Presentation on theme: "Pelvic Inflammatory Disease (PID)"— Presentation transcript:
1Pelvic Inflammatory Disease (PID) Max Brinsmead PhD FRANZCOGJuly 2011
2This talk What is Pelvic Inflammatory Disease? Why it is important How it is spreadDiagnosisTreatmentPrevention
3What is PID? Inflammation of female pelvic structures Ascending spread of infection from the the cervix through the uterus, to fallopian tubes, ovaries and adjacent peritoneumUpper genital tract infectionIt is not infection in the vagina or vulva
5PID comes in two forms... Acute Chronic Patient has generalised symptomsLasts a few daysMay recur in episodesVery infectious in this stageChronicPatient may have no symptomsOccurs over months and yearsProgressive organ damage & changeMay burn out (arrest)
6Why PID is important Affects up to 1:4 women in PNG Many hospital admissionsSometimes fatalChronic damage causes infertilityPredisposes to ectopic pregnancyCan affect a baby during birthLung inflammationEye infectionsIs a common cause of chronic menstrual problems
7Cause of PID85 – 95% is due to specific sexually transmitted organismsNeisseria gonorrhoeaChlamydia trachomatisOthers e.g. Mycoplasma species5 – 15% begins after reproductive tract damageFrom pregnancyFrom surgical procedures e.g. D&CIncludes insertion of IUCD
8Cause of PID (2) Endogenous infection occurs from commensal organisms Anaerobes e.g. BacteroidesAerobes e.g. E Coli, Streptococcus speciesActinomycosis with IUCDA smaller number of PID is due to Tuberculosis (TB)Bloodborne spread after primary lung infection
9EtiologyInfection can occur after procedures that break cervical mucous barrierThe adult vagina is lined by stratified squamous epithelium like skinBut the cervix has mucous to receive spermOrganisms can access higher when mucous is receptiveEndometrium sheds regularly so is infrequently a site of chronic infectionFallopian tubes and peritoneum should be sterile
10Chlamydia trachomatis Produces a mild form of salpingitisSlow growing in culture (48-72 hr)An intracellular organismInsidious onsetRemain in tubes for months/years after initial colonization of upper genital tractCan cause severe damage/changes over long periods
11Neissera gonorrhoea Gram negative Diplococcus Grows rapidly in culture (doubles every min)Causes a rapid & intense inflammatory responseMay occur after prior Chlamydia infectionMore likely to be symptomatic in the male partner
12Risk Factors for PID Age of 1st intercourse Number of sexual partners Number of sexual contacts by the sexual partnerCultural practicesPolygamy,ProstitutesAttitudes to menstruation and pregnancyFrequency of intercourse (Age)IUCD designPoor health resourcesAntibiotic exposure (resistance)
14Uterus, Bilateral Fallopian Tubes, and Ovaries CFOMU: UterusC: CervixF: Fallopian TubeO: Normal OvaryM: Inflamed Tubo-Ovarian MassNote 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.
15Normal Fallopian Tube - Low Power M: Mucosal FoldsL: LumenW: Wall of TubeNote the delicate mucosal folds lined by epithelium and a vascularized stroma. There are no inflammatory cells in the lumen or in the mucosa.
16Fallopian Tube – from a PID WMLW: Muscular WallM: Inflamed MucosaL: Lumen with InflammatoryCellsNotice the inflammatory infiltrate in the mucosa and muscular wall. Inflammatory cells have nearly obscured the lumen.
17Diagnosis of PIDRequires 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 cervixPelvic tendernessTestsRaised WCCEndocervical swab for organisms or PCRUltrasound evidence of pelvic fluid collectionsLaparoscopy
23Differential Diagnosis for PID EndometriosisAppendicitis & other gastro conditionsAppendicitis is unilateral and right sidedPID is bilateralEctopic pregnancyAlways do a pregnancy testUrinary tract infection or stone“Ovarian cysts”Lower genital tract infection
24PID Sequelae Chronic Pelvic Pain (15-20 %) Ectopic pregnancy (6-10 fold ↑Risk)At least 50% of tubal pregnancies have histology of PIDInfertility (Tubal)10 – 15% after one episode20% ~ 2 episode>40% ~ 3 episodesRecurrence of acute PID at least 25%Male genital disease in 25%
25Treatment of PID Antibiotics Surgical Rest and analgesia Needs appropriate spectrum of activitySpecific or broad spectrum?Issues of complianceOral or parenteral?Follow current guidelinesSurgicalDrain abscessSelective or radical removalRest and analgesiaNSAID’s useful
26Antibiotic 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.
27Follow up for PIDPartner or sexual contact tracing and testing or treatmentLook for other STD’sSTS, Hep B and HIVLower genital tract infectionsCounselling and supportPregnancy care
29Special Situations Pregnancy - Augmentin or Erythromycin - HospitalizationConcomitant 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
30Prevention of PID Screen & treat asymptomatic disease Sexual health counsellingBarrier contraceptivesProgestin-based contraceptionCOC & POPDepot and Implanon?MirenaSexual fidelity or abstinenceImproving the education and status of women
31PID – What we have covered What it isWhy it is importantHow it is spreadHow it is diagnosedHow it is treatedHow it might be prevented