Pelvic Inflammatory Disease – PID – Striroga, Gynecology | Liveveda

It is an inflammatory condition of the pelvic structures due to infection.

Ascending spread of infection from the lower reproductive tract (vagina, cervix) to the upper reproductive tract - ( uterus- endometrium, FT, Ovaries), pelvic peritoneum & surrounding structures.

Pathway of ascending infection -

Endometritis ----> Salphingitis ------> Oophoritis/ Tubo- ovarian abscess ----> Pelvic perotonitis

Risk Factors -

  1. Pervious history of acute PID
  2. Multiple partners
  3. Adolescence(menstruating, Estrogen decrease-PH increase, contaminated blood)
  4. Insertion of IUCD
  5. Area with high prevalence of STDs
  6. No use of OCP (progesterone pills - estrogen increase, decrease menstrual flow duration, Thick mucous plug.

Causative organisms

Usually polymicrobial infection

  • N. Gonorrhea
  • Chlaymydia trachomatis
  • Mycoplasma hominis

others - normally found in vagina

E.coli, Streptococcus, Staphylococcus, Fragilis, Bivius.

Pathology

  1. Mostly bilateral tube(both fallopian tube) involvement, usually following menses.
  2. Severe infection-acute inflammatory Rx- oedematous & hyperemic tubes - Epi cells, cilia & microvilli damaged.
  3. Exfoliated cells & exudates pour into lumen of tube & agglutinate the mucosal folds.
  4. Abdominal ostium - closed by inflammatory adhesions & indrawing of oedematous fimbrae.
  5. Uterine end - closed by congestion.
  6. Closure of both tubes - pent up exudates inside the tube.
  • Depending upon severity - exudate may be watery (Hydrosalpinx) or purulent (pyosalpinx) - favours growth of other organisms - more tissue destruction & deeper penetration.
  • As outer (serous) coat is not much affected - not so much adhesions of tubes with surrounding structures (unlike pyogenic/tubercular infection)
  • Sometimes - exudates pours by abdominal ostium- pelvic peritonitis, pelvic abscess or ovarian abscess - TO (Tubo-ovarian) mass

Clinical features

  1. Pain and tenderness in lower abdomen & pelvic region
  2. Irregular menstrual bleeding
  3. Dyspareunia (painful coitus)
  4. Abnormal vaginal discharge
  5. High grade temp., lassitude, headache, nausea & vomiting
  6. P/V - cervical motion tenderness, adnexal tenderness

Fitz-Hugh-Curtis syndrome - A rare complication of PID involving liver capsule inflammation (peri hepatitis) leading to Pain & discomfort in right hypochondrium.

Investigation

  1. C/S (Culture sensitivity) - of discharge from infection site.
  2. Blood - TLC > 10,000 cu/mm, ESR > 15 mm/hr, Serological test for syphilis (both H&W)
  3. USG - Dilated & fluid filled tubes, fluid in POD or adnexal mass.
  4. Laparoscopy - For direct visualization, gold standard, most reliable.
  5. Culdocentesis - Aspiration of peritoneal fluid- WBC count > 30000/ml - acute PID.

Complications

  • Infertility
  • chronic pelvic pain or ill health
  • Ectopic pregnancy
  • Chronic pelvic inflammation - adhesions/ hydrosalpnix/ pyosalpinx/ TO mass
  • Pelvic peritonitis, general peritonitis, septicemia.

Treatment

  • Preventive measures & education.
  • Male partner properly investigated & treated effectively.
  • Rest, analgesics, combination of antibiotics.

Acute PID T/t - BSA (as PID - polymicrobial) with rest & analgesics (CDC guideline) - Oral therapy - 14 days

  • Regimen A - Levofloxacin or, Oflaxacin OD with or without Metronidazole
  • Regimen B - Ceftriaxone IM single dose + Doxycycline + or - Metronidazole

If after 48 hours no response - Patient should be admitted - (CDC guideline)

  • Regimen A- Cefoxitin 2 gm IV QID for 2-4 days + Doxycycline 100 mg for 14 days
  • Regimen B - Gentamicin 2 mg/kg IV (loading) - 1.5 mg/kg IV TDS + Clindamicin 900 mg IV TDS
  • Alternative regimen - Levofloxacin 500 mg IV OD + or - Metronidazole 500 mg in 8 hourly.

Indication of Surgery

  1. General peritonitis
  2. Pelvic abscess
  3. T-O mass not responding to antimicrobial therapy

Follow up -

1. Repeat smear & culture from discharge after 7 days following full course of treatment.

2. Repeat tests following each MC until it becomes negative for 3 consecutive reports when patient is declared cured.

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