pelvic inflammatory disease (PID)

Dr.Tarig Mahmoud Ahmed

MD SUDAN

HAIL UNIVERSITY KSA

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.

CAUSATIVE ORGANISMS

Chlamydia.

Gonococcal.

bacterial vaginosis.

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.

• 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.

PERITUBAL ADHESIONS OF THE LEFT FALLOPIAN TUBE

• 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

FITZ HUGH CURTIS SYNDROME

SIGNS AND SYMPTOMS

Abdominal, pelvic pain and deep

dyspareunia.

Mucopurulent vaginal discharge.

Pyrexia (>38°C).

Heavy/intermenstrual bleeding.

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

LEFT FALLOPIAN TUBE HYDROSALPINX.

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)

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.

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.

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.

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.

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.

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.

In pregnancy, a combination of cefotaxime

+azithromycin + metronidazole should be

used.

Doxycycline, gentamycin and ofloxacin

should be avoided In pregnancy.

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.

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.

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.