1. Pelvic Inflammatory
Disease(PID)
Dr manal behery
Professor ob&gyne
Faculty of medicine , zagazig university

2. 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

3. 3
Pathway of Ascending Infection
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tubo-
ovarian abscess
Peritonitis
Pathogenesis

4. PID comes in two forms...
• Acute
• Patient has generalised symptoms
• Lasts a few days
• May recur in episodes
• Very infectious in this stage
• Chronic
• Patient may have no symptoms
• Occurs over months and years
• Progressive organ damage & change
• May burn out (arrest)

5. Why PID is important
• Affects up to 1:4 women in CBP
• 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

6. 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

7. 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

8. 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

9. Chlamydia trachomatis
• 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

10. 10
Normal Human Fallopian Tube Tissue
Source: Patton, D.L. University of Washington, Seattle, Washington
Pathogenesis

11. 11
C. trachomatis Infection (PID)
Source: Patton, D.L. University of Washington, Seattle, Washington
Pathogenesis

12. 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

13. Risk Factors for PID
• 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
• Frequency of intercourse (Age)
• IUCD design
• Poor health resources
• Antibiotic exposure (resistance)

14. Pathology

15. Diagnosis of PID
• Requires a high index of suspicion in a patient
“at risk” when there is:
• Lower abdominal pain (90%)
• Fever (sometimes with malaise, vomiting)
• Mucopurulent discharge from cervix
• Pelvic tenderness
• Tests
• Raised WCC
• Endocervical swab for organisms or PCR
• Ultrasound evidence of pelvic fluid collections
• Laparoscopy

17. Fitz-Hugh-Curtis Syndrome
• Perihepatic inflammation & adhesions
• Occurs with 1 – 10% acute PID
• Causes RUQ and pleuritic pain
• May be confused with cholecystitis or
pneumonia

18. Endometritis (thickened heterogenous endometrium)

19. Hydrosalpinx (anechoic tubular structure)

20. Hydrosalpinx.

21. PID BY LAPROSCAPY

22. By laparoscapy

23. 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

24. 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
• >50% ~ 3 episodes
• Recurrence of acute PID at least 25%
• Male genital disease in 25%

25. Treatment of PID
• Antibiotics
• 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

26. 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.

27. 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

28. Criteria for hospitalization

29. 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
Special Situations

30. Prevention of PID
• 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

31. 31
History: Jane Wheels
Case Study
• 24-year-old female who reports lower abdominal pain,
cramping, slight fever, and dysuria for four days.
• G1P1, LMP two weeks ago (regular without dysmenorrhea).
Uses oral contraceptives (for two years).
• Reports gradual onset of symptoms of lower bilateral
abdominal discomfort, dysuria (no gross hematuria),
abdominal cramping and a slight low-grade fever in the
evenings for four days. Discomfort has gradually worsened.
• Denies GI disturbances or constipation. Denies vaginal
discharge.
• States that she is happily married in a monogamous
relationship. Plans another pregnancy in about six months.
No condom use.
• No history of STDs. Reports occasional yeast infections.
• Douches regularly after menses and intercourse; last
douched this morning.

32. 32
Physical Exam
• Vital signs: blood pressure 104/72, pulse 84,
temperature 38°C, weight 132 lbs.
• Neck, chest, breast, heart, and musculoskeletal exam
within normal limits. No flank pain on percussion. No
CVA tenderness.
• On abdominal exam the patient reports tenderness in
the lower quadrants with light palpation. Several small
inguinal nodes palpated bilaterally.
• Normal external genitalia without lesions or discharge.
• Speculum exam reveals minimal vaginal discharge with
a small amount of visible cervical mucopus.
• Bimanual exam reveals uterine and adnexal tenderness
as well as pain with cervical motion. Uterus anterior,
midline, smooth, and not enlarged.
Case Study

33. 33
Questions
1. What should be included in the
differential diagnosis?
2. What laboratory tests should be
performed or ordered?
Case Study

34. 34
Laboratory
Results of office diagnostics:
• Urine pregnancy test: negative
• Urine dip stick for nitrates: negative
• Vaginal saline wet mount: vaginal pH was 4.5.
Microscopy showed WBCs >10 per HPF, no clue
cells, no trichomonads, and the KOH wet mount
was negative for budding yeast and hyphae.
3. What is the presumptive diagnosis?
4. How should this patient be managed?
5. What is an appropriate therapeutic regimen?
Case Study

35. 35
Partner Management
Sex partner: Joseph (spouse)
• First exposure: four years ago
• Last exposure: one week ago
• Frequency: two times per week
(vaginal only)
6. How should Joseph be managed?
Case Study

36. 36
Partner Management
• Male partners of women who have PID caused
by C. trachomatis or N. gonorrhoeae are often
asymptomatic.
• Sex partners should be treated empirically with
regimens effective against both C. trachomatis
and N. gonorrhoeae, regardless of the apparent
etiology of PID or pathogens isolated from the
infected woman.
Prevention

37. PID – What we have covered
• What it is
• Why it is important
• How it is spread
• How it is diagnosed
• How it is treated
• How it might be prevented

38. Any Questions or Comments?