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 -
- Pervious history of acute PID
- Multiple partners
- Adolescence(menstruating, Estrogen decrease-PH increase, contaminated blood)
- Insertion of IUCD
- Area with high prevalence of STDs
- No use of OCP (progesterone pills - estrogen increase, decrease menstrual flow duration, Thick mucous plug.
Usually polymicrobial infection
- N. Gonorrhea
- Chlaymydia trachomatis
- Mycoplasma hominis
others - normally found in vagina
E.coli, Streptococcus, Staphylococcus, Fragilis, Bivius.
- Mostly bilateral tube(both fallopian tube) involvement, usually following menses.
- Severe infection-acute inflammatory Rx- oedematous & hyperemic tubes - Epi cells, cilia & microvilli damaged.
- Exfoliated cells & exudates pour into lumen of tube & agglutinate the mucosal folds.
- Abdominal ostium - closed by inflammatory adhesions & indrawing of oedematous fimbrae.
- Uterine end - closed by congestion.
- 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
- Pain and tenderness in lower abdomen & pelvic region
- Irregular menstrual bleeding
- Dyspareunia (painful coitus)
- Abnormal vaginal discharge
- High grade temp., lassitude, headache, nausea & vomiting
- 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.
- C/S (Culture sensitivity) - of discharge from infection site.
- Blood - TLC > 10,000 cu/mm, ESR > 15 mm/hr, Serological test for syphilis (both H&W)
- USG - Dilated & fluid filled tubes, fluid in POD or adnexal mass.
- Laparoscopy - For direct visualization, gold standard, most reliable.
- Culdocentesis - Aspiration of peritoneal fluid- WBC count > 30000/ml - acute PID.
- chronic pelvic pain or ill health
- Ectopic pregnancy
- Chronic pelvic inflammation - adhesions/ hydrosalpnix/ pyosalpinx/ TO mass
- Pelvic peritonitis, general peritonitis, septicemia.
- 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
- General peritonitis
- Pelvic abscess
- 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.