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Pelvic Inflammatory Diseases

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1 Pelvic Inflammatory Diseases
It’s related problems M.D., Ph.D. Long Sui Obstetrics & Gynecology Hospital Fudan University 复旦大学附属妇产科医院

2 Contents: 复旦大学附属妇产科医院 PID related Terms & Definition
Diagnosis & Treat for PID New Guideline for Diagnosis & Treat of PID The implication of traditional Chinese medicine on the treatment of PID 复旦大学附属妇产科医院

3 Keystones What is PID? How common is PID? How do women get PID?
What are the signs and symptoms of PID? What are the complications of PID? How is PID diagnosed? What is the treatment for PID? How can PID be prevented?

4 tubo-ovarian abscess, TOA
PID(2010 CDC) Definition: PID is caused by micro-organisms colonizing the endocervix ascending to the endometrium and fallopian tubes. It is a clinical diagnosis implying that the patient has upper genital tract infection and inflammation. The inflammation may be present at any point along a continuum that includes endometritis, salpingitis, and peritonitis. Salpingal tubes is most common site. 输卵管炎 salpingitis 子宫内膜炎 endometritis PIDs PID is caused by micro-organisms colonizing the endocervix ascending to the Disease endometrium and fallopian tubes. It is a clinical diagnosis implying that the patient has upper genital tract infection and inflammation. The inflammation may be present at any point along a continuum that includes endometritis, salpingitis, and peritonitis . Pelvic inflammatory disease commonly is caused by the sexually transmitted micro-organisms N. gonorrhoeae (Neisseria gonorrhoeae )and C. trachomatis . 输卵管卵巢脓肿 tubo-ovarian abscess, TOA 盆腔腹膜炎 peritonitis

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7 Inflammatory Sequelae(after effect)(2006 CDC)
chronic pelvic inflammatory disease: not anymore!! Pelvic adhesion Infertility salpingo-oophoritis(subacute or atypical) Chronic Pelvic Pain Ectopic Pregnancy

8 Epidemiology

9 Epidemiology In the United States, more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers. PID causes over 100,000 women to become infertile in the US each year. N. gonorrhoea is isolated in 40–60% of women with acute salpingitis. C. trachomatis is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. 10% of women in one study had asymptomatic Chlamydia trachomatis infection and 65% had asymptomatic infection with Neisseria gonorrhoeae. It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID. In the United States, more than 750,000 women are affected by PID each year, and the rate is highest with teenagers and first time mothers. PID causes over 100,000 women to become infertile in the US each year. N. gonorrhoea is isolated in 40–60% of women with acute salpingitis. C. trachomatis is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. 10% of women in one study had asymptomatic Chlamydia trachomatis infection and 65% had asymptomatic infection with Neisseria gonorrhoeae.[4] It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID.

10 2006 CDC Guidelines Atypical Pathogen 重视 非典型 关注 病原体 新特征 New Features
诊断 新标准 关注 新特征 治疗 新指南 New Diagnostic Criteria Atypical Pathogen New Guideline New Features

11 Adherence of N. gonorrhoeae
Atypical Pathogen Two sources of pathogens of PID: Exogenous/extrinsic source Endogenous source Co-exist of these two sources occur in >50% of PIDs Adherence of N. gonorrhoeae

12 Exogenous/extrinsic source
N. gonorrhoeae C. trachomatis BV mycoplasma Mycoplasma genitalium生殖支原体 Mycoplasma urealytium解脲支原体 Etiology: atypical pathogen CT implicated in many cases N. gonorrhoea is isolated in 40–60% of women with acute salpingitis.[4] C. trachomatis is estimated to be the cause in about 60% of cases of salpingitis, which may lead to PID. However, not all PID is caused solely by STIs; organisms that are considered normal vaginal flora can be involved, and individual cases of PID can be due to either a single organism or a co-infection of many different species. 10% of women in one study had asymptomatic Chlamydia trachomatis infection and 65% had asymptomatic infection with Neisseria gonorrhoeae.[4] It was noted in one study that 10–40% of untreated women with N. gonorrhoea develop PID and 20–40% of women infected with C. trachomitis developed PID. All women diagnosed with acute PID should tested for CT

13 Endogenous Pathogen Endogenous microorganisms found in the vagina, parasitic bacteria Aerobic bacteria and Anaerobic bacteria 可以仅为aerobic bacteria需氧菌感染 也可以仅为anaerobe 厌氧菌感染 Mix infection or polyinfection are common in the new data. Endogenous microorganisms found in the vagina, particularly the BV micro-organisms, also often are isolated from the upper genital tract of women with PID. The BV micro-organisms include anaerobic bacteria such as Prevotella and peptostreptococci as well as G. vaginalis. BV often occurs in women with PID, and the resultant complex alteration of vaginal flora may facilitate the ascending spread of pathogenic bacteria by enzymatically altering the cervical mucus barrier. Less frequently, respiratory pathogens such as Haemophilus influenzae, group A streptococci, and pneumococci can colonize the lower genital tract and cause PID.

14 Distribution of Pathogens inPID,US
N. gonorrhoeae C. trachomatis Landers D V, et al. Am J Obstet Gynecol, 1991, I64(3); 849~59

15 Distribution of Pathogens inPID,China
N. gonorrhoeae mycoplasma hominis mycoplasma hominis C. trachomatis C. trachomatis N. gonorrhoeae ZG Zheng Tianjin Med 2003,5;3(5) DYSun,孙道媛 (2003) (n=200)

16 Distribution of Pathogens inPID,Guangzhou
Cases(601 cases) Control(306 cases) UU 421(70%) 126(41.2%) CT 153(25.5% ) 22( 7.2% ) CAN 90(15.0% ) 3(0.01% ) BV 17(0.03) HPV 12(0.02) Other 13 With different objects,research item and methods,non-RCT data!

17 Diagnosis

18 Diagnosis Traditionally, the diagnosis of PID has been based on a triad of symptoms and signs, including pelvic pain, cervical motion and adnexal tenderness, and the presence of fever. It is now recognized that there is wide variation in many symptoms and signs among women with this condition, which makes the diagnosis of acute PID difficult. The clinical diagnosis is roughly incorrect due to the inactive or concealed symptoms and signs PPV for symptomatic PID was only about 65~90% With high PPV in some special group(active sexual intercourse and STD clinic)

19 Concern for New Characteristics
It is now recognized that there is wide variation in many symptoms and signs among women with this condition, which makes the diagnosis of acute PID difficult. Some women may develop PID without having any symptoms. The diagnosis of PID should be considered in women with any genitourinary symptoms, including, but not limited to, lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms . A triad of PID Pelvic Pain Fever Many women with PID exhibit subtle or mild symptoms that are not readily recognized as PID. Consequently, delay in diagnosis and therapy probably contributes to the inflammatory sequelae in the upper reproductive tract (35). In the diagnosis of PID, the goal is to establish guidelines that are sufficiently sensitive to avoid missing mild cases but sufficiently specific to avoid giving antibiotic therapy to women who are not infected. Genitourinary tract symptoms may indicate PID; therefore, the diagnosis of PID should be considered in women with any genitourinary symptoms, including, but not limited to, lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms (36). Genitourinary tract symptoms may indicate PID; therefore, the diagnosis of PID should be considered in women with any genitourinary symptoms, including, but not limited to, lower abdominal pain, excessive vaginal discharge, menorrhagia, metrorrhagia, fever, chills, and urinary symptoms . cervical motion and adnexal tenderness

20 New Criteria for PID Sensitivity will become lowered
if a triad was necessary simultaneously minimum criteria (最低诊断标准) Cervical motion tenderness Uterine tenderness Adnexal tenderness Pelvic organ tenderness, either uterine tenderness alone or uterine tenderness with adnexal tenderness, is present in patients with PID. Cervical motion tenderness suggests the presence of peritoneal inflammation, which causes pain when the peritoneum is stretched by moving the cervix and causing traction of the adnexa on the pelvic peritoneum. Direct or rebound abdominal tenderness may be present. 若符合三项最低诊断标准中的一项 如果同时有泌尿生殖道症状的患者,应考虑PID诊断(诊断的特异性明显增加) 根据患者的STD危险因素决定治疗方案 可以根据最低诊断标准,开始抗生素治疗 如果患者出现腹痛,而没有其他引起腹痛的疾病存在 同时患者为年轻女性或STD的高危人群 2006 CDC Guidelines 《Chineses Guideline Protocol for PID》

21 Clinical Criteria for the Diagnosis of Pelvic Inflammatory Disease
Symptoms None necessary Signs Pelvic organ tenderness Leukorrhea and/or mucopurulent endocervicitis Additional criteria to increase the specificity of the diagnosis Endometrial biopsy showing endometritis Elevated C-reactive protein or erythrocyte sedimentation rate Temperature higher than 38°C Leukocytosis Positive test for gonorrhea or chlamydia Elaborate criteria Ultrasound documenting tubo-ovarian abscess Laparoscopy visually confirming salpingitis Evaluation of both vaginal and endocervical secretions is a crucial part of the workup of a patient with PID (37). In women with PID, an increased number of polymorphonuclear leukocytes may be detected in a wet mount of the vaginal secretions or in the mucopurulent discharge. More elaborate tests may be used in women with severe symptoms because an incorrect diagnosis may cause unnecessary morbidity (38) (Table 16.4). These tests include endometrial biopsy to confirm the presence of endometritis, ultrasound or radiologic tests to characterize a tubo-ovarian abscess, and laparoscopy to confirm salpingitis visually.

22 Differential diagnosis

23 Differential diagnosis
Appendicitis, ectopic pregnancy, septic abortion, hemorrhagic or ruptured ovarian cysts or tumors, twisted ovarian cyst, degeneration of a myoma, and acute enteritis must be considered. A sensitive serum pregnancy test should be obtained to rule out ectopic pregnancy. Culdocentesis will differentiate hemoperitoneum (ruptured ectopic pregnancy or hemorrhagic cyst) from pelvic sepsis (salpingitis, ruptured pelvic abscess, or ruptured appendix). No single test has adequate sensitivity and specificity to diagnose pelvic inflammatory disease. Pelvic inflammatory disease is more likely to occur when there is a history of pelvic inflammatory disease, recent sexual contact, recent onset of menses, or an IUD in place or if the partner has a sexually transmitted infection.

24 Pelvic and vaginal ultrasounds are helpful in the differential diagnosis of ectopic pregnancy of over six weeks. Laparoscopy is often utilized to diagnose pelvic inflammatory disease, and it is imperative if the diagnosis is not certain or if the patient has not responded to antibiotic therapy after 48 hours. A large multisite U.S. study found that cervical motion tenderness as a minimum clinical criterion increases the sensitivity of the CDC diagnostic criteria from 83% to 95%. However, even the modified 2002 CDC criteria does not identify women with subclinical disease

25 Advantages & Disadvantages on Laparoscopy
Direct visual monitoring and diagnosis Pathogen analysis through sampling Integration of Diagnosis & Treat Disadvantages Unacceptable Unable to diagnose on mild salpingitis Cannot observe the endometrium No single case history ,positive sign or symptom or lab test could be sensitive and specific at the same time

26 Prognosis

27 Prognosis This makes early identification by someone who can prescribe appropriate curative treatment very important in the prevention of damage to the reproductive system. Since early gonococcal infection may be asymptomatic, regular screening of individuals at risk for common agents (history of multiple partners, history of any unprotected sex, or people with symptoms) or because of certain procedures (post pelvic operation, postpartum, miscarriage or abortion). If the initial infection is mostly in the lower tract, after treatment the person may have few difficulties. If the infection is in the fallopian tubes or ovaries, more serious complications are more likely to occur. Although the PID infection itself may be cured, effects of the infection may be permanent. Prevention is also very important in maintaining viable reproduction capabilities.

28 What does “delayed” mean?
Complications Infertility Ectopic Pregnancy Complications Delayed Chronic Pelvic Pain PID can cause scarring inside the reproductive organs, which can later cause serious complications, including chronic pelvic pain, infertility, ectopic pregnancy (the leading cause of pregnancy-related deaths in adult females), and other dangerous complications of pregnancy. Occasionally, the infection can spread to in the peritoneum causing inflammation and the formation of scar tissue on the external surface of the liver (Fitz-Hugh-Curtis syndrome). Multiple infections and infections that are treated later are more likely to result in complications. Fertility may be restored in women affected by PID. Traditionally tuboplastic surgery was the main approach to correct tubal obstruction or adhesion formation, however success rates tended to be very limited. In vitro fertilization (IVF) has been used to bypass tubal problems and has become the main treatment for patients who want to become pregnant. Even subtle or mild PID Recurrent PID What does “delayed” mean?

29 Treatment

30 Basic Rules for Treatment of PID
Therapy regimens for PID must provide empirical, broad- spectrum coverage of likely pathogens, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes, and streptococci. An outpatient regimen of cefoxitin and doxycycline is as effective as an inpatient parenteral regimen of the same antimicrobials.

31 Principle of Treatment on PID
Antibiotics which must be empirical, broad-spectrum coverage of likely pathogens,surgical treatment will be carried out if necessary. Majority of PID could be cured through proper application of antibiotics Full dose and in time administration was important for treatment of PID,otherwise some complication will be arised.

32 Broad-spectrum coverage
Antibiotics Empirical Administration of Antibiotics prompt individual Broad-spectrum coverage Antibiotics should be administered before the result of drug sensitive test comes out

33 Treat Promptly Timely(24~48hrs)and proper therapy with antibiotics
Eliminate pathogen Meliorate symptom and sign Decrease complication

34 Indication for Surgery
No respond to antibiotics Persistent symptom and sign of PID Tube-Ovarian abscess or pelvic abscess after 48-72hrs of therapy Rupture of Abscess Lasting abscess Laparotomy must be carried out once ruptured abscess with antibiotics administration simultaniously

35 Outpatients Regimen A Cefoxitin, 2 g intramuscularly, plus probenecid, 1 g orally concurrently, or Ceftriaxone, 250 mg intramuscularly, or Equivalent cephalosporin Plus: Doxycycline, 100 mg orally 2 times daily for 14 days With or without: Metronidazole, 500 mg orally 2 times daily for 14 daysa Regimen B Ofloxacin, 400 mg orally 2 times daily for 14 days, or Levofloxacin, 500 mg orally once daily for 14 days

36 Inpatients Regimen A Cefoxitin, 2 g intravenously every 6 hours, or Cefotetan, 2 g intravenously every 12 hours, Plus: Doxycycline, 100 mg orally or intravenously every 12 hours Regimen B Clindamycin, 900 mg intravenously every 8 hours Gentamicin, loading dose intravenously or intramuscularly (2 mg/kg of body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours aUse of metronidazole recommended in those cases in which bacterial vaginosis is diagnosed concurrently with PID. Adapted from Centers for Disease Control and Prevention.The sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention, 2002; MMWR 2002; 51: RR-6. with permission.

37 Criteria for hospitalization
the diagnosis is uncertain,surgical emergency could not be excluded(appendicitis) compliance with an outpatient regimen is in question clinical disease is severe,withnausea,vomiting or high fever Pregnant women with PID No effect to orally antibiotics pelvic abscess is suspected

38 Criteria for discharge
Hospitalized patients can be considered for discharge when 1.their fever has lysed (99.5°F for more than 24 hours) 2.the white blood cell count has become normal 3.rebound tenderness is absent 4.repeat examination shows marked amelioration of pelvic organ tenderness

39 For sexual partners Sexual partners of women with PID should be evaluated and treated for urethral infection with chlamydia or gonorrhea. One of these STDs usually is found in the male sexual partners of women with PID not associated with chlamydia or gonorrhea.

40 Tubo-ovarian Abscess

41 Tubo-ovarian Abscess An end-stage process of acute PID, tubo-ovarian abscess is diagnosed when a patient with PID has a pelvic mass that is palpable during bimanual examination. The condition usually reflects an agglutination of pelvic organs (tube, ovary, bowel) forming a palpable complex. Tubo-ovarian abscess is treated with an antibiotic regimen administered in a hospital . About 75% of women with tubo-ovarian abscess respond to antimicrobial therapy alone. Failure of medical therapy suggests the need for drainage of the abscess . Although drainage may require surgical exploration, percutaneous drainage guided by imaging studies (ultrasound or computed tomography) should be used as an initial option if possible. Trocar drainage, with or without placement of a drain, is successful in up to 90% of cases in which the patient failed to respond to antimicrobial therapy after 72 hours. Occasionally, an ovarian abscess can result from the entrance of micro-organisms through an ovulatory site. Although drainage may require surgical exploration, percutaneous drainage guided by imaging studies (ultrasound or computed tomography) should be used as an initial option if possible. Trocar drainage, with or without placement of a drain, is successful in up to 90% of cases in which the patient failed to respond to antimicrobial therapy after 72 hours.

42 Prevention

43 Prevention Risk reduction against sexually transmitted infections through barrier methods such as condoms. Going to the doctor immediately if symptoms of PID, sexually transmitted infections appear, or after learning that a current or former sex partner has, or might have had a sexually transmitted infection. Getting regular gynecological (pelvic) exams with STI testing to screen for symptomless PID. Discussing sexual history with a trusted physician in order to get properly screened for sexually transmitted diseases. Getting a STI history from your current partner and insisting they be tested and treated before intercourse. Treating partners to prevent reinfection or spreading the infection to other people. Diligence in avoiding vaginal activity, particularly intercourse, after the end of a pregnancy (delivery, miscarriage, or abortion) or certain gynecological procedures, to ensure that the cervix closes.

44 Q & A What is PID? How common is PID? How do women get PID?
What are the signs and symptoms of PID? What are the complications of PID? How is PID diagnosed? What is the treatment for PID? How can PID be prevented?

45 THANKS FOR YOUR ATTENTION


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