Transcript PID
Katie DePlatchett, M.D.
AM Report
January 4th, 2010
Pelvic Inflammatory Disease
An infection in the upper genital tract not
associated with pregnancy or intraperitoneal
pelvic operations
Anatomy 101
Epidemiology
Annual incidence: 300,000 cases
~20% of 1.5 million cases of GC/Chlamydia
85% of infections are spontaneous in sexually
active females.
15% of infections develop following procedures
that break the cervical mucus barrier
Risk Factors
age at first voluntary intercourse less than 18
nonuse of barrier contraception
less than 12 years of education
more than one male sexual partner in the
previous 30 days
prior gonorrhea infection
intercourse during menses
Pathogenesis
Ascending infection
- Along mucosa
- Bacterial colonization
fallopian tubes &
endometrium
- Chlamydia trachomatis
- Neisseria gonorrhoeae
Complications
Tuboovarian abscesses
Perihepatitis, also known as Fitz-Hugh–Curtis
syndrome
tubal factor infertility
ectopic pregnancy
chronic pelvic pain
Symptoms according to ACOG
Abnormal vaginal discharge
Pain in the lower abdomen (often of a mild, aching
nature)
Fever and chills
Dysuria
Nausea and vomiting
Dysparunea
Diagnosis, per CDC Guidelines
Minimum Criteria:
Sexually active
Lower abdominal tenderness or Adnexal tenderness or Cervical
motion tenderness
No other plausible causes
Routine Criteria:
Oral temperature >38° C
Abnormal cervical or vaginal discharge (mucopurulent)
Presence of abundant WBCs on microscopy of vaginal secretions
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
Laboratory documentation of cervical infection with N.
gonorrhoeae or C. trachomatis
Diagnosis, per CDC Guidelines
Definitive Criteria for Diagnosing PID
Histopathologic evidence of endometritis on
endometrial biopsy
Transvaginal sonography or MRI showing thickened
fluid-filled tubes with or without free pelvic or
tuboovarian complex
Laparoscopic abnormalities consistent with PID
Diagnosis
Gold Standard = Direct visualization via the
laparoscope
However… operative laparoscopy during acute
infection has not been proven to reduce the
prevalence of long-term sequelae.
Hence, the diagnosis of the majority of episodes
of acute PID is made on the basis of clinical
history and physical examination.
Imaging
Ultrasonography
sensitivity 75%–82%
helpful in documenting an adnexal mass, especially
during difficult pelvic examination (tenderness or
BMI)
CT
sensitivity 90%–100%
CDC Ambulatory Management of
Acute PID
Levofloxacin 500 mg PO once daily for 14 days
PLUS
Metronidazole 500 mg PO bid for 14 days
OR
Ceftriaxone 250 mg IM in a single dose OR other
parenteral third-generation cephalosporin
PLUS
Doxycycline 100 mg PO bid for 14 days
Metronidazole 500 mg PO bid for 14 days
Admission Worthy
• Surgical emergencies (eg, appendicitis) cannot be
excluded
• Pregnancy
• The patient does not respond clinically to oral
antimicrobial therapy
• The patient is unable to follow or tolerate an
outpatient oral regimen
• Severe illness, nausea and vomiting, or high fever
• The patient has a TOA (tuboovarian abscess)
Inpatient Treatment
Cefotetan 2 g intravenously (IV) every 12 hours
OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
“carefully monitored for an adequate response to
antibiotics and any signs of rupture of the TOA
and discharged after sufficient response to
parenteral antibiotics is demonstrated “
Surgical Management
life-threatening infections
ruptured tuboovarian abscesses
laparoscopic drainage of a pelvic abscess
persistent masses in older women for whom
future childbearing is not a consideration
removal of a persistent symptomatic mass.
Back to our patient…
Studies have demonstrated an overall 70% success
rate with conservative medical management of
TOAs
Success of medical management has been
demonstrated to be inversely proportional to the
size of the TOA.
Reed and colleagues evaluated 119 women with
TOAs
>10 cm 60% required surgery
4 to 6 cm 20% required surgery
What about IUDs??
Increase risk in developing PID in the first month after
insertion
The PID risk in IUD users is modified by:
the number of sexual partners of the IUD user and that
of her partner(s)
community prevalence of STDs
age of the IUD user
Case reports of pelvic/abdominal actinomyces
abscesses in IUD users , mostly out of Europe
Why Should You Care?
Chronic Pain
-- pelvic pain
--dyspareunia
-- abdominal pain
Why should you care?
Lifetime cost of $1060 to $3180 per case.
During 2008:
$15.9 billion annually spent on tx of STDs
$166 million was spent on treatment of chronic
pelvic pain
$295 million was spent on treatment of ectopic
pregnancies
$360 million was spent on infertility treatments as a
direct result of previous PID infection.
What Can You Do?
CDC recommends :
yearly chlamydia testing of all sexually active women
age 25 or younger.
2. Older women with risk factors for chlamydial
infections (those who have a new sex partner or
multiple sex partners),
1.
References
Katz. Comprehensive Gyn, 5th Ed. 2006.
Pelvic Inflammatory Disease and Tubo-ovarian Abscess.
Infectious Disease Clinics of North America - Volume 22, Issue 4
(December 2008).
Centers for Disease Control and Prevention: 2006 Guidelines for
treatment of sexually transmitted disease. MMWR 55:11, 2006
Intrauterine devices - upper and lower genital tract infections.
Contraception. 2007 Jun;75(6 Suppl):S41-7.
Yeh J., Hook , III , IIIE., Goldie S.: A refined estimate of the
average lifetime cost of pelvic inflammatory disease. Sex Transm
Dis 30. 369-378.2003
Rein D.B., Kassler W.J., Irwin K.L., et al: Direct medical cost of
pelvic inflammatory disease and its sequelae: decreasing, but
still substantial. Obstet Gynecol 95. 397-402.2008.