Pelvic Inflammatory Disease

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Pelvic Inflammatory Disease CDC, 2006 Prof.
Aboubakr Elnashar Benha University Hosp.
Egypt Chief Ob Gyn Dept. KJO Hosp Email
elnashar53_at_hotmail.com
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• Definition
• Inflammatory disorders of the upper FGT,
  including any combination of endometritis,
  salpingitis, tubo-ovarian abscess, pelvic
  peritonitis.
• Primary (STD, no precipitating cause)
• Secondary (to precipitating cause IUCD, HSG,
  abortion or infection elsewhere in the body
  appendicitis)

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• Aetiology
• ST organisms
• N. Gonorrhoeae (NG), C. trachomatis (CT)
• Vaginal flora
• Anaerobes, G. vaginalis,
• H influenzae, enteric Gram- rods
• Streptococcus agalactiae
• Rare
• M. hominis, U. urealyticum, M. genitalium.

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Diagnosis
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• Difficult
• 1. No single historical, physical, or laboratory
  finding is both sensitive specific
• Combinations of diagnostic findings to improve
  sensitivity specificity

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2. Clinical Diagnosis PPV 65 90 compared
with laparoscopy. a. Wide variation in S S.
b. Sym No Subtle, mild, non specific
e.g. AUB Dyspareunia VD
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• 3. Laparoscopy
• accurate diagnosis of salpingitis
• bacteriologic diagnosis.
• not readily available
• not easy to justify when sym are mild or vague.
• not detect endometritis
• might not detect subtle inflammation of FT.

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Grading (Soper,1991) Mild erythema, edema,
exudates, tubes are patent mobile, Moderate
purulent discharge fixed tubes Severe TO
abscess, pyosalpinx
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• Empiric treatment of PID
• WHY?
• Diagnosis is difficult
• Delay in diagnosis tt inflam sequelae in upper
  FGT.
• Diagnosis management of other causes of lower
  abd pain (ectopic pregnancy, ac appendicitis,
  functional pain) are not impaired by initiating
  empiric antimicrobial tt for PID.

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• Recommendation
• lack of definitive clinical diagnostic criteria
• a low threshold for empirical tt of PID is
  recommended (RCOG, 2003, B)
• Outpatient antibiotic tt should be commenced as
  soon as the diagnosis is suspected. (RCOG, 2003,
  A)

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• When?
• Sexually active young women and other women at
  risk for STDs
• Pain pelvic or lower abd
• Other causes are excluded
• Tenderness on pelvic examination (minimum
  criteria)
• cervical motion OR
• uterine OR
• adnexal.

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• Hager criteria (Hager et al,1983)
• Abdominal pain tenderness,
• Cervical movement tenderness
• Adenxal tenderness 1 or more of the following
• T.gt 38 C,
• Leucocytosis gt 10000,
• ESR gt 15 mm/h,
• Gram ve intracellular diplcocci,
• 6 WBC/HPF,
• I.F. stain CT
• U/S adenxal mass,
• culdocentesis purulent discharge

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• The requirement that all 3 minimum criteria be
  present before the initiation of empiric tt
  insufficient sensitivity for the diagnosis of
  PID.

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Additional criteria enhance the specificity of
the minimum criteria support a diagnosis T
gt38.3C, Discharge mucopurulent Saline
microscopy WBC 6-10/HPF ESR elevated CRP
elevated laboratory documentation of NG or
CT.
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The most specific criteria 1. TVS or MRI
thickened, fluid-filled tubes with or without
free pelvic fluid or tubo-ovarian complex 2.
Doppler tubal hyperemia 3. laparoscopy
abnormalities consistent with PID. 4. Endometrial
biopsy endometritis Done if, laparoscopy do not
show salpingitis some women with PID have
endometritis alone.
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Tubo-ovarial abscess an echo poor septated
process close to the uterus (U).
PID tubo-ovarian complex
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Treatment
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• Treatment should be initiated as soon as the
  presumptive diagnosis has been made prevention
  of long-term sequelae

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• Indication of hospitalization
• Surgical emergencies (appendicitis) cannot be
  excluded
• Pregnant
• No response to oral antimicrobial therapy
• Unable to follow or tolerate an outpatient oral
  regimen
• Severe illness (NV, or high fever)
• Tubo-ovarian abscess.

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Recommended Parenteral Regimen A (RCOG, 2003,
B) Cefotetan (Cefotan) 2 g IV every 12
h OR Cefoxitin (Mefoxin) 2 g IV/ 6
h PLUS Doxycycline 100 mg orally or IV/12
h Parenteral therapy may be discontinued 24 h
after a patient improves clinically, and oral
therapy with doxycycline (100 mg twice a day)
should continue to complete 14 days of therapy.
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• Tubo-ovarian abscess
• Clindamycin or metronidazole with doxycycline,
  for continued therapy, rather than doxycycline
  alone more effective anaerobic coverage.

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• Surgical treatment should be considered in severe
  cases or where there is clear evidence of a
  pelvic abscess. (RCOG, 2003,B)
• Hospitalization at least 24 h
• Laparotomy/laparoscopy
• division of adhesions drainage of pelvic
  abscesses.
• adhesiolysis in cases of perihepatitis although
  there is no evidence as to whether this is
  superior to antibiotic therapy alone.
• 3. US-guided aspiration
• less invasive and may be equally effective.

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Recommmended Parenteral Regimen B Clindamycin 900
mg IV every 8 hours PLUS Gentamicin loading dose
IV or IM (2 mg/kg of body weight), followed by a
maintenance dose (1.5 mg/kg) every 8 h.
Parenteral therapy can be discontinued 24 hours
after a patient improves clinically continuing
oral therapy should consist of doxycycline 100 mg
orally twice a day or clindamycin 450 mg orally
four times a day to complete a total of 14 days
of therapy.
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• Bevan CD, Ridgway GL, Rothermel CD. Efficacy and
  safety of azithromycin as monotherapy or combined
  with metronidazole compared with two standard
  multidrug regimens for the treatment of acute
  pelvic inflammatory disease. J Int Med Res
  2003314554.
• Azithromycin (Zithromax)
• 500 mg/d IV for 1 day or 2 days followed by 250
  mg/d orally for a total of 7 days, alone or with
• Metronidazole
• 400 mg tds or 500 mg IV then
• orally for a total of 14 days.

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• Rates of clinical success for
• Azithromycin alone 97.1
• with metronidazole 98.1
• Conclusion
• Azithromycin, alone or with metronidazole,
  provides a shorter, simpler treatment option for
  the successful management of acute PID.

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Recommended Oral Regimen A (RCOG, 2003,
B) Levofloxacin 500 mg orally once daily for 14
days OR Ofloxacin 400 mg orally once daily for
14 days WITH OR WITHOUT Metronidazole 500 mg
orally twice a day for 14 days
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Azithromycin 250 mg daily for 7
days Plus Metronidazole 500 mg tds for 14 d
effective against anaerobes and BV (Bevan et
al, 2003).
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• Management of Sex Partners
• Examined and treated if they had sexual contact
  with the patient during the 60 days preceding the
  patients onset of symptoms.
• a. Risk for reinfection of the patient
• b. strong likelihood of urethral gonococcal or
  chlamydial infection in the sex partner.
• With regimens effective against both of these
  infections

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• IUD
• Risk of PID
• confined to the first 3 w after insertion and is
  uncommon thereafter.
• A Cochrane review
• Doxycycline or azithromycin (Zithromax) before
  IUD insertion confers little benefit.
• PID in IUD users
• No evidence that IUDs should be removed
• Close clinical follow-up is mandatory.
• IUCD may be left in mild PID but should be
  removed in severe cases (RCOG, 2003,B)

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HSG Postoperative PID is an uncommon but
potentially serious complication. Patients with
dilated fallopian tubes are at greater risk. 1.
Dilated fallopian tubes 100 mg of doxycycline
twice daily for 5 d. 2. History of pelvic
infection doxycycline before the procedure
continued if dilated fallopian tubes are found
(ACOG, 2006).
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Surgical Abortion/DC periabortal antibiotics
had a 42 overall decreased risk of infection.
ACOG antibiotic prophylaxis is effective,
regardless of risk. Doxycycline 100 mg orally 1
h before procedure 200 mg after
procedure Metronidazole 500 mg orally twice
daily for 5 d
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• COC and PID
• BTB screen for C. trachomatis (RCOG, 2003, C)
• COC has been regarded as protective against
  symptomatic PID.
• Increased risk of CT.
• may mask endometritis.
• Effectiveness may be reduced when taking
  antibiotic

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Thank you Prof. Aboubakr Elnashar Benha
University Hosp. Egypt Chief Ob Gyn Dept. KJO
Hosp Email elnashar53_at_hotmail.com