by MAGAJA DICKSON MBCHB KAMPALA INTERNATIONAL UNIVERSITY

1. SCHISTOSOMIASIS
BY
MAGAJA DICKSON
6/28/2019for more info inbox magajadickson@gmail.com
1
PELVIC INFLAMMATORY
DISEASE
BY
MAGAJA DICKSON
MBchB V

2. OUTLINE
1. Define PID
2. Outline aetiology of PID
3. Describe the protective and risk factors of PID
4. Describe the epidemiology of PID
5. Defense mechanism of female genital tract
6. Describe the pathogenesis of PID.
7. Discuss the clinical manifestations of PID.
8. Describe the investigations of PID.
9. Diagnosis and ddx of PID
10. treatment regimens for PID.
11. Describe complications/sequelae of PID
12. Patient counseling/prevention
13. Follow up of PID patients
14. Describe Prognosis of PID

3. Definition
 Clinical syndrome associated with ascending spread of
microorganisms from the vagina or cervix to the
endometrium, fallopian tubes, ovaries, and pelvic
peritoneum (i.e. Genital tract infection above the level of
the cervical internal os ).
 Comprises a spectrum of inflammatory disorders including
any combination of endometritis, salpingitis, Tubo-ovarian
abscess, and pelvic peritonitis.

4. Aetiology: routes of infection
 Routes of infection:
1. Ascending sexually acquired infection (90%)
2. Child birth/ instrumentation
3. Intra peritoneal spread(e.g. appendicitis)
4. Haematogenous spread (e.g. Tuberculosis)
5. Lymphatic dissemination (puerperal infection)-
may be complicated by opportunistic bacteria.

5. Aetiology: Organisms
Often polymicrobial
 Chlamydial trachomatis (50-65%),
 Gonococcal infection (15- 30 %),
 Staphylococcus,
 Escherichia coli,
 streptococcus faecalis.

6. Risk Factors
 Adolescence
 History of PID
 Gonorrhea or chlamydia, or a history of gonorrhea
or chlamydia.
 Male partners with gonorrhoea or chlamydia
 Multiple sexual partners
 recurrent douching
 Insertion of IUD
 Bacterial vaginosis
 Oral contraceptive use (in some cases)
 Demographics (socio economic status)

7. Protective factors associated with PID
 Barrier contraception,
 Oral contraception,
 Tubal ligation,
 Pregnancy.

8. EPIDEMIOLOGY
1-2% of sexually active women per year.
 Peak incidence of PID is at 15-25 years of age.

9. DEFENSIVE MECHANISMS OF THE
FEMALE GENITAL TRACT
 VULVA
Apposition of labia majora
Rich blood supply which promotes rapid healing.
Apocrine gland secretions have fungicidal properties.
 VAGINA
The absence of glands in the stratified squamous
epithelium of the vagina provides few entry sites for
organisms

10. Cont…….
Vaginal acidity: lactic acid
Vaginal flora: hydrogen peroxide producing
lactobacilli.
 CERVIX
A mucus plug (with bacteriolytic properties)
obliterates the lumen of the cervix between
menstrual periods.
 UTERUS
The uterine epithelium is regularly shed.

11. Pathophysiology
 Once the infection has ascended to the upper genital
tract, the Fallopian tubes are commonly damaged.
 There is inflammation of the mucosal lining which, if
progressive, will destroy the cilia within the
Fallopian tube followed by scarring in the tubal
lumen.
 This can cause pocketing within the lumen with
partial obstruction and thus predispose to ectopic
pregnancy

12. Pathophysiology
 In severe infection, mucopurulent discharge exudes
through the fimbrial end of the Fallopian tube
causing peritoneal inflammation.
 This can lead to scarring and adhesion formation
between the pelvic structures.
 It can affect the ovary and form a tube-ovarian
abscess with distortion of the anatomy.
 Infections are usually contained by the omentum and
frequently omental adhesions are seen in the areas
affected

13. Pathophysiology
 Chlamydia and gonorrhea can also cause
perihepatitis leading to adhesions between the liver
and the peritoneal surface.
 This gives a typical violin string appearance at
laparoscopy and is known as the fitz Hugh Curtis
syndrome manifested as RUQ pain

14. Spread of infection

15. Clinical features
SYMPTOMS
 LAP
 Mucopurulent vaginal discharge (50%)
 Irregular vaginal bleeding (33%)
 Dyspareunia
 Fever (41%)
 Frequency and dysuria
 Lower back pain
 Vomiting (10%)
 Diarrhoea
 Constitutional symptoms
 RUQ discomfort ( Fitz-Hugh-Curtis syndrome-is xterized by PID
with an associated perihepatitis. It represents < 5% of PID cases).

16. Clinical features
SIGNS
 The signs elicited depend on the severity of disease.
 General exam may reveal :
An ill- looking patient;
Dehydration
Pyrexia;
Tachycardia;
Hypotension;
Tachypnoea

17. Clinical features
ABDOMINAL EXAM:
 LAT;
 Pelvic peritonitis;
 Generalized peritonitis
 Mucopurulent cervical discharge
• BIMANUAL EXAM:
 Bilateral supra pubic tenderness
 Bilateral adnexal tenderness
 Cervical excitation/motion tenderness
 +/- Palpable mass

18. Investigations
• Lab tests
Pregnancy test to r/o abnormal pregnancy (ectopic
preg)
Hb and WBC(raised)
ESR ≥60 is suggestive of TOA
Urine dip stick analysis
RCT
Syphilis screening test
Pap smear (if no recent result).

19. Investigations
• Microbiological tests
 Urine microscopy and culture
 Endocervical swabs
 Gram stain of vaginal discharge to demonstrate> 5
leucocytes per oil immersion field
• Imaging of the pelvis
 Transvaginal ultrasound (if available) for detection of
tubo ovarian masses , free fluid, peritonitis
 Doppler Transvaginal ultrasound
 CT scan
 MRI

20. Investigations
 Surgical Investigations
Laparoscopy;
Laparotomy;
Strongly recommended in the following situations;
 Pt > 40 years old
 Recurrent PID attacks
 History of tubal ligation

21. Diagnosis
Based on clinical findings:
 Raised white cell count (neutrophilia suggestive of
acute inflammatory process)
 Reduced white cell count (neutropenia in severe
infections)
 Raised C reactive protein and ESR
 Adnexal masses on ultrasound
 Laparoscopy is the gold standard to give a definitive
diagnosis, however, in mild cases it may not be very
obvious.

22. DDX of PID
 Ectopic pregnancy
 Pyelonephritis
 Torsion of an ovarian cyst,
 Rupture of an ovarian cyst
 Haemorrhage into an ovarian cyst
 Bleeding corpus luteum cyst
 Ruptured endometrioma
 Mittelschmerz pain

23. DDX of PID
 Appendicitis
 Diverticulitis
 Amoebiasis
 Regional lymphadenitis
 Typhoid
 Gastro enteritis
 Renal colic

24. Treatment
Medical :
 bed rest, hospital admission (severe cases),
 adequate fluids,
 correct electrolytes,
 analgesics (NSAIDs),
 antibiotics
 Ceftriaxone 2 g i.v. + i.v./oral doxcycline 100 mg twice
daily + i.v. metronidazole 500 mg twice daily.
 This should be continued until the patient gets clinically
better which is usually within 24 hours, following which
the antibiotics should be changed to oral therapy for 14
days

25. treatment

26. treatment

27. Treatment
Surgical:
 conservative surgery e.g. laparoscopy for abscess
drainage, lavage in failed drug treatment / pelvic
mass/generalised peritonitis
Other:
 trace and treat contacts, follow up, advise on fertility,
? Risk of ectopic pregnancy.

28. Sequelae/complications
Immediate:
 (1) Pelvic peritonitis or even generalized peritonitis.
 (2) Septicemia—producing arthritis or myocarditis
late
 ectopic pregnancy
 Infertility
 chronic pelvic pain and ill health
 Dyspareunia.
 Formation of adhesions or hydrosalpinx or
pyosalpinx and tubo-ovarian abscess.

29. Patient counseling
 Partner and other sexual contacts should be
screened.
 There is a risk of reinfection if the partner is not
treated.
 Use of barrier contraception will reduce the risk of
further recurrences.
 Risks of tubal damage leading to sub fertility, ectopic
pregnancy and chronic pelvic pain which increases
with further episodes of infection.

30. Patient counseling
 Prompt and early treatment will reduce the risk of
sub fertility.
 Seek early medical advice if pregnant, due to the risk
of an ectopic pregnancy.

31. Follow up
 Repeat smears and cultures from the discharge/swab
are to be done after 7 days following the full course of
treatment.
 The tests are to be repeated following each
menstrual period until it becomes negative for three
consecutive reports when the patient is declared
cured.
 Until she is cured and her sexual partner(s) have
been treated and cured, the patient must be
prohibited from intercourse.

32. prognosis
 Recurrence: 30% (1 year)
 Ectopic : 7-10-fold increases risk.
 Infertility: 15-20% increases to > 50 after 2-3
recurrences.

33. GREAT THANKS FOR LISTENING
6/28/2019
33