes are patent &
mobile,
Moderate: purulent discharge & fixed tubes
Severe: TO abscess, pyosalpinx
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19. Purulent discharge
Culture: poor correlation
Contraindicated: mass in cul de sac
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20. Indication: all cases
Value: define adenxal mass,
differentiate between adenxal mass & TO abscess,
exclude IU or ectopic pregnancy,
follow up
TVS:
1. Features of PID: Tubes: Thickened(>5mm) fluid filled in 85%.
Ovaries: Polycystic like, Cog-wheel sign
D pouch: free fluid, incomplete septa (Molander et al,2001)
2. Aspiration of TOA with 16 gauge needle as used in ovum retrieval
3. Follow up
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21. Indication: Not a routine,
Extreme tenderness,
No response to T.T
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22. Abdominal pain & tenderness,
Cervical movement tenderness &
Adenxal tenderness + 1 or more of the following
T.> 38 C,
Leucocytosis > 10000,
ESR > 15 mm/h,
Gram –ve intracellular diplcocci,
6 WBC/HPF,
I.F. stain: Ch tr,
U/S: adenxal mass,
culdocentesis: purulent discharge (Hager et al,1983)ABOUBAKR ELNASHAR

23. 1. Ectopic pregnancy
2. Complicated ovarian cyst
3. Endometriosis
4. Septic abortion
5. UTI
6. Acute appendicitis
7. Acute cholycystitis
8. Inflammatory bowel disease
9. Mesenteric lymphadenitisABOUBAKR ELNASHAR

24. Indication: mild PID
(CDC,1998)
Regimen A: Ofloxacin 400 mg po bid X 14 d
plus metronidazole 500 mg po bid for 14 d
Regimen B: Ceftriaxone (Fortum,Rocephin, Cefotrex)
250 mg IM OR Cefoxitin 2 gm plus probencid 1
gm po. PLUS doxycyclin 100 mg po bid for 14 d
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25. Treatment of CT:
Single dose azithromycin (1 gm) & 7 d doxycyclin
have comparable cure rate & side effects
(Martin et al, 1992)
Actinomycosis
sensitive to doxycyclin, penicillin, & cephalosporin
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26. IUCD may be left in situ in women with clinically mild
PID but should be removed in cases of severe
disease.
RCOG, 2003
An IUCD only increases the risk of developing PID
in the first few weeks after insertion.
A single small randomised controlled trial suggests
that removing an IUCD does not affect the response
to treatment but the study has suboptimal outcome
measures. An observational study also showed no
benefit in removing an IUCD in this situation.
ABOUBAKR ELNASHAR

27. Indication:
T > 38 C,
Nausea & vomiting,
Signs of peritoneal irritation,
? pelvic or Tubo-ovarian abscess,
? ectopic preg or appendicitis,
IUCD,
Adolescents,
No follow-up,
Failure of out-patient T.T
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28. General:
Fowler position,
Fluids, light diet,
Analgesics, antipyretics,
Removal of IUCD (resolution of the disease may be
slower & less complete) & examination for
actinomycosis & culture
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29. Antibiotics
Combined regimen, covers the 3 major pathogens
Success rate: 85-95%
Failure of improvement:
Tubo-ovarian or pelvic abscess,
Anaerobic infection, Penicillinase producing. N.
gon.,
Recurrent long standing PID.
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30. Treatment of Chlamydia tachomatis (CDC,1998)
Non-pregnant
Azithromycin 1gm PO X 1 dose or
Doxycycline 100 mg PO BID X 7d or
Erythromycin base 500 mg PO QID 7 d or
Erythromycin ethylsuccinate 800 mg PO QID X 7d
or
Ofloxacin 300 mg PO BID X 7 d
Pregnant
Erythromycin base 500 mg PO QID X 7 d or
Amoxacillin 500 mg PO TID X 7 dABOUBAKR ELNASHAR

31. Antibiotics for Gonorrhea (CDC 1998)
Uncomplicated uretheral, cervical or rectal infection
Cefixime 400 mg PO X 1 dose or
Ceftriaxone 125 mg IM X 1 dose or
Ciprofloxacin 500 mg PO x 1 dose or
Ofloxacin 400 mg PO X 1 dose
All single dose regimen should be followed with
azithromycin 1gm PO X 1 dose or doxycyclin 100 mg
PO BID X 7 d to cover possible concomitant infection
with CT
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32. Antibiotic combinations (CDC,1998)
A.Uncomplicated acute PID
Cefotetan 2gm IV q12 h or cefoxitin 2gm IV q6h
PLUS doxycyclin 100 mg IV or po q 12 h.
Oral therapy may be started 24 h after signs of
clinical improvement & continued for a total of 14 d.
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33. B.Complicated PID (TOA or inflammatory complex)
Clindamycin 900 mg IV q 8 h plus gentamycin
loading dose of 2 mg /k IV or IM followed by 1.5 mg/k
q 8 h. parentral therapy for at least 4 d.
Subsequent oral therapy of clindamycin 450 mg or
doxycyclin 100 mg bid for a total of 14 d
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34. Indication:
1. Uncertain diagnosis
2. Multiple recurrent PID
3. Tubo-ovarian abscess
(persistent fever, leucocytosis, Increased ESR,
Increased size)
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35. Lines:
1. Drainage:
posterior colpotomy or percutaneous
2. Laparotomy:
unilateral salpingo-ovarectomy (fertility is required)
or
total abdominal hysterectomy & bilateral salingo-
ovarectomy (fertility is not required)
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36. Management of tubo-ovarian abscess
? Ruptured Otherwise
Surgery after antibiotic Antibiotic for 48-72 h
No response Response*
Drainage laparotomy
Posterior-colpotomy percutaneous USO TAH + BSO
*75-80% respond to antibiotics. Most TOA <8cm respond (Reed et al,1991)ABOUBAKR ELNASHAR

37. Other modes of treatment
Surgical treatment should be considered in severe
cases or where there is clear evidence of a pelvic
abscess.
Laparotomy/laparoscopy may help early resolution of
the disease by division of adhesions and drainage of
pelvic abscesses.
Ultrasound-guided aspiration of pelvic fluid
collections is less invasive and may be equally
effective.
It is also possible to perform adhesiolysis in cases of
perihepatitis although there is no evidence as to
whether this is superior to antibiotic therapy alone.
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38. To exclude development of adenxal mass,
Adenxal mass: follow-up until disappear,
Adenxal mass persist: laparoscopy
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39. 1. Recurrent PID: 25%
2. Infertility: 1: 12%, 2: 35%, 3: 75%, TOA: 85%
3. Ectopic pregnancy: 50% of ectopic
4. Chronic pelvic pain & dysparunia: increase 4 fold
5. Mortality: rare
6. Preterm labor: 40%
7. Increased incidence of CIN
(Wilson et al,1990)
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40. 1. Screening & treating asymptomatic females at risk
for CT (young, ectopy,purulent cervical discharge
multiple sexual partners)
2. Doxycyclin 200 mg or azithromycin 500 mg at
insertion of IUCD
(Sinei et al, 1999). Little benefit (Cochrane library,2002)
3. Routine antibiotic prophylaxis before surgical
evacuation of incomplete abortion, No difference in
postabortal infection
(Cochrane libarary,2002)
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41. 4.Treatment of symptomatic & asymptomatic sexual
partners. No sexual intercourse until the husband is
checked & treated
5. Assessment of the partner for CT & Gon
6.Women diagnosed as PID should be evaluated for
other types of STD
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42. 1. PID is the most important infection in gynecology
2. PID is preventable disease & safe sexual practice
can decrease its incidence
3. Accurate diagnosis, appropriate treatment & close
follow-up are required to prevent its serious
complications
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43. ABOUBAKR ELNASHAR