PID & its Management
Contents
● Pelvic Inflammatory Disease (PID) is a spectrum of
inflammatory disorders of the upper female genital tract,
including any combination of endometritis, salpingitis, tubo-
ovarian abscess, and pelvic peritonitis
● Sexually transmitted organisms, especially N. gonorrhoea and
C. trachomatis, are More common
● However, microorganisms of the vaginal flora (e.g., anaerobes,
G. vaginalis, Haemophilus influenzae, enteric Gram-negative
rods, and Streptococcus agalactiae) also have been associated
with PID
● In addition, M. [Mycoplasma] hominis and U. [Ureaplasma]
urealyticum might be etiological agents of PID
● PID is commonly associated with Sexually Transmitted
Diseases (STDs)
Incidence is on rise due to rise in STDs
Among sexually active women: Incidence is 1-2 % per year
About 85% are spontaneous infection in sexually active females
of reproductive age
Remaining 15% follow procedures, which favors the organism to
ascend up
Risk Factors
Strong evidence Weak evidence
● 1. Prior infection with chlamydia ● 1. Low socio-economic status
or gonorrhea ● 2. Substance abuse
● 2. Younger age at onset of ● 3. Douching
sexual activity
● 4. High frequency of coitus
● 3. Prior H/O PID
● 5. Cigarette smoking
● 4. Sexually Transmitted Infection
● 6. Intercourse during
● 5. Non-use of barrier menstruation
contraceptive 6. Unprotected
sexual intercourse with multiple
partner
● 7. IUD use
Mode of transmission
● Ascending infection (Canalicular spread)
● Ascend of gonococcal & chlamydial organisms by surface
extension from the lower genital tract through the cervical canal
by way of the endometrium to the fallopian tubes
● Facilitated by the sexually transmitted vectors such as sperms
& trichomonads
● Reflux of menstrual blood along with gonococci into the
fallopian tubes may be the other possibility
Contd…
● Through uterine lymphatic & blood vessels across parametrium
● Gynecological procedures favoring ascend of infection
● E.g. D&C, D&E
● Blood-borne transmission
● Pelvic tuberculosis
● Direct spread from contaminated structures in abdominal cavity
● E.g. Appendicitis, cholecystitis
Acute PID pathology
Cervicitis
Endometritis
Salpingitis
Oopharitis
TO abscess
Peritonitis
Pathology
● Involvement of the fallopian tubes is almost bilateral
● Pathological process is initiated primarily in the endosalpinx
● It usually follows menses due to loss of genital defence
● Gross destruction of epithelial cells, cilia & microvilli
● Acute inflammatory reaction: all layers are involved
● Tubes become edematous & hyperemic; exfoliated cells & exudate
pour into lumen & agglutinate the mucosal folds
● Abdominal ostium:
● closed by edema & inflammation
● Uterine end: closed by congestion
● Depending on the virulence: watery or purulent exudate
● Hydrosalpinx or Pyosalpinx
● Deeper penetration & more destruction
● Possibilities
● Oophoritis Tubo-ovarian abscess
● Peritonitis
● Pelvic abscess
or
● Resolution in 2-3 weeks with/without chronic sequelae
● Diagnosis of Acute PID is difficult because of wide variation &
non-specific nature of symptoms & signs
● Many women with PID have subtle or mild symptoms
● A diagnosis of PID usually is based on clinical findings
● Delay in diagnosis and treatment probably contributes to
inflammatory sequelae in the upper reproductive tract
● The patient should be asked about the location, intensity, radiation,
timing, duration, and exacerbating and mitigating factors of the pelvic
pain: Bilateral lower abdominal & pelvic dull aching pain is
characteristic of acute PID
● H/O Fever (Oral temperature > 38.3˚C/101F)
● H/O Abnormal vaginal discharge
● H/O symptoms suggestive of dysuria
● Previous H/O abdominal or gynecological surgeries
● H/O previous gynecological problem
● H/O IUD insertion (6 times higher risk within 20 days)
● Social history: Should include patient’s sexual and STDs history &
partner’s history in terms of STDs
● Fitz Hugh & Curtis Syndrome
● Consists of rt. upper quadrant pain resulting from ascending pelvic
infection and inflammation of the liver capsule or diaphragm
● Although it is typically associated with acute salpingitis, it can exist
without signs of acute pelvic inflammatory disease (PID)
● Physical examination
● Abdominal & pelvic examination is most important
● Bilateral abdominal tenderness
● Adnexal mass & adnexal tenderness
● Cervical motion tenderness
● Uterine tenderness
● Vaginal mucopurulent discharge
Imaging
● Transvaginal ultrasonography is the imaging modality of choice
● Trans abdominal ultrasonography for DD
● Abdominal CT or MRI : When USG indeterminate
● Diagnostic procedures
● Culdocentesis
● Endometrial biopsy
● Diagnostic laparoscopy
Acute PID: Most common DD
● Most common DD of acute PID
1. Appendicitis
2. Ectopic pregnancy
3. Endometritis
4. Ovarian cyst
5. Ovarian torsion
DIAGNOSIS
● If delayed
● Chronic Pelvic pain
● Infertility
● Adhesions
● Tubo-ovarian abscess
● Ectopic pregnancy
Clinical Diagnostic criteria
● A sexually active woman
● Other woman at risk factor for PID
● C/o lower abdominal/ pelvic pain
● No other cause identified
● PLUS
● Any one of the Minimum Criteria
Cervical motion
tenderness Uterine tenderness Adnexal tenderness
Additional Criteria
Oral temperature->101 degree F(>38.3 degree C)
Cervical/ Vaginal Mucopurulent discharge
Abundant WBCs on saline microscopy of vaginal
fluid
Elevated ESR
At least One
Elevated CRP
Lab documentation of cervical infection with N.
gonorrheae or C. Trachomatis
Most Specific criteria
● Any one of
● Endometrial Biopsy
● TVS/MRI
● Laproscopy
Further Testing (CDC 2015, European
Guideline 2012)
●Serology for HIV
● Testing for N. gonorrhea
● Testing for chlamydia
● Testing for Bacterial vaginosis (BV)-?
●Urine pregnancy test
Principles
● Prompt (as soon as presumptive diagnosis)
● Empiric broad spectrum- N. gonorrheae and C. trachomatis
● Regimens with anti-anaerobic activity should be considered
Therapeutic goal
● Elimination of acute infection
● Prevention of complications.
Which regime?
Outpatient Therapy of Acute PID
Regimen A
Ceftriaxone* (IM) 250mg** Single dose
Doxycycline (Orally) 100mg BD for 14 days
Metronidazole (orally) 500mg BD for 14days
*Best coverage against N. gonorrheae
**500mg (UK guideline 2011)
● Regimen B
Cefoxitin* (IM) 2g Single Dose
Probenacid (Oral) 1g Single dose
Doxycycline(Oral) 100mg BD for 14 days
Metronidazole (oral) 500mg BD for 14 days
*Better anaerobic coverage
Review
● After 72 hours
● Clinical improvement is evident by
● Reduction in direct and rebound abdominal
tenderness
● Uterine, adnexal and cervical motion
tenderness
If no improvement in 72 hours
● Consider:
● Subsequent hospitalization
● Antimicrobial sensitivity assessment
● Review diagnosis
● Diagnostic laproscopy
● Surgical modalities
Indications for admission
● Surgical emergency cannot be excluded
● Clinically severe disease(high fever, peritonitis, severe illness.)
● TO-Abscess (at least 24hr observation)
● PID in pregnancy
● Lack of response to oral therapy (72 hrs)
● Intolerance to oral therapy.
Surgical Management
● INDICATIONS:
● Uncertain diagnosis
● Failed medical management
● Severe disease
● TO abscess
● Pelvic abscess
Laproscopy
● Confirm diagnosis
● Prognosis predicted
● Management can be planned
1.Explore all the organs
2.Aspiration
3.Drainage of abscess
4.Peritoneal fluid send for culture and sensitivity
5.Adhesiolysis-Pelvic and perihepatic adhesions
6.Irrigation
Pelvic Abscess
● Resuscitation
● Management of septic shock
● Drainage
1.Percutaneous guided
1. USG guided-less invasive
2. If fails CT guided
3. Drain may be placed
2.Laproscopy
3.Colpotomy
4.Laprotomy
Advice
● Avoidance of unprotected intercourse until declared cured
● Review at 4 weeks
● If documented chlamydial or gonococcal PID
● Retest 3 months after treatment (or at least once before next 12
months)
Management of sexual partners
● Screening for gonorrhea and chlamydia
● Empirical therapy for both gonorrhea and chlamydia
● Abstinence until both have completed the course
● Test for HIV
● Condom promotion
● Expedited partner therapy (EPT) or patient delivered partner
therapy(PDPT).
●Thank
you
