PEDIATRIC UROLITHIASIS

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PID
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PID

• Ascending infection of the upper female genital
  tract and includes
• Endometritis
• Salpingo-oophritis
• Pelvic peritonitis
• Parametritis
• Perihepatitis

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Vaginal flora
Grade 1 (Normal)
Grade III (Vaginosis)

• Lactobacilli
• Diphtheroids
• Staph. Epidermidis
• Strep. Fecalis
• GBS
• E.Coli
• C. Albicans

• G. Vaginalis
• B. Fragilis
• M. Hominis
• Peptococci
• Cl. Welchii
• Listeria

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Microbiology of PID
STD N. gonorrhoea C. trachomatis
Endogenous Pathogens G. Vaginalis E.
coli Anaerobic streptococci B. Fragilis M.
Hominis
Respiratory Pathogens H.Influenza Strep.
Pyogenes Pneumococci
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How does the organism overcome the genital
barrier?

• Menstruation
• Instrumentation
• Sperm transport
• IUCD

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Adolescent PID
Westrom in 1980 gave the following figures in
sexually active adolescent girls Age in years
Risk of PID 15
1/8 16
1/10 24 1/80

• Why the incidence is high?
• Sexual activity
• Cervical ectopy
• Poor sex education

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Factors That Enhance or Inhibit the Development
of Acute Salpingitis
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Risk factors

• Sexual PID
• Sexual activity
• Sexual partners
• Sex
• During menses
• Orogenital sex

• Non-sexual PID
• Instrumentation
• Pregnancy termination
• IUD-related
• Douching

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Ascending infection
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Incidence of PID

• Difficulty of estimation
• Silent PID
• Atypical PID
• No confirmatory Lap.
• 3 of women have PID during their lifetime
• It is more in adolescents, blacks and prostitutes
• Risk of recurrence is 25

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Acute salpingitis
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Acute salpingitis
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Pyosalpinx
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Chronic PID
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Manifestations of PID

• Essential criteria
• Tender lower abdomen
• Tender tubal points
• Cervical motion tenderness

• Additional criteria
• Fever gt 38.30C (PO)
• Mucopurulent cervicitis
• Lab
• ESR gt 40 mm/hr
• CRP gt 5 mg
• Leucocytosis gt 104/?l
• Positive smear
• Positive culture
• Serodiagnosis

• Elaborate criteria
• Plasma cell endometritis
• Sonography
• X-ray
• Culdocentesis
• Lap.

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Fluid per culdocentesis
Blood Disturbed ectopic Leaking corpus haematoma Retrograde menstruation
Pus Leaking TOA Appendicular abscess Diverticular abscess
Cloudy fluid Peritonitis Adnexal torsion Ovarian cyst
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Differential diagnosis of PID

• Spontaneous abortion
• Appendicitis
• Ectopic pregnancy
• Ruptured ovarian cyst
• Degenerating myoma
• Endometriosis
• IBD
• Diverticulitis

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Atypical PID

• Silent PID
• Recurrent PID
• Fitz-Hugh-Curtis syndrome

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Silent PIDthree times manifest PID

1. No clinical manifestations
2. Tubal infertility
3. Antibody to chlamydia trachomatis

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Long-term sequelae of PID

• Infertility
• Ectopic pregnancy
• Pelvic pain
• Hydrosalpinx
• Pyosalpinx
• Tubo-ovarian abscess
• Pelvic abscess
• Pelvic adhesion

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Westrom in 1980 gave the following statistics
Previous PID Infertility Ectopic
No 1 attack 2 attacks 3 attacks 10 11 23 54 0.5 5 10 20
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Fate of tubal infection

• Recovery
• Tubal deciliation
• Tubal occlusion
• Pelvic abscess
• Pelvic adhesion

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Chronic PID

• Tuberculosis
• Actinomycosis
• Schistosomiasis

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Pelvic infection
Item Pelvic abscess Pelvic cellulitis
Cause PID Appendicitis Diverticulitis Post-hysterectomy Post-partum Post-cconisation
Mass Fluctuant Tender Cul-de-sac Ill-defined diffuse Tender Side of pelvis
Pain
Fertility Impaired normal
Complications Rupture Pointing in 7 site DVT Septic emboli
Treatment Antibiotic Colpotomy Antibiotic Heparin Drainage
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Non-specific IBD
Item Crohn disease Ulcerative colitis
Site Small gut (Ileum) Large gut (Rectum)
Lesion Granuloma Transmural affection Skip area Fistulas Crypt abscesses Mucosal affection Diffuse No fistula
Age Young Aged
Cancer No Yes
Resection Is not curative Curative
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Prevention of PID

• Sex education
• Barrier contraceptives
• Antibiotic for high risks, HSG, IUCD
• Aggressive treatment

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Indications for hospitalization

• Poor patient compliance
• Severe clinical disease
• Suspected anaerobiosis
• Uncertain diagnosis

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General advice

• Bed rest (Fowler position)
• Avoidance of sex
• Treatment of male partner
• Screen for STD
• Any patient with fever and abdominal pain is not
  given antibiotic unless the diagnosis is certain
  or laparotomy is decided

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Indications for laparoscopy

• Uncertain diagnosis
• Poor responders
• Recurrent case

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Laparoscopic adhesiolysis
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Antibiotic therapy

• Parenteral versus oral therapy
• Monotherapy versus multiple ones
• Before versus after microbial diagnosis

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Antibiotic therapy

• Inpatient regimen
• Regimen 1
• Mefoxin 2g IV/6hr 1w
• doxycycline 100 mg bid 2 w
• Regimen II
• Dalacin 0.9 g IV/8hr 1w
• Garamycin 60 mg/8hr 1 w
• doxycycline 100 mg bid 2 w

• Outpatient regimen
• Regimen 1
• Mefoxin 2g IM
• doxycycline 100 mg bid 2 w
• Regimen II
• Amoxicillin 3g PO (Probenecid)
• doxycycline 100 mg bid 2 w

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Failure of antibiotic therapy

• Question the diagnosis of PID
• Causes of failure
• Capsule that protects from phagocytosis
• L-form of bacteria
• B-lactamase production

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Fertility Surgery?????
Pelvic Clearance