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PID
(Pelvic Inflammatory Disease)
PELVIC INFLAMATORY DISEASE
DEFINITION
ETIOLOGY
PATHOPHYSIOLOGY
RISK FACTORS
MODE OF TRANSMISSION
SYMPTOMS
DIAGNOSIS
INVESTIGATIONS
TREATMENT
PREVENTION
PID
• Clinical syndrome associated with ascending spread of
microorganisms from the vagina or cervix to the
endometrium, fallopian tubes, ovaries, and contiguous
structures
• A common and serious complication of STDs (Sexual
Transmitted Diseases)
What is PID ?
• An infection of
– vagina (Colpitis)
– Cevix (Endocervicitis)
– Uterus ( Endometritis)
– Fallopian tubes
( Salpingitis)
– Ovaries (oophoritis),
– Pelvic peritonitis
– Tubo-ovarian abscess
Pathway of Ascendant Infection
Cervicitis
Endometritis
Salpingitis/
oophoritis/ tubo-ovarian abscess
Peritonitis
Female reproductive organ
Microbial Etiology
• Most cases of PID are polymicrobial
• Most common pathogens:
– N. gonorrhoeae: recovered from cervix in 30%-80% of women
with PID
– C. trachomatis: recovered from cervix in 20%-40% of women
with PID
– N. gonorrhoeae and C. trachomatis are present in combination
in approximately 25%-75% of patients
How do women get PID?
Bacteria move upward from vagina or cervix
into reproductive organs.
Acute PID : Pathology
Cervicitis
Endometritis
Salpingitis
Oophoritis
Tubo-ovarian abscess
Peritonitis
PID : Epidemiology
Risk factors
ACCEPTED PROPOSED
1. Menstruating teens 1. Low socio-economic status
2. Multiple sex partners 2. Early age of sexual activity
3. Prior H/O PID 3. Urban living
4. Sexually Transmitted Infection 4. High frequency of coitus
5. Non-use of barrier
contraceptive
5. Use of IUCD
6. Cigarette smoking
7. Substance abuse
8. Douching
PID : Mode of transmission
Ascending infection (Canalicular spread)
 Ascend of gonococcal & chlamydial organisms by
surface extension from the lower genital tract through
the cervical canal by way of the endometrium to the
fallopian tubes
 Facilitated by the sexually transmitted vectors such as
sperms & trichomonads
 Reflux of menstrual blood along with gonococci into the
PID : Mode of transmission
Through uterine lymphatic & blood vessels across
parametrium
 Mycoplasma hominis
 Secondary organisms
PID : Mode of transmission
Gynecological procedures favoring ascend of infection
 E.g. D&C, D&E
Blood-borne transmission
 Pelvic tuberculosis
Direct spread from contaminated structures in abdominal
cavity
 E.g. Appendicitis, cholecystitis
Abnormal discharge
Symptoms
• lower abdomen pain, may worse when move
• pain during or after sex
• bleeding between periods or after sex
• lower back pain
• sense of pressure or swelling in the lower abdomen
• fever (often with chills)
• feeling tired or unwell
• abnormal vaginal discharge
• nausea, vomiting and dizziness
• leg pain
• increased period pain
• increased pain at ovulation
• dysuria, frequently urination
Acute PID : CDC DiagnosisCriteria
3
5
3
Acute PID : Staging
(I-IDSOG-USA recommends following stages)
Stage I
 Women who fulfil the CDC major diagnostic criteria and
>1 of its minor criteria but who do not have overt
peritonitis (as demonstrated by the absence of rebound
tenderness) and who have not had any prior
documented STD upper tract infections
Stage II
 The above criteria, with peritonitis
Stage III
 Women with demonstrable tubo-ovarian complex or
tubo-ovarian abscess evident on either physical or
ultrasonographic examination
Stage IV
 Women with ruptured tubo-ovarian abscesses
Investigation
• Laboratory may be entirely normal
• An elevated leukocyte count does not distinguish PID from other diagnoses
• Cervical cultures for gonorrhea or Chlamydia require 3-7 days for results
• HIV and syphilis testing should be recommended
• Pelvic ultrasonography can detect pelvic abscesses
• Laparoscopy when the diagnosis is unclear or when the patient fails to
improve.
Complications and long-term problems
• Recurrent PID
• Ruptured abscess
• Chronic pain
• Ectopic pregnancy
• Infertility
• Perihepatic adhesions ( Fitz-Hugh-
Curtis syndrome)
• Perihepatic adhesions (arrow) usually associated with
pelvic gonorrhoeal or chlamydial infection (Fitz-Hugh-
Curtis syndrome).
Acute PID : Most common DD
Most common DD of acute PID
1. Appendicitis
2. Ectopic pregnancy
3. Endometritis
4. Ovarian cyst
5. Ovarian torsion
Rupture tubo-ovarian abscess
Acute PID : Management
(Antibiotics for specific pathogen)
Organism Antibiotics
N. gonorrhea Cephalosporins, Quinolones
Chlamydia
Doxycycline, Erythromycin &
Quinolones (Not to
cephalosporins)
Anaerobic organisms
Flagyl, Clindamycin &
in some cases to Doxycycline
ß-Haemolytic
streptococci.
&
E. coli
Penicillin derivatives,
Tetracyclines, and
Cephalosporins.,
E. Coli is most often treated with
Parenteral Treatment
• Regimen A
Cefoxitin 2 g IV every 6
hours
+
Doxycycline 100
mg
orally or IV every
12 hours
14 days
•Regimen B
Clindamycin
900 mg IV every
8 hours
+
Gentamicin loading dose
(2 mg/kg ) IV or IM
followed by a maintenance
dose (1.5 mg/kg)
every 8 hours
Oral Treatment
• Regimen A
Levofloxacin 500
mg once daily
for 14 days
OR
+
Metronidazole 500 mg
twice a day
for 14 daysOfloxacin 400 mg
twice daily
for 14 days
•Regimen B
1. Ceftriaxone 250 mg IM in a single dose
+ Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
2. Cefoxitin 2 g IM single dose and Probenecid, 1 g
orally administered concurrently single dose
+ Doxycycline 100 mg orally twice a day for 14 days
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
3. Third-generation cephalosporin
+ Doxycycline 100 mg orally twice a day for 14 day
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
Management & Follow-up
Out-patient
Oral regimen
In-patient
Parenteral regimen
3 Days (72 hours)
Substantial clinical improvement ????
 Defervescence
 Reduction in direct or rebound abdominal tenderness
 Reduction in uterine, adnexal & cervical motion
tenderness
NO
 Reassessment of patient & treatment
 Additional diagnostic testing
After 6 - months
Repeat testing of all women who have been diagnosed with chlamydia or
gonorrhoea
Yes
 Switch to oral from parenteral after
24 hours of clinical improvement
 If on oral – continue the same
Admit Out-patient
Prevention
Screening
• To reduce the incidence of PID, screen and treat for
chlamydia.
• Annual chlamydia screening is recommended for:
– Sexually active women 25 and under
– Sexually active women >25 at high risk
• Screen pregnant women in the 1st trimester.
Management of Sex Partners
• Male sex partners of women with PID should be
examined and treated
• Male partners of women who have PID caused by C.
trachomatis and/or N. gonorrhoeae frequently are
asymptomatic.
Partner Management (continued)
• 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.
Patient Counseling and Education
• Nature of the infection
• Transmission
• Risk reduction
– Assess patient's behavior-change potential
– Discuss prevention strategies
– Develop individualized risk-reduction plans
Thank you

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Presentation1

  • 2. PELVIC INFLAMATORY DISEASE DEFINITION ETIOLOGY PATHOPHYSIOLOGY RISK FACTORS MODE OF TRANSMISSION SYMPTOMS DIAGNOSIS INVESTIGATIONS TREATMENT PREVENTION
  • 3. PID • Clinical syndrome associated with ascending spread of microorganisms from the vagina or cervix to the endometrium, fallopian tubes, ovaries, and contiguous structures • A common and serious complication of STDs (Sexual Transmitted Diseases)
  • 4. What is PID ? • An infection of – vagina (Colpitis) – Cevix (Endocervicitis) – Uterus ( Endometritis) – Fallopian tubes ( Salpingitis) – Ovaries (oophoritis), – Pelvic peritonitis – Tubo-ovarian abscess
  • 5. Pathway of Ascendant Infection Cervicitis Endometritis Salpingitis/ oophoritis/ tubo-ovarian abscess Peritonitis
  • 7. Microbial Etiology • Most cases of PID are polymicrobial • Most common pathogens: – N. gonorrhoeae: recovered from cervix in 30%-80% of women with PID – C. trachomatis: recovered from cervix in 20%-40% of women with PID – N. gonorrhoeae and C. trachomatis are present in combination in approximately 25%-75% of patients
  • 8. How do women get PID? Bacteria move upward from vagina or cervix into reproductive organs.
  • 9. Acute PID : Pathology Cervicitis Endometritis Salpingitis Oophoritis Tubo-ovarian abscess Peritonitis
  • 10. PID : Epidemiology Risk factors ACCEPTED PROPOSED 1. Menstruating teens 1. Low socio-economic status 2. Multiple sex partners 2. Early age of sexual activity 3. Prior H/O PID 3. Urban living 4. Sexually Transmitted Infection 4. High frequency of coitus 5. Non-use of barrier contraceptive 5. Use of IUCD 6. Cigarette smoking 7. Substance abuse 8. Douching
  • 11. PID : Mode of transmission Ascending infection (Canalicular spread)  Ascend of gonococcal & chlamydial organisms by surface extension from the lower genital tract through the cervical canal by way of the endometrium to the fallopian tubes  Facilitated by the sexually transmitted vectors such as sperms & trichomonads  Reflux of menstrual blood along with gonococci into the
  • 12. PID : Mode of transmission Through uterine lymphatic & blood vessels across parametrium  Mycoplasma hominis  Secondary organisms
  • 13. PID : Mode of transmission Gynecological procedures favoring ascend of infection  E.g. D&C, D&E Blood-borne transmission  Pelvic tuberculosis Direct spread from contaminated structures in abdominal cavity  E.g. Appendicitis, cholecystitis
  • 14.
  • 16. Symptoms • lower abdomen pain, may worse when move • pain during or after sex • bleeding between periods or after sex • lower back pain • sense of pressure or swelling in the lower abdomen • fever (often with chills) • feeling tired or unwell • abnormal vaginal discharge • nausea, vomiting and dizziness • leg pain • increased period pain • increased pain at ovulation • dysuria, frequently urination
  • 17. Acute PID : CDC DiagnosisCriteria 3 5 3
  • 18. Acute PID : Staging (I-IDSOG-USA recommends following stages) Stage I  Women who fulfil the CDC major diagnostic criteria and >1 of its minor criteria but who do not have overt peritonitis (as demonstrated by the absence of rebound tenderness) and who have not had any prior documented STD upper tract infections Stage II  The above criteria, with peritonitis Stage III  Women with demonstrable tubo-ovarian complex or tubo-ovarian abscess evident on either physical or ultrasonographic examination Stage IV  Women with ruptured tubo-ovarian abscesses
  • 19. Investigation • Laboratory may be entirely normal • An elevated leukocyte count does not distinguish PID from other diagnoses • Cervical cultures for gonorrhea or Chlamydia require 3-7 days for results • HIV and syphilis testing should be recommended • Pelvic ultrasonography can detect pelvic abscesses • Laparoscopy when the diagnosis is unclear or when the patient fails to improve.
  • 20. Complications and long-term problems • Recurrent PID • Ruptured abscess • Chronic pain • Ectopic pregnancy • Infertility • Perihepatic adhesions ( Fitz-Hugh- Curtis syndrome)
  • 21. • Perihepatic adhesions (arrow) usually associated with pelvic gonorrhoeal or chlamydial infection (Fitz-Hugh- Curtis syndrome).
  • 22. Acute PID : Most common DD Most common DD of acute PID 1. Appendicitis 2. Ectopic pregnancy 3. Endometritis 4. Ovarian cyst 5. Ovarian torsion
  • 24. Acute PID : Management (Antibiotics for specific pathogen) Organism Antibiotics N. gonorrhea Cephalosporins, Quinolones Chlamydia Doxycycline, Erythromycin & Quinolones (Not to cephalosporins) Anaerobic organisms Flagyl, Clindamycin & in some cases to Doxycycline ß-Haemolytic streptococci. & E. coli Penicillin derivatives, Tetracyclines, and Cephalosporins., E. Coli is most often treated with
  • 25. Parenteral Treatment • Regimen A Cefoxitin 2 g IV every 6 hours + Doxycycline 100 mg orally or IV every 12 hours 14 days
  • 26. •Regimen B Clindamycin 900 mg IV every 8 hours + Gentamicin loading dose (2 mg/kg ) IV or IM followed by a maintenance dose (1.5 mg/kg) every 8 hours
  • 27. Oral Treatment • Regimen A Levofloxacin 500 mg once daily for 14 days OR + Metronidazole 500 mg twice a day for 14 daysOfloxacin 400 mg twice daily for 14 days
  • 28. •Regimen B 1. Ceftriaxone 250 mg IM in a single dose + Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days 2. Cefoxitin 2 g IM single dose and Probenecid, 1 g orally administered concurrently single dose + Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days 3. Third-generation cephalosporin + Doxycycline 100 mg orally twice a day for 14 day WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days
  • 29. Management & Follow-up Out-patient Oral regimen In-patient Parenteral regimen 3 Days (72 hours) Substantial clinical improvement ????  Defervescence  Reduction in direct or rebound abdominal tenderness  Reduction in uterine, adnexal & cervical motion tenderness NO  Reassessment of patient & treatment  Additional diagnostic testing After 6 - months Repeat testing of all women who have been diagnosed with chlamydia or gonorrhoea Yes  Switch to oral from parenteral after 24 hours of clinical improvement  If on oral – continue the same Admit Out-patient
  • 31. Screening • To reduce the incidence of PID, screen and treat for chlamydia. • Annual chlamydia screening is recommended for: – Sexually active women 25 and under – Sexually active women >25 at high risk • Screen pregnant women in the 1st trimester.
  • 32. Management of Sex Partners • Male sex partners of women with PID should be examined and treated • Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic.
  • 33. Partner Management (continued) • 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.
  • 34. Patient Counseling and Education • Nature of the infection • Transmission • Risk reduction – Assess patient's behavior-change potential – Discuss prevention strategies – Develop individualized risk-reduction plans