Pelvic Inflammatory Disease

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Pelvic Inflammatory Disease

• Edwin M. Thorpe, Jr. M.D.
• Associate Professor
• Division of Gynecologic Specialties
• Department of Obstetrics and Gynecology
• University of Tennessee Health Science Center

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CREOG Educational Objectives Pelvic
Inflammatory Disease

• Describe the diagnostic criteria for PID
• List the common infectious agents implicated in
  PID
• Elicit a pertinent history from a patient
  suspected to have PID
• Perform a physical exam to confirm the diagnosis
  of PID

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CREOG Educational Objectives Pelvic
Inflammatory Disease

• Describe the appropriate diagnostic tests to
  confirm PID, including
• Indications for the tests
• How to perform the tests
• Interpretation of the results
• Endocervical swab for culture or nucleic acid
  probe
• Endometrial biopsy
• Laparoscopy

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CREOG Educational Objectives Pelvic
Inflammatory Disease

• Treatment of PID with appropriate antimicrobial
  and surgical options
• Summarize the potential long-term effects of
  PID and counsel patients regarding the risks of
  further complications, including
• Chronic pelvic pain
• Infertility
• Ectopic pregnancy

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Pelvic Inflammatory Disease

• Upper genital tract infections that involve the
  endometrium (endometritis), fallopian tubes
  (salpingitis), and pelvic peritoneum
  (peritonitis).
• These infections result from ascending spread of
  lower genital tract infection

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Infectious agents - STDs
PID Ascending infection
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Pelvic Inflammatory Disease

• Estimates of the annual incidence of PID in the
  United States are
• Between 9.5 to 14 cases per 1,000 fertile women,
  with a higher rate of 18 to 20 per 1,000 among
  women aged 15 to 24 years.
• As many as 1,000,000 cases of PID occur annually
  in the United States resulting in approximately
  200,000 hospitalizations.
• Due to under reporting, incidence figures are
  unreliable

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Risk Factors for PID Adolescents

• Younger age at first intercourse
• Older sex partners
• Involvement with child protection agency
• Prior suicide attempt(s)
• Consumption of alcohol before sex
• Current chlamydia infection

Suss AL. Sex Transm Dis 2000 27(5)259-91.
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Pelvic Inflammatory Disease

• The most common etiologic agents in PID are
• Neisseria gonorrhoeae,
• Chlamydia trachomatis
• Anaerobic bacterial species found in the vagina,
  particularly Bacteroides spp.,
• Anaerobic gram-positive cocci, (Peptostreptococci)
  ,
• E. coli
• Mycoplasma hominis

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Pelvic Inflammatory Disease

• These organisms initially cause lower genital
  tract infections and then spread into the upper
  genital tract via the endometrium.
• Many cases - polymicrobial in etiology. Pure
  gonococcal or chlamydial PID is possible.
• The relative frequency of the various agents
  depends somewhat on
• the population tested,
• the site cultured (i.e., cervix, endometrium, or
  Fallopian tubes),
• the sensitivity of the diagnostic tests performed.

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PID History and Examination

• Symptoms suggestive of PID include
• Abdominal pain (usually bilateral and in the
  lower quadrants),
• Dyspareunia,
• abnormal Vaginal discharge,
• Menometrorrhagia,
• Dysuria,
• Onset of pain in association with menses,
• Fever, and/or chills
• Nausea or vomiting

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PID History and Examination

• Women with endometritis may present with
• vaginal discharge or
• intermenstrual bleeding, and
• have uterine tenderness on pelvic exam

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PID Additional Considerations

• PID is difficult to accurately diagnose, in part,
  because manifestations range from mild to quite
  severe
• All young, sexually active women presenting with
  lower abdominal pain should be carefully
  evaluated for the presence of salpingitis and
  endometritis
• Routine bimanual and abdominal exams should be
  done on all women with an STD, since some women
  with salpingitis or endometritis will not
  complain of lower abdominal pain.

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Diagnosis of Acute PID CDC Criteria

• Minimum findings
• Cervical motion tenderness and uterine and
  adnexal tenderness, along with WBCs seen on
  vaginal wet mount
• Additional supportive criteria to increase the
  specificity
• - Oral temperature higher than 101ºF (38.3ºC)
• - Abnormal cervical or vaginal mucopurulent
  discharge
• - Elevated erythrocyte sedimentation rate
• - Elevated C-reactive protein level
• - Laboratory documentation of cervical
  infection with N gonorrhoeae or C
  trachomatis

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Diagnosis of PID Laboratory Tests

• 1. Gram-stained endocervical smear (to quantify
  PMNs/1000x field and to look for intracellular
  Gram-negative diplococci)
• 2. Endocervical NAAT or endocervical (and rectal)
  cultures for N. gonorrhoeae
• 3. Culture of endocervical swab or NAAT for
  endocervical swab or first void urine for C.
  trachomatis
• 4. Wet prep for WBCs
• 5. If menses is late or if the patient is not
  using reliable contraception
• - check pulse and blood pressure (supine and
  seated)
• - obtain serum or sensitive urine pregnancy test
  if ectopic pregnancy is suspected.

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Diagnosis of PID Association of LGTI

• Evaluation of vaginal discharge
• Underutilized
• Consistent predictor
• Criteria
• Inflammatory cells outnumber all other cellular
  elements
• Absence for WBCs plus clear mucous high
  negative predictive value

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Diagnosis of PID Endometrial biopsy

• Prevalence and manifestations of endometritis
  among women with cervicitis.Paavonen J, Kiviat
  N, Brunham RC, Stevens CE, Kuo CC, Stamm WE,
  Miettinen A, Soules M, Eschenbach DA, Holmes
  KK.Thirty-five women referred from an STD
  Clinic, because of suspected cervicitis, studied
  for the presence of endometritis by transcervical
  endometrial biopsies and cervical and endometrial
  cultures.
• Fourteen (40) of the patients had histologic
  evidence of endometritis.
• Findings that significantly correlated with
  endometritis included a history of intermenstrual
  vaginal bleeding, the presence of Chlamydia
  trachomatis, Neisseria gonorrhoeae, or
  Streptococcus agalactiae in the cervix, and the
  presence of serum antibodies to C. trachomatis or
  to Mycoplasma hominis.

Am J Obstet Gynecol. 1985 Jun 1152(3)280-6
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Diagnosis of PID Laparoscopy

• Gold Standard
• University of Helsinki study (N33)
• Confirmed PID in 20 (61)
• 11 (33) other diseases
• 2 (6) no evidence of disease
• Final diagnosis in 91
• Lysis of adhesions, drainage, irrigation,
  extirpation

Molander P. J Am Assoc Gynecol Laparosc
20007(1)107-10.
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Laparoscopic findings Acute PID
Pyosalpinx
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CT Scan Findings Acute PID
Thickened Fallopian tube
Thickened Fallopian tube
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Diagnosis of PID Additional considerations

• Enlargement or induration of one or both
  fallopian tubes, a tender pelvic mass, and direct
  or rebound abdominal tenderness may also be
  present.
• Temperature may be elevated but is normal in many
  cases
• In general, clinicians should err on the side of
  over-diagnosing and treating milder cases.
• Some women have chlamydial infection of the upper
  genital tract without apparent clinical
  manifestations of PID (i.e., silent
  salpingitis).

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Treatment Strategies
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Treatment of PID

• Often unclear, based on cervical samples, which
  etiologic agents are causative in a given
  patient, thus
• broad spectrum antimicrobial coverage should be
  provided to cover gonorrhea, chlamydia, and
  anaerobes.
• Patients should be advised to
• Rest for 1 to 3 days or until symptoms have
  resolved or pain is significantly improved (pain
  score decreased by 50) and to,
• Abstain from sexual intercourse until follow-up
  cultures are negative (usually a minimum of 2
  weeks).
• An IUD should be removed in moderate to severe
  cases of PID.

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Treatment of PID CDC Criteria for
Hospitalization

• Surgical emergencies such as appendicitis cannot
  be excluded
• Pregnancy
• No clinical response to oral antimicrobial
  therapy
• Inability to follow or intolerance of the
  outpatient oral regimen
• Severe illness, nausea and vomiting, or high
  fever
• Tubo-ovarian abscess

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Outpatient Treatment of PID CDC Treatment
Guidelines 2002

• Regimen A
• Either of the following
• - Ofloxacin 400 mg orally twice a day for 14
  days
• - Levofloxacin 500 mg orally once daily, with or
  without Metronidazole
• 500 mg orally twice a day for 14 days.
• Regimen B
• Any of the following
• - Ceftriaxone 250 mg IM once,
• - Cefoxitin or Cefotetan 2 g IM plus Probenecid,
  1 g orally in a single dose,
• Other parenteral third-generation
  cephalosporins (e.g., ceftizoxime or
  cefotaxime),
• plus
• - Doxycycline 100 mg orally twice a day for 14
  days, with or without Metronidazole 500 mg
  orally twice a day for 14 days.

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Inpatient Treatment of PID CDC Treatment
Guidelines 2002

• Regimen A
• Either of the following
• Cefotetan 2 g IV every 12 hours,
• Cefoxitin 2 g IV every 6 hours, plus Doxycycline
  100 mg orally or IV every 12 hours.
• 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 hours. Single daily dosing may be
  substituted.

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Inpatient Treatment of PID CDC Treatment
Guidelines 2002

• Alternative parenteral regimens
• Limited data supports the use of other parenteral
  regimens, but the following three regimens have
  been investigated in at least one clinical trial,
  and they have broad spectrum coverage.
• - Ofloxacin 400 mg IV every 12 hours,
• - Levofloxacin 500 mg IV once daily with or
  without Metronidazole 500 mg IV every 8 hours,
• - Ampicillan/Sulbactam 3 g IV every 6 hours
  plus Doxycycline 100 mg orally or IV every 12
  hours.

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Treatment of PID Additional Considerations

• In non-PID patients, Chlamydia and anaerobes in
  the cervix / vagina ascend to the endometrium in
  45-60 of cases (only 20 for N. gonorrhoeae).
• Outpatient regimens are effective in eradicating
  N. gonorrhoeae from the endometrium and although
  C. trachomatis and anaerobic flora are variably
  reduced (endometrium.
• Ofloxacin and clindamycin appear to be more
  effective in clearing the endometrium of
  anaerobic organisms than ceftriaxone and
  doxycycline, but (at 4 weeks) appear to be no
  different in improving histopathologic evidence
  of endometritis.

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Transvaginal Ultrasound Guided Aspiration

• Wayne State University Medical Center
• N22 women 27 pelvic abscesses (13 TOA, 14 POA)
• Mean age 30
• Mean duration (d) - diagnosis to drainage 5.6/2.0
• Mean diameter - 86mm
• Volume of purulent material 70-750cc
• Cultures positive in 51
• Successful in 25/27 cases

Corsi PJ. Infect Dis Obstet Gynecol 19997(5)
216-21.
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Treatment of PID Follow-up

• The follow-up schedule should be individualized,
  but an ideal follow-up schedule would be
• 1. 1 to 3 days after starting treatment
• The patients therapy should be reevaluated in
  light of microbiological results at the 3-day
  follow-up visit.
• In patients who are not improved after 3 days of
  treatment, consideration should be given to
  hospitalizing the patient for parenteral therapy
  and further diagnostic evaluation.
• 2. 7 to 10 days after completing treatment
• Repeat endocervical and rectal gonorrhea
  cultures (applies to both gonococcal and
  nongonococcal PID).
• Repeat endocervical chlamydia culture or NAAT
  (although a positive NAAT could be due to
  non-viable organisms after effective treatment).

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Treatment of PID Follow-up

• MANAGEMENT OF SEX PARTNERS
• Examination and urethral smear and culture for
  gonorrhea and NAAT for chlamydia for all sex
  partners within the preceding 4 weeks, regardless
  of symptoms.
• Empirically treat partners with cefixime and
  doxycycline or azithromycin to cover C.
  trachomatis and N. gonorrhoeae, regardless of the
  apparent etiology of the PID.
• Cases should be reported to the state/local
  health department

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Sequelae of Pelvic Inflammatory Disease

• Reported sequelae occurs in up to 25 of cases
• - Infertility (12 to 50)
• - Ectopic Pregnancy (6 to 10 fold increase)
• - Chronic Pelvic Pain (18)
• - 100,000 surgical procedures
• Psychological Problems devastating

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PID Postmenopausal Women

• Exact mechanism unclear
• Direct extension from adjacent viscera
• Risks
• Uterine instrumentation
• Structural abnormalities (stenosis, polyps, etc)
• Forgotten IUD
• Degenerating myomas
• Postmenopausal vaginal flora (anaerobic)

Jackson SL. Infect Dis Obstet Gynecol 19997(5)
248-52.
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PID Postmenopausal Women

• Presenting symptoms include
• Vaginal spotting, bleeding, pain, fever, nausea,
  change in bowel habits
• Majority have tuboovarian abscess USG or CT
• Differential diagnosis
• Diverticulitis, appendicitis, bowel perforation
• Liberal use of laparoscopy

Jackson SL. Infect Dis Obstet Gynecol 1999 7(5)
248-52.
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PID Postmenopausal Women

• Treatment
• Hospitalization
• IV antibiotics
• Remove IUD
• Early surgical intervention
• Mortality up to 25

Jackson SL. Infect Dis Obstet Gynecol 1999 7(5)
248-52.
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PID Where Do We Go From Here?

• 1. Reduction in risk factors effective
  behavioral interventions
• 2. Vaccine development (chlamydial and gonococcal
  infection)
• 3. Better screening
• a. More sensitive screening tests (specificity
  can be compromised)
• b. Broader based and more frequently applied
  screening programs
• 4. Better diagnostics
• a. Identification of STD agents more quickly
  sensitive specific methods
• b. Identification of silent PID
• 5. Better evaluation of therapy using outcome
  measures to assess efficacy
• a. Short term eradication of infecting agents,
  evidence of tissue healing
• b. Long term - fertility

Peter Rice MD 2002
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Prevention of PID Screening

• Adolescents
• Annual exams
• History of change of sex partners
• Every 6 months
• Prior to initiating contraception
• All women
• All women reporting signs symptoms of vaginitis
  or PID