medical students lecture

1. pelvic inflammatory disease
(PID)
Dr.Tarig Mahmoud Ahmed
MD SUDAN
HAIL UNIVERSITY KSA

2. Pelvic inflammatory disease is characterized by
inflammation and infection arising from the
endocervix leading to endometritis,
salpingitis,oophoritis, pelvic peritonitis and
subsequently formation of tubo-ovarian and
pelvic abscesses.

3. CAUSATIVE ORGANISMS
Chlamydia.
Gonococcal.
bacterial vaginosis.

4. PATHOPHYSIOLOGY
• infection to the upper genital tract, lead to Fallopian
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.

5. • In severe infection, mucopurulent discharge
exudes through the fimbrial end of the
Fallopian tube causing peritoneal
inflammation and adhesion formation
between the pelvic structures.
• It can affect the ovary and form a tubo-
ovarian abscess with distortion of the
anatomy.

6. PERITUBAL ADHESIONS OF THE LEFT
FALLOPIAN TUBE

7. • Chlamydia and gonorrhoea 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

8. FITZ HUGH CURTIS SYNDROME

9. SIGNS AND SYMPTOMS
 Abdominal, pelvic pain and deep
dyspareunia.
Mucopurulent vaginal discharge.
Pyrexia (>38°C).
 Heavy/intermenstrual bleeding.

10. Pelvic tenderness and cervical excitation
during examination.
Tender adnexal or palpable pelvic mass.
Generalized sepsis in severe and systemic
infection.
Tubal damage leading to tubal occlusion,
abscess and hydrosalpinx

11. LEFT FALLOPIAN TUBE
HYDROSALPINX.

12. 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
(erythrocyte sedimentation rate)

13.  Adnexal masses on ultrasound
Laparoscopy is the gold standard to give a
definitive diagnosis, however, in mild cases it
may not be very obvious.
Testing for gonorrhoea and chlamydia in the
lower genital tract is recommended since a
positive result supports the diagnosis of PID.
pregnancy test should be done in all cases
to rule out ectopic pregnancy.

14. CRITERIA FOR ADMISSION
Severe infection.
Adnexal masses suspicious of abscess.
Generalized sepsis.
Poor/inadequate response to oral treatment.
 Severe pelvic/abdominal pain requiring
strong analgesics.

15. TREATMENT
mild/moderate disease can be managed on
outpatient .
severe disease need hospital admission.
intrauterine contraceptive device, if present,
should be removed
pregnancy test should be done in all cases
to rule out ectopic pregnancy.

16. ANTIBIOTIC REGIMES
Mild/moderate infection (outpatient treatment)
 Oral ofloxacin 400 mg twice a day + oral
metronidazole 400 mg twice a day × 14 days
Ceftriaxone 250 mg single intramuscular
injection + oral doxycycline 100 mg twice a
day + oral metronidazole 400 mg twice a day ×
14 days
Single intramuscular dose of ceftriaxone 250
mg+ azithromycin 1 g/week × 2 weeks.

17. Severe infection (in patient)
Ceftriaxone 2 g i.v. + i.v./oral doxycycline 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.

18. Clindamycin 900 mg i.v. three times daily +
gentamycin i.v. (loading dose 2 mg/kg followed by
1.5 mg/kg three times a day) followed by either
clindamycin 450 mg four times daily or oral
doxycycline twice daily + oral metronidazole 400 mg
daily for 14 days.
Ofloxacin i.v. 400 mg twice daily + metronidazole i.v.
three times a day × 14 days.

19. In pregnancy, a combination of cefotaxime
+azithromycin + metronidazole should be
used.
Doxycycline, gentamycin and ofloxacin
should be avoided In pregnancy.

20. SURGICAL TREATMENT
In patients with a pelvic abscess or patients
not responding to therapy, a laparoscopy is
indicated.
This may also exclude other causes of pain,
such as appendicitis, endometriosis or
ovarian pathology.
The usual treatment would involve drainage
of the abscess and sometimes the affected
tube/ovary may have to be removed.

21. PATIENT COUNSELLING
Partner and other sexual contacts should be
screened.
 There is a risk of re infection if the partner
is not treated.
 Use of barrier contraception will reduce the
risk of further recurrences.

22.  Risks of tubal damage leading to
subfertility, ectopic pregnancy and chronic
pelvic pain which increases with further
episodes of infection.
 early treatment will reduce the risk of
subfertility.
 Seek early medical advice if pregnant, due
to the risk of an ectopic pregnancy.