Pelvic Inflammatory Disease 1

Pelvic Inflammatory Disease
INTRODUCTION
Background: Pelvic inflammatory disease (PID) is an inflammatory disorder of the uterus, fallopian tubes, and adjacent pelvic structures. Risk factors for PID include young age at first intercourse, multiple sexual partners, intrauterine device (IUD) insertion, and tobacco smoking. A delay in diagnosis or treatment can result in long-term sequelae such as tubal infertility.
Pathophysiology: In PID, the upper female genital tract is infected by direct spread of microorganisms ascending from the vagina and cervix. The cervix produces mucus that usually protects against upward spread, but bacteria may penetrate the cervical mucus and cause widespread extension of infection.
Frequency:
In the US: PID affects 11% of women of reproductive age. Approximately 1 million women experience an episode of PID per year, and 20% of these women require hospitalization for treatment. The disease produces 2.5 million office visits and 125,000-150,000 hospitalizations yearly.
Internationally: Public health efforts implemented in Scandinavia to decrease incidence of sexually transmitted disease (STD) have been quite effective.
Mortality/Morbidity: A delay in diagnosis or treatment can result in long-term reproductive sequelae, such as tubal infertility. Each repeat episode of PID doubles the risk for tubal factor infertility. Women with a history of PID have a 7- to 10-fold increased risk for ectopic pregnancy (tubal pregnancy) compared with women with no history of PID. Chronic pelvic pain can also follow PID and occurs in 25-75% of women.
Sex: PID is an infection of the female genital tract.
Age: PID may occur more frequently in adolescents (ie, 15-19 y), but it can occur in any patients who are sexually active. Age distributions vary with geographical location and etiology. Young age at first intercourse increases risk for PID.
CLINICAL
History: Patients can present with a variety of symptoms, ranging from lower abdominal pain to dysuria. A direct correlation exists between the incidence of STDs and PID in any given population.
Pain is present in more than 90% of documented cases and is by far the most common presenting symptom.
Usually, pain is described as dull, aching, and constant; it begins a few days after the onset of the last menstrual period and tends to be accentuated by motion, exercise, or coitus.
Pain from PID usually lasts less than 7 days; if pain lasts longer than 3 weeks, the likelihood that PID is the correct diagnosis declines substantially.
Abnormal vaginal discharge is present in approximately 75% of cases.
Unanticipated vaginal bleeding coexists in about 40% of cases.
Temperature higher than 38°C (30%), nausea, and vomiting manifest late in the clinical course of the disease.
Physical: The sensitivity of the pelvic examination is only 60%. The Centers for Disease Control and Prevention (CDC) recommends the following minimal clinical criteria for the diagnosis of PID: lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness.
In addition to the preceding criteria, at least 1 of the following findings also should be present:
Meets the case surveillance definition of chlamydial or gonorrheal infection
Temperature higher than 100.4°F or 38°C
Leukocytosis greater than 10,000 WBC/mm3
Purulent material in the peritoneal cavity obtained by culdocentesis or laparoscopy
Pelvic abscess or inflammatory complex detected by bimanual examination or by sonography
Patient is a sexual contact of a person known to have gonorrhea, Chlamydia infection, or nongonococcal urethritis
Causes: The classic high-risk patient is a menstruating woman younger than 25 years who has multiple sex partners, does not use contraception, and lives in an area with a high prevalence of STD. PID is also more prevalent among unmarried women and individuals who are young at first intercourse. The IUD confers a relative risk of 2.0-3.0 for the first 4 months following insertion, but then it decreases to baseline thereafter. Women who are not sexually active have a very low incidence of upper genital tract infection, as do women who have undergone tubal sterilization.
Chlamydia trachomatis: C trachomatis, an intracellular bacterial pathogen, is the predominant STD organism causing PID. Clinically, infection with this obligate intracellular parasite may manifest as mucopurulent cervicitis.
Cytomegalovirus (CMV): CMV has been found in the upper genital tracts of women with PID, suggesting a potential role of CMV in PID.
Endogenous microflora: In iatrogenically induced infections, the endogenous microflora of the vagina predominate.
Gardnerella vaginalis
Haemophilus influenzae
Enteric gram-negative organisms (Escherichia coli)
Peptococcus species
Streptococcus agalactiae
Bacteroides fragilis: This can cause tubal and epithelial destruction.
Pregnancy: PID is rare in pregnancy.
Neisseria gonorrhea: In the United States, the role of N gonorrhea as the primary cause of PID has decreased. DIFFERENTIALS
Adnexal Tumors Appendicitis Ectopic Pregnancy Endometriosis
Other Problems to be Considered:
Rupture of an adnexal massAdnexal torsionPerihepatic inflammation (Fitz-Hugh and Curtis syndrome)
WORKUP
Lab Studies:
Additional criteria may be used to increase the specificity of the diagnosis as listed below.
Vaginal wet mount - Increased amount of white cells
Erythrocyte sedimentation rate (ESR) - Elevated, nonspecific
C-reactive protein (CRP) - Elevated, nonspecific
CBC count - Elevated white blood cell count
Gonorrhea cultures - Generally used to confirm diagnosis (frequently negative in later stages)
Chlamydial cultures - Generally used to confirm diagnosis (large variability in recovery from cervix [5-56%])
Imaging Studies:
Transvaginal sonography may not be useful in the diagnosis of PID. It has poor sensitivity (81%) and specificity (78%) with mild or atypical PID. It can be used to document an adnexal mass or demonstrate fluid-filled fallopian tubes.
Although the specificity (95%) and sensitivity (95%) of MRI is relatively high, it is costly and rarely indicated in acute PID. If used in the management of PID, MRI can demonstrate thickened fluid-filled tubes with or without free pelvic fluid or tuboovarian complex.
Procedures:
Culdocentesis: With the advent of transvaginal sonography, culdocentesis rarely is performed. In the absence of current technology, insertion of an 18-gauge spinal needle attached to a syringe can be performed. The needle is inserted transvaginally into the cul-de-sac, yielding either purulent fluid or bloody fluid from the peritoneum. TREATMENT
Medical Care:
Most patients are now managed as outpatients, but physicians should consider hospitalization for patients with the following conditions, although no clear data suggest that these patients benefit from hospitalization:
Uncertain diagnosis
Pelvic abscess on ultrasound
Pregnancy
Failure to respond to outpatient management
Inability to tolerate outpatient PO regimen
Severe illness or nausea and vomiting precluding outpatient treatment
Immunodeficiency (eg, HIV with low CD4 count, using immunosuppressive medications)
Failure to improve clinically after 72 hours with outpatient therapy
Inpatient treatment includes the following:
Regimen A: Administer cefoxitin IV or cefotetan IV plus doxycycline PO/IV every 12 hours. Continue this regimen for 48 hours after the patient remains clinically improved, then start doxycycline PO twice daily for a total of 14 days. Administer doxycycline PO when possible because of pain associated with infusion. Bioavailability is similar with PO and IV administrations. IV antibiotics may be discontinued 24 hours after the patient improves clinically, and PO therapy with doxycycline is continued for a total of 14 days. If tuboovarian abscess is present, use clindamycin or metronidazole with doxycycline for more effective anaerobic coverage.
Regimen B: Administer clindamycin IV every 8 hours plus a loading dose of gentamicin IV or IM, followed by a maintenance dose every 8 hours. IV therapy may be discontinued 24 hours after the patient improves clinically, and PO therapy of doxycycline should be continued for a total of 14 days of therapy.
Outpatient treatment
Regimen A: Cefoxitin plus probenecid should be taken PO in a single dose. Alternatively, ceftriaxone (less active against anaerobic bacteria compared to cefoxitin) can be taken once IM with doxycycline PO twice daily for 14 days. Cefoxitin has better anaerobic coverage, and ceftriaxone has better coverage against N gonorrhea.
Regimen B: Ofloxacin should be taken PO for 14 days with either clindamycin or metronidazole, which also are taken PO for 14 days. PO ofloxacin lacks anaerobic coverage but is effective against N gonorrhea and C trachomatis.
Surgical Care: The advantage of laparoscopy is that it allows direct visualization of the pelvis and provides a more accurate and bacteriologic diagnosis if cultures are obtained. However, laparoscopy is not always available in acute PID. In addition, this procedure is costly and requires general anesthesia. It should be used if the diagnosis is in doubt. However, if operative laparoscopy is used early in the course of the disease, copious irrigation and separation of thin adhesions by blunt dissection may prevent later sequelae.
Consultations:
Obstetrician
Gynecologist
Diet: Patients should take nothing by mouth (NPO) if the diagnosis is uncertain or if the patient is scheduled for surgery.