Pelvic Inflammatory Disease

By: Kallianpur Vaibhav Vinayanand.

ML- 610 2012

Upper Genital Tract InfectionsThe Cervix is considered the boundary between the lower and upper genital tracts. Upper genital tract infections affect primarily the cervix, uterus, or fallopian tubesSevere infections may affect one or both ovaries.

Topic Defined: Pelvic Inflammatory Disease (PID)

Infection of the upper female genital tract.

Refers to the clinical syndrome among women resulting from infection

Includes endometritis (infection of the uterine cavity)

Salpingitis (infection of the fallopian tubes)

Mucopurulent Cervicitis (infection of the cervix),

Oophoritis (infection of the ovaries).

Pathway of Ascendant Infection

Cervicitis

Endometritis

Salpingitis/ oophoritis/ tubo-ovarian abscess

Peritonitis

Pathologic Processes of PID

• PID has a broad clinical spectrum that includes a) acute PIDb) silent PID c) atypical PID d) the PID residual syndrome or

chronic PID and e) postpartum/postabortal PID

PID Classification

Severe symptoms

4%

Subclinical/silent60%

Mild to moderate symptoms

36%

Overt

40%

PID Specifically defined:

• Individual cases of PID can also be more specifically defined by – a) the site (s) of disease (i.e.,

endometritis, salpingitis, salpingo-oophoritis)

–b) the etiologic agent (s) involved (those that cause chlamydial endometritis, gonococcal salpingitis, nonchlamydial/nongonococcal salpingo-oophoritis).

Relevance to Women’s Health:• Commonly occurs in women <35 years.• Rarely occurs before menarche, after menopause or

during pregnancy.• About 1.2 million women are treated for PID. • Over 100,000 women with PID are hospitalized each

year.• About 15% are acutely ill that require intensive

inpatient treatment. • Approximately 85,000 women with mild or moderate

PID who currently are being hospitalized, treating them as outpatients may save around $500 million each year.

Relevance to Women’s Health

Is one of the major causes of gynecologic morbidity

InfertilityEctopic pregnancyChronic pelvic painDiagnosis and treatment

must be prompt to avoid these conditions.

PID: Etiology

PID results from microorganisms transmitted during intercourse.

Certain procedures that open the cervix and allow possible bacteria to pass through (D&C, abortion, cesarean birth, miscarriage, I.U.D. insertion)

The infection is usually multifactorial, involving aerobic and anaerobic organisms

PID: Risk Factors Multiple sexual partners or partner with

multiple sexual partners Intercourse with partner with untreated

urethritisPrevious history of PIDUse of an IUDPresence of bacterial vaginosis or an STDNulliparityRecent instrumentation of the uterus DouchingCigarette smokingSex with menses

Causative Agents of PID• Neiserria Gonorrhoeae and Chlamydia

trachomatis are the 2 major causative organisms.

• Chlamydia trachomatis is the predominant STD organism causing PID.

• In the U.S., the role of Neisseria Gonorrhoeae as the primary cause of PID has decreased.

• Other agents: Mixed infection caused by both aerobic and anaerobic organisms

• Recent studies demonstrate the presence of Bacterial Vaginosis and trichomoniasis in cases of confirmed PID

C. trachomatis Infection (PID)

Causative Agents of PID• Cytomegalovirus (CMV) has been found

in the upper genital tracts of women with PID.

• Enteric gram-negative organisms (E-coli)• Peptococcus species• Streptococcus agalactiae• Bacteroides fragilis• Mycoplasma hominis • Gardnerella vaginalis• Haemophilus influenzae

Signs & Symptoms of PID

The patient presents with lower abdominal pain, fever, vaginal discharge, and/or abnormal uterine bleeding.

Symptoms frequently occur during or after menses.

Peritoneal irritation produces marked abdominal pain with or without rebound tenderness

The abdomen should be palpated gently to prevent abscess rupture

Chlamydial Pyosalpinx• Pelvic inflammatory disease, proven Chlamydial

Pyosalpinx. • Right tube is swollen and tortuous (arrow)

(Holmes, 1999, Plate 17; reprinted with permission from McGraw Hill.)

Cervicitis The cervix appears red and bleeds easily when touched with a spatula or cotton swab. Mucopurulent discharge is yellow-greenContains >10 polymorphonuclear WBCs per oil immersion field (using Gram stain)

Acute Salpingitis

Onset is usually shortly after menses.

Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness, and cervical motion tenderness.

Involvement is usually bilateral. Nausea and vomiting occur with

severe infection.In the early stages, acute

abdominal signs are often absent

Acute Salpingitis (PID)Bowel sounds are present unless peritonitis with ileus has developed. Fever, leukocytosis, and mucopurulent cervical discharge are commonIrregular bleeding and bacterial vaginosis often accompany the pelvic infection.

Acute Salpingitis (PID)

Pelvic infection due to N. Gonorrhoeae is usually more acute than that due to C. trachomatis

Onset is rapid, and pelvic pain develops shortly after menses starts.

Although the pain is often localized to one side, both tubes are probably infected.

The infection produces a diffuse exudate, leading to agglutination, adhesions, and tubal occlusion.

Peritonitis may occur, causing upper abdominal pain and adhesions

Acute Salpingitis: Chlamydia & Gonorrhea C. trachomatis produces symptoms that

often seem mild, but it can cause more damage than N. Gonorrhoeae in the long term.

Chlamydial organisms may remain in tubal mucosa for many months before clinical manifestations of acute disease appear.

Untreated or inadequately treated acute infection can lead to chronic salpingitis, with tubal scarring and possible adhesion formation.

Chronic pelvic pain, menstrual irregularities, and infertility are long-term sequelae

Complications of PID Tubo-ovarian abscess develops in

about 15% of women with salpingitis. It can accompany acute or chronic

infectionThe tube and ovary can become

completely matted together.May require prolonged hospitalization,

sometimes with surgical percutaneous drainage.

Rupture of the abscess is a surgical emergency

Rapidly progressing from severe lower abdominal pain to N & V, generalized peritonitis, and septic shock

Tubo-ovarian abscess

Pyosalpinx, in which one or both fallopian tubes are filled with pus, may also be present.

Hydrosalpinx (fimbrial obstruction and tubal distention with nonpurulent fluid) develops if treatment is late or incomplete.

The consequent mucosal destruction leads to infertility.

Hydrosalpinx is generally asymptomatic but can cause pelvic pressure, chronic pelvic pain, or dyspareunia.

Women with HIV infection are more likely to have tubo-ovarian abscess

Tubo-ovarian abscess• Here at least the ovaries, tubes and uterus can still be recognized as

separate structures

Fitz-Hugh-Curtis syndrome

Can be a complication of gonococcal or chlamydial salpingitis.

Characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis.

Acute cholecystitis may be suspected, but signs and symptoms of PID are present or develop rapidly.

Diagnostic Studies:

• CBC with differential • Erythrocyte Sedimentation Rate • Cervical cultures • Blood Cultures • Urine Pregnancy Test • Rapid Plasma Reagin (RPR)• Cervical infection due to N.

Gonorrhoeae can also be diagnosed by Gram stain showing intracellular gram-negative diplococci

Diagnostic studies

Leukocytosis is typical.Pelvic ultrasonography may be used

when a patient cannot be adequately examined because of tenderness or pain

When a pelvic mass may be present, or when no response to antibiotic therapy occurs within 48 to 72 h. --

Laparoscopy should be performed only if the diagnosis is uncertain or if the patient does not promptly improve with medical therapy

CDC’s Minimum Criteria for Empiric Treatment of PID• Lower Abdominal Tenderness &

Rebound• Adnexal Tenderness• Cervical Motion Tenderness

Diagnosis

And one or more minor criteria • Temperature over 100.9F or 38.3 C • White Blood Cell count > 10,000 • Elevated ESR• Elevated C-reactive protein• Pus in cul-de-sac • Pelvic abscess or inflammatory

complex • Cervical Mucus findings • Gram Stain: Gram Positive diplococci • Intracellular parasites

Diagnosis

ESR and C-reactive protein are elevated in many disorders and are therefore not specific for PID.

Endometrial biopsy with aerobic and anaerobic culture may assist in the diagnosis.

All three major criteria and at least one minor criterion must be present to diagnose PID.

Endometritis (thickened heterogenous endometrium)

Hydrosalpinx (anechoic tubular structure)

Hydrosalpinx.

Pyosalpinx (tubular structure with debris in adnexa

Tuboovarian abscess resulting from tuberculosis

Right hydrosalpinx with an occluded left fallopian tube

Differential Diagnosis

Condition Characteristic Signs/Symptoms

Acute Appendicitis Anorexia, N & V, decreased or absent bowel signs, unilateral pain limited to right or left lower quadrant

Ectopic Pregnancy Unilateral pain; missed menstrual period usually warrants hCG test

Ruptured Ovarian Cyst

Unilateral pain

Endometriosis Constant pain begins 2-7 days before menses

Urinary Tract Infection

Dysuria, abnormal urinalysis. No cervical motion tenderness

Renal calculus Severe unilateral pain, hematuria

Adnexal torsion Unilateral pain

Proctocolitis Anorectal pain, tenesmus, rectal discharge or bleeding

Hemorrhaging corpus luteum

Unilateral pain

Treatment Goals & Benefits

Therapeutic goals include complete resolution of the infection and prevention of infertility and ectopic pregnancy.

Management OutpatientRegimen A: Initial Treatment at Diagnosis • Ofloxacin 400 mg orally BID for 14

days(95% cure)

Or• Levofloxacin 500 mg orally once

daily for 14 daysWith or without:

• Metronidazole 500 mg orally twice a day for 14 days.

Management Outpatient: Regimen B• Ceftriaxone 250 mg IM in a single dose

Or• Cefoxitin 2 g IM in a single dose and

Probenecid, 1 g orally administered concurrently in a single dose

Or• Other parenteral third-generation

cephalosporin (ceftizoxime or cefotaxime)

Plus• Doxycycline 100 mg PO BID for 14 days

(75% cure)With or without

• Metronidazole 500 mg PO BID for 14 days

Management Inpatient•Toxic appearance •Unable to take oral fluids •Unclear DX •Appendicitis •Ectopic Pregnancy •Ovarian torsion

•Pelvic abscess •Pregnancy •HIV positive •Adolescents •Outpatient TX failure•Unreliable patient

Inpatient Treatment Regimens:General: Treat for at least 48 hours

IV Regimen A • Cefotetan 2g IV q12 hours

OR• Cefoxitin 2g IV q6 hours

Plus• Doxycycline 100 mg orally or IV

every 12 hours

Inpatient TreatmentRegimen B • Clindamycin 900 mg IV q8 hours

Plus• Gentamicin 2 mg/kg IV loading dose,

then 1.5 mg/kg IV q8h

• Discharge Regimen (after IV antibiotics)

• Doxycycline 100mg PO BID for 10 daysor

• Clindamycin 450mg PO QID for 14 days

Alternative Parenteral Regimens

• Ofloxacin 400 mg IV q 12 hoursOr

• Levofloxacin 500 mg IV once dailyWith or without

• Metronidazole 500 mg IV every 8 hoursOr

• Ampicillin/Sulbactam 3 g IV every 6 hours

Plus• Doxycycline 100 mg orally or IV every

12 hours

Prognosis

• Therapy using antibiotics alone is successful in 33-75% of cases.

• If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage and copious irrigation or unilateral adnexectomy, if possible.

• Further surgical therapy is needed in 15-20% of cases so managed.

Prognosis

• Chronic pelvic pain occurs in approximately 25% of patients with a history of PID.

• This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or Hydrosalpinx.

• Impaired fertility is a major concern in women with a history of PID.

• The rate of infertility increases with the number of episodes of infection.

• The risk of ectopic pregnancy is increased in women with a history of PID.

• Ectopic pregnancy is a direct result of damage to the fallopian tube.

Sequelae

Infertility– ¼ of pt have acute salpingitis– occur 20%– infertility rate increase direct with number of

episodes of acute pelvic infection

Ectopic pregnancy– increase 6-10 fold– 50% occur in fallopian tubes (previous

salpingitis)– mechanism ; interfere ovum transport

entrapment of ovum

Sequelae

Chronic pelvic pain– 4 times higher after acute salpingitis– caused by hydrosalpinx, adhesion around

ovaries– should undergo laparoscope R/o other

disease

Mortality– acute PID 1%– rupture TOA 5-10%

Sequelae

Prevention• Randomized controlled trials suggest that

preventing chlamydial infection reduces the incidence of PID.

• Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide.

• Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs.

• Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended

Relevance of topic for clinical NP Practice

• NPs can help reduce the risk for PID and its sequelae.

• Timely diagnosis and appropriate treatment of lower-genital-tract chlamydial and gonococcal infection among both men and women can reduce the risk of adverse consequences among infected individuals and can reduce the risk of further transmission to others.

Relevance of topic for clinical NP Practice

• Also, NPs can influence men's and women's risk of infection by providing effective counseling about their sexual behavior, health- care-seeking behavior, and contraceptive practice, and by convincing them to comply with management instructions.

• Finally, by ensuring timely and effective treatment of patients' sex partners, NPs can reduce risk of reinfection.

Relevance of topic for clinical NP Practice

• Because the partners' infections may be asymptomatic, interviewing and treating these persons will help reduce further transmission of infection in the community and may facilitate identifying other infected persons.

Management of Sex Partners

• Treatment for sex partners of women with PID is imperative.

• The management of women with PID should be considered inadequate unless their sex partners have been appropriately evaluated and treated.

• Failure to manage her sex partner (s) effectively places a woman at risk for recurring infection and related complications.

• Moreover, untreated sex partners often unknowingly transmit STD in a community because of asymptomatic infection.

Surveillance

• At all levels, PID surveillance is affected by four main constraints:

• PID is difficult to diagnose accurately. • PID is diagnosed in a wide variety of

clinical settings. • Microbiology test results are needed to

determine the etiology of PID.

Patient Education

• The NP’s role as a health educator is central to effective management.

• NPs should explain to women the nature of their disease and should encourage them to comply with therapy and prevention recommendations.

• Specifically, NPs should: • Emphasize the need for taking all the

medication, regardless of symptoms.

• http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Patient Education

• Review contraindications and potential side effects.

• Identify and discuss potential compliance problems.

• Review the medical purpose of follow-up evaluation.

• Emphasize the need to avoid sex until treatment is completed.

• Emphasize the need to refer sex partners for evaluation and treatment.

• http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Patient Education

• When medical-care messages are clear, explicit, relevant, and rigorously delivered by providers, patients are likely to comply.

• Reinforcement of these messages can be achieved by providing written information.

• Information on written materials for patient distribution can be obtained from CDC or local and state health departments

• http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Controversies Surrounding PIDThe exact incidence of PID is unknown The disease cannot be diagnosed

reliably from clinical signs and symptoms.

Laparoscopy exam of the pelvic organs continues to be the "gold standard" approach to diagnosis of PID.

But, because this is a surgical procedure which requires an incision in the abdomen, the high priority is to design and development of non-invasive techniques, with smaller costs and fewer risks.

OC may reduce the risk of PID that is not attributable to C. trachomatis.

Relevant Research Findings

• Recently, a study conducted at the University of Washington School of Medicine confirmed that regular douching is associated with pelvic inflammatory disease.

• An earlier study had shown a significant association between vaginal douching and ectopic pregnancy.

• Pelvic inflammatory disease is also a major factor in ectopic pregnancy.

Research Findings

• In a comparison of 100 women with confirmed pelvic inflammatory disease (PID) and 762 randomly selected controls, at Harborview Medical Center in Seattle

• The investigators report that women who douche once or twice a month were 2.5 times more likely to have PID than those who douched less than once a month.

• However, the risk of PID does not appear to increase with more frequent douching.

Relevant Research Studies on PID

• It is thought that douching increases the risk of PID by wiping out beneficial vaginal bacteria making it possible for disease producing bacteria to get the upper hand.

• Another theory is that douching flushes vaginal and cervical bacteria back into the uterine cavity where they cause trouble.

Research Study• According to a study funded by the Agency for

Healthcare Research and Quality (AHRQ), women with mild to moderate PID who are treated as outpatients have recovery and reproductive outcomes similar to those for women treated in hospitals.

• The PID Evaluation and Clinical Health (PEACH) study was a randomized clinical trial designed to compare the effectiveness of inpatient and outpatient treatment strategies in preserving fertility and preventing PID recurrence, chronic pelvic pain and ectopic pregnancy for women with mild to moderate PID.

Research Study

• Women treated as outpatients received a single injection of Cefoxitin and an oral dose of probenecid, followed by a 14-day supply of oral doxycycline.

• Those treated in a hospital were given multiple intravenous doses of Cefoxitin plus doxycycline during a minimum inpatient stay of 48 hours.

• The women’s care then was followed for 35 months to document long-term outcomes

Research Study

• The short-term clinical improvements were similar for women treated in inpatient and outpatient settings.

• After 35 months of follow-up, pregnancy rates were nearly equal between the groups, as was the amount of time it took to become pregnant.

• There also were no statistically significant differences between the proportion of women with ectopic pregnancy, chronic pelvic pain or PID recurrence .

Relevant Research Questions

• Should suspected PID be treated empirically or should treatment be delayed until results of microbiological investigations are known?

• Do parental antibiotic treatment

provide optimal effectiveness than oral antibiotic treatment for PID?

Case Study

History: Jane Wheels

24-year-old female who presents reporting lower abdominal pain, cramping, slight fever, and dysuria for 4 daysP 1001, LMP 2 weeks ago (regular without dysmenorrhea). Uses oral contraceptives (for 2 years). Reports gradual onset of symptoms of lower bilateral abdominal discomfort, dysuria (no gross hematuria), abdominal cramping and a slight low-grade fever in the evenings for 4 days. Discomfort has gradually worsened. Denies GI disturbances or constipation. Denies vaginal d/c. States that she is happily married in a monogamous relationship. Plans another pregnancy in about 6 months. No condom use. No history of STDs. Reports occasional yeast infections.Douches regularly after menses and intercourse; last douched this morning.

Case Study

Physical Exam

Vital signs: blood pressure 104/72, pulse 84, temperature 38°C, weight 132

Neck, chest, breast, heart, and musculoskeletal exam within normal limits. No flank pain on percussion. No CVA tenderness.

On abdominal exam the patient reports tenderness in the lower quadrants with light palpation. Several small inguinal nodes palpated bilaterally.

Normal external genitalia without lesions or discharge.Speculum exam reveals minimal vaginal discharge with

a small amount of visible cervical mucopus. Bimanual exam reveals uterine and adnexal tenderness

as well as pain with cervical motion. Uterus anterior, midline, smooth, and not enlarged.

Case Study

Questions

1. What should be included in the differential diagnosis?

2. What laboratory tests should be performed or ordered?

Case Study

Laboratory

Results of office diagnostics: Urine pregnancy test: negative Urine dip stick for nitrates: negative Vaginal saline wet mount: vaginal pH was 4.5.

Microscopy showed WBCs >10 per HPF, no clue cells, no trichomonads, and the KOH wet mount was negative for budding yeast and hyphae.

3. What is the presumptive diagnosis?4. How should this patient be managed?5. What is an appropriate therapeutic

regimen?

Case Study

Partner Management

Sex partner: Joseph (spouse)First exposure: 4 years agoLast exposure: 1 week agoFrequency: 2 times per week

(vaginal only)

6. How should Joseph be managed?

Case Study

Follow-Up

On follow up 3 days later, Jane was improved clinically. The culture for gonorrhea was positive. The nucleic acid acid amplification test (NAAT) for chlamydia was negative.

Joseph (Jane’s husband) came in with Jane at follow-up. He was asymptomatic but did admit to a "one-night stand" while traveling. He was treated. They were offered HIV testing which they accepted.

7.Who is responsible for reporting this case to the local health department?

8. What are appropriate prevention counseling recommendations for this patient?

Case Study

Question:

1. Pelvic inflammatory disease (PID) in women is most commonly caused by: A) Leptotrichia buccalis B) Treponema pallidum C) Chlamydia trachomatisD) Bacillus anthracis E) Borelia burgdorferi

Answer

The correct answer is #C. Chlamydia Trachomatis

Question:

2. IUD use has been linked with: A. pelvic inflammatory disease   B. tubal infections   C. uterine infections   D. all of the above   E. none of the above

Answer

The correct answer is #D. All of the above

Question

3. Which of the following conditions is not a risk factor for pelvic inflammatory disease (PID)?

A. Smoking B. Multiple sexual partners C. Young age at first intercourse D. Hepatitis B E. Intrauterine device (IUD) insertion

Answer

The correct answer is D: •Hepatitis B is not a known risk

factor for PID.

Question:

4.) Which of the following is not used to treat symptoms associated with pelvic inflammatory disease (PID)?

A: Azithromycin B: Ceftriaxone C: Ampicillin D: Ofloxacin E: Cefoxitin

Answer

The correct answer is A:• No data suggest that Azithromycin is an

appropriate oral regimen for the tx of PID.• Most patients are now managed as

outpatients. • One outpatient regimen is Cefoxitin and

probenecid taken orally in a single dose. • Alternatively, ceftriaxone (less active

against anaerobic bacteria compared to Cefoxitin) can be taken once IM with doxycycline orally twice daily for 14 days.

• Another regimen is ofloxacin taken orally for 14 days with either clindamycin or metronidazole, which also are taken orally for 14 days.

Question

5.) (T/F): The major criteria for the diagnosis of pelvic inflammatory disease (PID) include –Leukocytosis–elevated C-reactive protein (CRP)

–elevated erythrocyte sedimentation rate (ESR)

–fever.

Answer

The correct answer is False: The major criteria for the diagnosis of

PID include:–Cervical motion tenderness–Adnexal tenderness– Lower abdominal tenderness.

ESR, CRP, and laboratory documentation of Neisseria gonorrhea or Chlamydia trachomatis cervical infection, among others, can aid in increasing the specificity of diagnosis

Question:

6.) (T/F): All of the following are indications for hospitalization for treatment of pelvic inflammatory disease (PID): –failed outpatient therapy– Inability to tolerate oral therapy

–Pregnancy–pelvic abscess.

Answer

The correct answer is True: These are circumstances in which women

should be hospitalized for treatment of PID.

Other conditions that may require hospitalization are:

• uncertain diagnosis• severe illness• Severe N & V• Immunodeficiency (HIV,

immunosuppressive medications).

Question:

7.) (T/F): In the initial workup, laparoscopy should be used to confirm the diagnosis of pelvic inflammatory disease (PID).

Answer

The correct answer is False:•Laparoscopy is costly and not

always available. • It should be used if the

diagnosis is in doubt

Question

8.) (T/F): Consider hospitalizing patients who do not improve clinically after 72 hours with outpatient therapy for pelvic inflammatory disease (PID).

Answer

The correct answer is True: •While most patients are now

treated on an outpatient basis, these patients should be admitted to the hospital and treated appropriately

Any Questions???

THANK YOU FOR YOUR ATTENTION !!