PELVIC INFLAMMATORY DISEASE - PowerPoint Presentation

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PELVIC INFLAMMATORY DISEASE

ASAL ALQUM

CASE:

A 19 year old nulligravida presents to the emergency department with

bilateral lower abdominal pelvic pain

for 24 hours. She

just finished her menses

. She is

sexually active

but using no contraception. Speculum examination reveals

mucopurulent cervical discharge

. Bimanual pelvic examination shows

bilateral adnexal tenderness

and

cervical motion tenderness

. She is afebrile. Qualitative urinary

b-

hCG

test is negative

. Complete blood cell count shows

WBC 14,000

.

ESR is elevated

.

What is PID?

PID is a non specific term for a spectrum of upper genital tract conditions ranging from acute bacterial infection to massive adhesions from old inflammatory scarring.

The most common initial organisms are chlamydia

and

gonorrhea

.

With persistent infection, secondary bacterial invaders include

anaerobes

and

gram-negative

organisms.

PID is an ascending infection

Cervicitis

Acute salpingo-ophritis

Treatment

No treatment

Heals

without

adhesions

Normal pelvis

Heals

with

adhesions

Chronic PID

Gets worse

TOA

Transmission:

Sexual transmission via the vagina &

cervix.

Gynecological surgical

procedures.

Child birth/

Abortion.

A foreign body inside uterus (IUCD). Contamination from other inflamed structures in abdominal cavity (appendix,

gallbladder).Blood-borne transmission (pelvic TB)

Risk factors:

The most common risk factor is female sexual activity in adolescence, with multiple partners.

Exposure immediately prior to menstruation

.

Relative

ill-health & poor nutritional

status.

Previously

infected tissues (STD/

PID).Frequent vaginal douching.

Cervicitis

The initial infection starts with invasion of endocervical glands chlamydia and gonorrhea.

Mucopurulent cervical discharge and friable cervix.

No pelvic tenderness. The patient is afebrile.

Positive culture for chlamydia or gonorrhea.

WBCs and ESR are normal.

Management: single dose orally of cefixime and azithromycin.

Acute Salpingo-Oophritis

Bilateral lower abdominal pain may be variable.

Onset may be gradual to sudden.

Nausea and vomiting may be found if abdominal involvement is present.

Mucopurulent cervical discharge, cervical motion tenderness and bilateral adnexal mass tenderness.

Fever, tachycardia, abdominal tenderness, peritoneal signs and guarding may be found depending on the extent of infection progression.

Acute salpingo-ophritis

CLINICAL DIAGNOSIS.

Minimal criteria:

1)

Pain

: pelvic or lower abdominal.

2)

Tenderness: cervix, uterus, adnexa.

3) Sexually active woman. 4) No other identified cause.

Acute salpingo-ophritis

Supportive

crieteria

:

Fever.

Mucopus

: cervical or vaginal.

Leukocytes: vaginal fluid.

Elevated WBC or ESR or CRP.

Positive GC or Chlamydia testing.

Acute salpingo-ophritis

Most specific criteria for diagnosis:

Endometrial biopsy showing endometritis.

Vaginal sono or MRI imaging showing abnormal adnexa.

Laparoscopic abnormalities consistent with PID.

Management

Inpatient criteria:

High fever.

Nausea and vomiting.

Failed outpatient therapy.

Severe pain

Unsure diagnosis

TOA

Antibiotics

:

Cefotetan

2g IV q 12handDoxycycline 100mg IV q 12h

Management

Outpatient criteria:

Absence of inpatient criteria.

Ceftraxone

250mg IM x1

Doxycycline

100mg bid x 14d

With or without

Metronidazole

Differential diagnosis

Adnexal torsion

Ectopic pregnancy

Endometriosis

Appendicitis

Diverticulitis

Crohns

disease

Tubo-Ovarian Abcess

Is the accumulation of pus in the adnexa forming an inflammatory mass involving the oviducts, ovaries, uterus or omentum.

T

he patient will look septic

Lowe abdominal pain is severe

Often there is severe back pain, rectal pain and pain with bowel movements.

Nausea and vomiting are present.

High fever

Tubo-Ovarian Abcess

Tachycardia

May be in septic shock with hypotension

Abdominal exam: peritoneal signs, guarding and rigidity

Bilateral adnexal masses may be palpable.

Investigative findings: WBCs and ESR are markedly elevated, positive cervical culture for chlamydia or gonorrhea, blood cultures may be positive for gram-negative bacteria and anaerobic organisms.

Sono or CT will show bilateral complex pelvic masses.

Tubo-Ovarian Abcess

Management:

Inpatient IV

gentamycin

and

clindamycin

If

no response

or there is

rupture

of the abcess exposing free pus into the peritoneal cavity then an exploratory laparotomy with possible TAH and BSO

or percutaneous drainage may be required.

Tubo-Ovarian Abcess

Differential diagnosis:

Septic abortion

Diverticular or appendicular

abcess

Adnexal torsion

Chronic PID

Chronic bilateral lower abdominal pain and tenderness

Cervical motion tenderness

History of

infertility, dyspareunia, ectopic pregnancy

Nausea and vomiting are absent

Normal WBC and ESR

No

mucopus

No fever

Chronic PID

Diagnosis:

laparoscopic

visualization of diffuse pelvic adhesions

Mild analgesics, lysis, severe unremitting pain may require TAH-BSO.