Transcript Pelvic Inflammatory Disease (PID)

Pelvic Inflammatory Disease
(PID)
Max Brinsmead MB BS PhD
May 2015
This talk
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What is Pelvic Inflammatory Disease?
Why it is important
How it is spread
Diagnosis
Treatment
Prevention
What is PID?
• Inflammation of female pelvic
structures
• Ascending spread of infection from the
the cervix through the uterus, to
fallopian tubes, ovaries and adjacent
peritoneum
• Upper genital tract infection
• It is not infection in the vagina or vulva
Anatomy
PID comes in two forms...
• Acute
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Patient has generalised symptoms
Lasts a few days
May recur in episodes
Very infectious in this stage
• Chronic
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Patient may have no symptoms
Occurs over months and years
Progressive organ damage & change
May burn out (arrest)
Why PID is important
• Affects up to 1:4 women in PNG
• Many hospital admissions
• Sometimes fatal
• Chronic damage causes infertility
• Predisposes to ectopic pregnancy
• Can affect a baby during birth
• Lung inflammation
• Eye infections
• Is a common cause of chronic menstrual
problems
Cause of PID
• 85 – 95% is due to specific sexually
transmitted organisms
• Neisseria gonorrhoea
• Chlamydia trachomatis
• Others e.g. Mycoplasma species
• 5 – 15% begins after reproductive tract
damage
• From pregnancy
• From surgical procedures e.g. D&C
• Includes insertion of IUCD
Cause of PID (2)
• Endogenous infection occurs from
commensal organisms
• Anaerobes e.g. Bacteroides
• Aerobes e.g. E Coli, Streptococcus species
• Actinomycosis with IUCD
• A smaller number of PID is due to
Tuberculosis (TB)
• Bloodborne spread after primary lung infection
Pathogenesis
• Infection can occur after procedures that
break cervical mucous barrier
• The adult vagina is lined by stratified
squamous epithelium like skin
• But the cervix has mucous to receive sperm
• Organisms can access higher when mucous is
receptive
• Endometrium sheds regularly so is
infrequently a site of chronic infection
• Fallopian tubes and peritoneum should be
sterile
Chlamydia trachomatis
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Produces a mild form of salpingitis
Slow growing in culture (48-72 hr)
An intracellular organism
Insidious onset
Remain in tubes for months/years after
initial colonization of upper genital tract
• Can cause severe damage/changes over
long periods
Neissera gonorrhoea
• Gram negative Diplococcus
• Grows rapidly in culture (doubles every
20-40 min)
• Causes a rapid & intense inflammatory
response
• May occur after prior Chlamydia infection
• More likely to be symptomatic in the male
partner
Risk Factors for PID
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Age of 1st intercourse
Number of sexual partners
Number of sexual contacts by the sexual partner
Cultural practices
• Polygamy,
• Prostitutes
• Attitudes to menstruation and pregnancy
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Frequency of intercourse (Age)
IUCD design
Poor health resources
Antibiotic exposure (resistance)
Pathology
Uterus, Bilateral Fallopian Tubes, and Ovaries
U: Uterus
C: Cervix
U
M
F
O
F: Fallopian Tube
O: Normal Ovary
M: Inflamed TuboOvarian Mass
C
Note the hemorrhagic, oedematous fallopian tubes, architecture of the right tube and ovary is
obscured. The surface of this tubo-ovarian mass is red and shaggy.
This fibrinogen exudate is deposited as fibrin, a sign of increased vascular permeability.
Normal Fallopian Tube - Low Power
M: Mucosal Folds
L: Lumen
W: Wall of Tube
M
W
L
Note the delicate mucosal folds lined by epithelium and a vascularized stroma.
There are no inflammatory cells in the lumen or in the mucosa.
Fallopian Tube – from a PID
W: Muscular Wall
W
W
M: Inflamed Mucosa
L: Lumen with
Inflammatory
M
Cells
M
L
M
W
Notice the inflammatory infiltrate in the mucosa and muscular wall. Inflammatory cells have
nearly obscured the lumen.
Diagnosis of PID
• Requires a high index of suspicion in a
patient “at risk” when there is:
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Lower abdominal pain (90%)
Fever (sometimes with malaise, vomiting)
Mucopurulent discharge from cervix
Pelvic tenderness
• Tests
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Raised WCC
Endocervical swab for organisms or PCR
Ultrasound evidence of pelvic fluid collections
Laparoscopy
Fitz-Hugh-Curtis
Fitz-Hugh-Curtis Syndrome
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Perihepatic inflammation & adhesions
Occurs with 1 – 10% acute PID
Causes RUQ and pleuritic pain
May be confused with cholecystitis or
pneumonia
Endometritis (thickened heterogenous endometrium)
Hydrosalpinx (anechoic tubular structure)
Hydrosalpinx.
Differential Diagnosis for PID
• Endometriosis
• Appendicitis & other gastro conditions
• Appendicitis is unilateral and right sided
• PID is bilateral
• Ectopic pregnancy
• Always do a pregnancy test
• Urinary tract infection or stone
• “Ovarian cysts”
• Lower genital tract infection
PID Sequelae
• Chronic Pelvic Pain (15-20 %)
• Ectopic pregnancy (6-10 fold ↑Risk)
• At least 50% of tubal pregnancies have
histology of PID
• Infertility (Tubal)
• 10 – 15% after one episode
• 20% ~ 2 episode
• >40% ~ 3 episodes
• Recurrence of acute PID at least 25%
• Male genital disease in 25%
Treatment of PID
• Antibiotics
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Needs appropriate spectrum of activity
Specific or broad spectrum?
Issues of compliance
Oral or parenteral?
Follow current guidelines
• Surgical
• Drain abscess
• Selective or radical removal
• Rest and analgesia
• NSAID’s useful
Antibiotic Therapy
Gonorrhea : Cephalosporins, Quinolones
Chlamydia: Doxycycline, Erythromycin &
Quinolones (Not cephalosporins)
Anaerobic organisms: Metronidazole,
Clindamycin and, in some cases,
Doxycycline.
Beta hemolytic Streptococcus and E. Coli
Penicillin derivatives, Tetracyclines, and
Cephalosporins , Gentamicin.
Follow up for PID
• Partner or sexual contact tracing and
testing or treatment
• Look for other STD’s
• STS, Hep B and HIV
• Lower genital tract infections
• Counselling and support
• Pregnancy care
Criteria for hospitalization
Special Situations
Pregnancy
- Augmentin or Erythromycin
- Hospitalization
Concomitant HIV infection
- Hospitalization and i.v. antimicrobials
- More likely to have pelvic abscesses
- Respond more slowly to antimicrobials
- Require changes of antibiotics more often
- Concomitant Candida and HPV infections
Prevention of PID
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Screen & treat asymptomatic disease
Sexual health counselling
Barrier contraceptives
Progestin-based contraception
• COC & POP
• Depot and Implanon
• ?Mirena
• Sexual fidelity or abstinence
• Improving the education and status of
women
PID – What we have covered
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What it is
Why it is important
How it is spread
How it is diagnosed
How it is treated
How it might be prevented
Any Questions or Comments?
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