1. Pelvic Inflammatory Disease
By: Kallianpur Vaibhav Vinayanand.
ML- 610
2012

2. Upper Genital Tract Infections
The Cervix is considered the boundary between the lower and upper genital tracts.
Upper genital tract infections affect primarily the cervix, uterus, or fallopian tubes
Severe infections may affect one or both ovaries.

3. Topic Defined: Pelvic Inflammatory Disease (PID)
Infection of the upper female genital tract.
Refers to the clinical syndrome among women resulting from infection
Includes endometritis (infection of the uterine cavity)
Salpingitis (infection of the fallopian tubes)
Mucopurulent Cervicitis (infection of the cervix),
Oophoritis (infection of the ovaries).

4. Pathway of Ascendant Infection
Cervicitis
Endometritis
Salpingitis/ oophoritis/ tubo-ovarian abscess
Peritonitis

5. Pathologic Processes of PID
PID has a broad clinical spectrum that includes
acute PID
silent PID
atypical PID
the PID residual syndrome or chronic PID and
postpartum/postabortal PID

6. PID Classification
Overt
40%

7. PID Specifically defined:
Individual cases of PID can also be more specifically defined by
a) the site (s) of disease (i.e., endometritis, salpingitis, salpingo-oophoritis)
b) the etiologic agent (s) involved (those that cause chlamydial endometritis, gonococcal salpingitis, nonchlamydial/nongonococcal salpingo-oophoritis).

8. Relevance to Women’s Health:
Commonly occurs in women <35 years.
Rarely occurs before menarche, after menopause or during pregnancy.
About 1.2 million women are treated for PID.
Over 100,000 women with PID are hospitalized each year.
About 15% are acutely ill that require intensive inpatient treatment.
Approximately 85,000 women with mild or moderate PID who currently are being hospitalized, treating them as outpatients may save around $500 million each year.

9. Relevance to Women’s Health
Is one of the major causes of gynecologic morbidity
Infertility
Ectopic pregnancy
Chronic pelvic pain
Diagnosis and treatment must be prompt to avoid these conditions.

10. PID: Etiology
PID results from microorganisms transmitted during intercourse.
Certain procedures that open the cervix and allow possible bacteria to pass through (D&C, abortion, cesarean birth, miscarriage, I.U.D. insertion)
The infection is usually multifactorial, involving aerobic and anaerobic organisms

11. PID: Risk Factors
Multiple sexual partners or partner with multiple sexual partners
Intercourse with partner with untreated urethritis
Previous history of PID
Use of an IUD
Presence of bacterial vaginosis or an STD
Nulliparity
Recent instrumentation of the uterus
Douching
Cigarette smoking
Sex with menses

12. Causative Agents of PID
Neiserria Gonorrhoeae and Chlamydia trachomatis are the 2 major causative organisms.
Chlamydia trachomatis is the predominant STD organism causing PID.
In the U.S., the role of Neisseria Gonorrhoeae as the primary cause of PID has decreased.
Other agents: Mixed infection caused by both aerobic and anaerobic organisms
Recent studies demonstrate the presence of Bacterial Vaginosis and trichomoniasis in cases of confirmed PID

13. C. trachomatis Infection (PID)

14. Causative Agents of PID
Cytomegalovirus (CMV) has been found in the upper genital tracts of women with PID.
Enteric gram-negative organisms (E-coli)
Peptococcus species
Streptococcus agalactiae
Bacteroides fragilis
Mycoplasma hominis
Gardnerella vaginalis
Haemophilus influenzae

15. Signs & Symptoms of PID
The patient presents with lower abdominal pain, fever, vaginal discharge, and/or abnormal uterine bleeding.
Symptoms frequently occur during or after menses.
Peritoneal irritation produces marked abdominal pain with or without rebound tenderness
The abdomen should be palpated gently to prevent abscess rupture

16. Chlamydial Pyosalpinx
Pelvic inflammatory disease, proven Chlamydial Pyosalpinx.
Right tube is swollen and tortuous (arrow)
(Holmes, 1999, Plate 17; reprinted with permission from McGraw Hill.)

17. Cervicitis
The cervix appears red and bleeds easily when touched with a spatula or cotton swab.
Mucopurulent discharge is yellow-green
Contains >10 polymorphonuclear WBCs per oil immersion field (using Gram stain)

18. Acute Salpingitis Onset is usually shortly after menses.
Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness, and cervical motion tenderness.
Involvement is usually bilateral.
Nausea and vomiting occur with severe infection.
In the early stages, acute abdominal signs are often absent

19. Acute Salpingitis (PID)
Bowel sounds are present unless peritonitis with ileus has developed.
Fever, leukocytosis, and mucopurulent cervical discharge are common
Irregular bleeding and bacterial vaginosis often accompany the pelvic infection.

20. Acute Salpingitis (PID)
Pelvic infection due to N. Gonorrhoeae is usually more acute than that due to C. trachomatis
Onset is rapid, and pelvic pain develops shortly after menses starts.
Although the pain is often localized to one side, both tubes are probably infected.
The infection produces a diffuse exudate, leading to agglutination, adhesions, and tubal occlusion.
Peritonitis may occur, causing upper abdominal pain and adhesions

21. Acute Salpingitis: Chlamydia & Gonorrhea
C. trachomatis produces symptoms that often seem mild, but it can cause more damage than N. Gonorrhoeae in the long term.
Chlamydial organisms may remain in tubal mucosa for many months before clinical manifestations of acute disease appear.
Untreated or inadequately treated acute infection can lead to chronic salpingitis, with tubal scarring and possible adhesion formation.
Chronic pelvic pain, menstrual irregularities, and infertility are long-term sequelae

22. Complications of PID
Tubo-ovarian abscess develops in about 15% of women with salpingitis.
It can accompany acute or chronic infection
The tube and ovary can become completely matted together.
May require prolonged hospitalization, sometimes with surgical percutaneous drainage.
Rupture of the abscess is a surgical emergency
Rapidly progressing from severe lower abdominal pain to N & V, generalized peritonitis, and septic shock

23. Tubo-ovarian abscess
Pyosalpinx, in which one or both fallopian tubes are filled with pus, may also be present.
Hydrosalpinx (fimbrial obstruction and tubal distention with nonpurulent fluid) develops if treatment is late or incomplete.
The consequent mucosal destruction leads to infertility.
Hydrosalpinx is generally asymptomatic but can cause pelvic pressure, chronic pelvic pain, or dyspareunia.
Women with HIV infection are more likely to have tubo-ovarian abscess

24. Tubo-ovarian abscess
Here at least the ovaries, tubes and uterus can still be recognized as separate structures

25. Fitz-Hugh-Curtis syndrome
Can be a complication of gonococcal or chlamydial salpingitis.
Characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis.
Acute cholecystitis may be suspected, but signs and symptoms of PID are present or develop rapidly.

26. Diagnostic Studies:
CBC with differential
Erythrocyte Sedimentation Rate
Cervical cultures
Blood Cultures
Urine Pregnancy Test
Rapid Plasma Reagin (RPR)
Cervical infection due to N. Gonorrhoeae can also be diagnosed by Gram stain showing intracellular gram-negative diplococci

27. Diagnostic studies Leukocytosis is typical.
Pelvic ultrasonography may be used when a patient cannot be adequately examined because of tenderness or pain
When a pelvic mass may be present, or when no response to antibiotic therapy occurs within 48 to 72 h. --
Laparoscopy should be performed only if the diagnosis is uncertain or if the patient does not promptly improve with medical therapy

28. CDC’s Minimum Criteria for Empiric Treatment of PID
Lower Abdominal Tenderness & Rebound
Adnexal Tenderness
Cervical Motion Tenderness

30. Diagnosis And one or more minor criteria
Temperature over 100.9F or 38.3 C
White Blood Cell count > 10,000
Elevated ESR
Elevated C-reactive protein
Pus in cul-de-sac
Pelvic abscess or inflammatory complex
Cervical Mucus findings
Gram Stain: Gram Positive diplococci
Intracellular parasites

31. Diagnosis
ESR and C-reactive protein are elevated in many disorders and are therefore not specific for PID.
Endometrial biopsy with aerobic and anaerobic culture may assist in the diagnosis.
All three major criteria and at least one minor criterion must be present to diagnose PID.

32. Endometritis (thickened heterogenous endometrium)

33. Hydrosalpinx (anechoic tubular structure)

34. Hydrosalpinx.

35. Pyosalpinx (tubular structure with debris in adnexa

36. Tuboovarian abscess resulting from tuberculosis

37. Right hydrosalpinx with an occluded left fallopian tube

38. Differential Diagnosis
Condition
Characteristic Signs/Symptoms
Acute Appendicitis
Anorexia, N & V, decreased or absent bowel signs, unilateral pain limited to right or left lower quadrant
Ectopic Pregnancy
Unilateral pain; missed menstrual period usually warrants hCG test
Ruptured Ovarian Cyst
Unilateral pain
Endometriosis
Constant pain begins 2-7 days before menses
Urinary Tract Infection
Dysuria, abnormal urinalysis. No cervical motion tenderness
Renal calculus
Severe unilateral pain, hematuria
Adnexal torsion
Proctocolitis
Anorectal pain, tenesmus, rectal discharge or bleeding
Hemorrhaging corpus luteum

40. Treatment Goals & Benefits
Therapeutic goals include complete resolution of the infection and prevention of infertility and ectopic pregnancy.

41. Management Outpatient
Regimen A:
Initial Treatment at Diagnosis
Ofloxacin 400 mg orally BID for 14 days
(95% cure) Or
Levofloxacin 500 mg orally once daily for 14 days
With or without:
Metronidazole 500 mg orally twice a day for 14 days.

42. Management Outpatient: Regimen B
Ceftriaxone 250 mg IM in a single dose Or
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose
Other parenteral third-generation cephalosporin (ceftizoxime or cefotaxime)
Plus
Doxycycline 100 mg PO BID for 14 days (75% cure)
With or without
Metronidazole 500 mg PO BID for 14 days

43. Toxic appearance Unable to take oral fluids Unclear DX Appendicitis
Management Inpatient
Toxic
appearance
Unable to take
oral fluids
Unclear DX
Appendicitis
Ectopic
Pregnancy
Ovarian torsion
Pelvic abscess
Pregnancy
HIV positive
Adolescents
Outpatient
TX failure
Unreliable
patient

44. Inpatient Treatment Regimens:
General: Treat for at least 48 hours IV
Regimen A
Cefotetan 2g IV q12 hours OR
Cefoxitin 2g IV q6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours

45. Inpatient Treatment Regimen B Clindamycin 900 mg IV q8 hours Plus
Gentamicin 2 mg/kg IV loading dose, then 1.5 mg/kg IV q8h
Discharge Regimen (after IV antibiotics)
Doxycycline 100mg PO BID for 10 days or
Clindamycin 450mg PO QID for 14 days

46. Alternative Parenteral Regimens
Ofloxacin 400 mg IV q 12 hours Or
Levofloxacin 500 mg IV once daily
With or without
Metronidazole 500 mg IV every 8 hours
Ampicillin/Sulbactam 3 g IV every 6 hours
Plus
Doxycycline 100 mg orally or IV every 12 hours

47. Prognosis
Therapy using antibiotics alone is successful in 33-75% of cases.
If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage and copious irrigation or unilateral adnexectomy, if possible.
Further surgical therapy is needed in 15-20% of cases so managed.

48. Prognosis
Chronic pelvic pain occurs in approximately 25% of patients with a history of PID.
This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or Hydrosalpinx.
Impaired fertility is a major concern in women with a history of PID.
The rate of infertility increases with the number of episodes of infection.
The risk of ectopic pregnancy is increased in women with a history of PID.
Ectopic pregnancy is a direct result of damage to the fallopian tube.

49. Sequelae Infertility ¼ of pt have acute salpingitis occur 20%
infertility rate increase direct with number of episodes of acute pelvic infection

50. Ectopic pregnancy Sequelae increase 6-10 fold
50% occur in fallopian tubes (previous salpingitis)
mechanism ; interfere ovum transport entrapment of ovum

51. Chronic pelvic pain Mortality Sequelae
4 times higher after acute salpingitis
caused by hydrosalpinx, adhesion around ovaries
should undergo laparoscope  R/o other disease
Mortality
acute PID 1%
rupture TOA 5-10%

52. Prevention
Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID.
Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide.
Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs.
Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended

53. Relevance of topic for clinical NP Practice
NPs can help reduce the risk for PID and its sequelae.
Timely diagnosis and appropriate treatment of lower-genital-tract chlamydial and gonococcal infection among both men and women can reduce the risk of adverse consequences among infected individuals and can reduce the risk of further transmission to others.

54. Relevance of topic for clinical NP Practice
Also, NPs can influence men's and women's risk of infection by providing effective counseling about their sexual behavior, health- care-seeking behavior, and contraceptive practice, and by convincing them to comply with management instructions.
Finally, by ensuring timely and effective treatment of patients' sex partners, NPs can reduce risk of reinfection.

55. Relevance of topic for clinical NP Practice
Because the partners' infections may be asymptomatic, interviewing and treating these persons will help reduce further transmission of infection in the community and may facilitate identifying other infected persons.

56. Management of Sex Partners
Treatment for sex partners of women with PID is imperative.
The management of women with PID should be considered inadequate unless their sex partners have been appropriately evaluated and treated.
Failure to manage her sex partner (s) effectively places a woman at risk for recurring infection and related complications.
Moreover, untreated sex partners often unknowingly transmit STD in a community because of asymptomatic infection.

57. Surveillance
At all levels, PID surveillance is affected by four main constraints:
PID is difficult to diagnose accurately.
PID is diagnosed in a wide variety of clinical settings.
Microbiology test results are needed to determine the etiology of PID.

58. Patient Education
The NP’s role as a health educator is central to effective management.
NPs should explain to women the nature of their disease and should encourage them to comply with therapy and prevention recommendations.
Specifically, NPs should:
Emphasize the need for taking all the medication, regardless of symptoms.

59. Patient Education Review contraindications and potential side effects.
Identify and discuss potential compliance problems.
Review the medical purpose of follow-up evaluation.
Emphasize the need to avoid sex until treatment is completed.
Emphasize the need to refer sex partners for evaluation and treatment.

60. Patient Education
When medical-care messages are clear, explicit, relevant, and rigorously delivered by providers, patients are likely to comply.
Reinforcement of these messages can be achieved by providing written information.
Information on written materials for patient distribution can be obtained from CDC or local and state health departments

61. Controversies Surrounding PID
The exact incidence of PID is unknown
The disease cannot be diagnosed reliably from clinical signs and symptoms.
Laparoscopy exam of the pelvic organs continues to be the "gold standard" approach to diagnosis of PID.
But, because this is a surgical procedure which requires an incision in the abdomen, the high priority is to design and development of non-invasive techniques, with smaller costs and fewer risks.
OC may reduce the risk of PID that is not attributable to C. trachomatis.

62. Relevant Research Findings
Recently, a study conducted at the University of Washington School of Medicine confirmed that regular douching is associated with pelvic inflammatory disease.
An earlier study had shown a significant association between vaginal douching and ectopic pregnancy.
Pelvic inflammatory disease is also a major factor in ectopic pregnancy.

63. Research Findings
In a comparison of 100 women with confirmed pelvic inflammatory disease (PID) and 762 randomly selected controls, at Harborview Medical Center in Seattle
The investigators report that women who douche once or twice a month were 2.5 times more likely to have PID than those who douched less than once a month.
However, the risk of PID does not appear to increase with more frequent douching.

64. Relevant Research Studies on PID
It is thought that douching increases the risk of PID by wiping out beneficial vaginal bacteria making it possible for disease producing bacteria to get the upper hand.
Another theory is that douching flushes vaginal and cervical bacteria back into the uterine cavity where they cause trouble.

65. Research Study
According to a study funded by the Agency for Healthcare Research and Quality (AHRQ), women with mild to moderate PID who are treated as outpatients have recovery and reproductive outcomes similar to those for women treated in hospitals.
The PID Evaluation and Clinical Health (PEACH) study was a randomized clinical trial designed to compare the effectiveness of inpatient and outpatient treatment strategies in preserving fertility and preventing PID recurrence, chronic pelvic pain and ectopic pregnancy for women with mild to moderate PID.

66. Research Study
Women treated as outpatients received a single injection of Cefoxitin and an oral dose of probenecid, followed by a 14-day supply of oral doxycycline.
Those treated in a hospital were given multiple intravenous doses of Cefoxitin plus doxycycline during a minimum inpatient stay of 48 hours.
The women’s care then was followed for 35 months to document long-term outcomes

67. Research Study
The short-term clinical improvements were similar for women treated in inpatient and outpatient settings.
After 35 months of follow-up, pregnancy rates were nearly equal between the groups, as was the amount of time it took to become pregnant.
There also were no statistically significant differences between the proportion of women with ectopic pregnancy, chronic pelvic pain or PID recurrence .

68. Relevant Research Questions
Should suspected PID be treated empirically or should treatment be delayed until results of microbiological investigations are known?
Do parental antibiotic treatment provide optimal effectiveness than oral antibiotic treatment for PID?

69. Case Study

70. Case Study
History: Jane Wheels
24-year-old female who presents reporting lower abdominal pain, cramping, slight fever, and dysuria for 4 days
P 1001, LMP 2 weeks ago (regular without dysmenorrhea). Uses oral contraceptives (for 2 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 4 days. Discomfort has gradually worsened.
Denies GI disturbances or constipation. Denies vaginal d/c.
States that she is happily married in a monogamous relationship. Plans another pregnancy in about 6 months. No condom use.
No history of STDs. Reports occasional yeast infections.
Douches regularly after menses and intercourse; last douched this morning.

71. Normal external genitalia without lesions or discharge.
Case Study
Physical Exam
Vital signs: blood pressure 104/72, pulse 84, temperature 38°C, weight 132
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.

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

73. What is the presumptive diagnosis? How should this patient be managed?
Case Study
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.
What is the presumptive diagnosis?
How should this patient be managed?
5. What is an appropriate therapeutic regimen?

74. Sex partner: Joseph (spouse) First exposure: 4 years ago
Case Study
Partner Management
Sex partner: Joseph (spouse)
First exposure: 4 years ago
Last exposure: 1 week ago
Frequency: 2 times per week
(vaginal only)
6. How should Joseph be managed?

75. Case Study
Follow-Up
On follow up 3 days later, Jane was improved clinically. The culture for gonorrhea was positive. The nucleic acid acid amplification test (NAAT) for chlamydia was negative.
Joseph (Jane’s husband) came in with Jane at follow-up. He was asymptomatic but did admit to a "one-night stand" while traveling. He was treated. They were offered HIV testing which they accepted.
Who is responsible for reporting this case to the local health department?
8. What are appropriate prevention counseling recommendations for this patient?

76. Leptotrichia buccalis Treponema pallidum Chlamydia trachomatis
Question:
1. Pelvic inflammatory disease (PID) in women is most commonly caused by:
Leptotrichia buccalis
Treponema pallidum
Chlamydia trachomatis
Bacillus anthracis
Borelia burgdorferi

77. The correct answer is #C. Chlamydia Trachomatis

78. 2. IUD use has been linked with: A. pelvic inflammatory disease
Question:
2. IUD use has been linked with:
A. pelvic inflammatory disease  
B. tubal infections  
C. uterine infections  
D. all of the above  
E. none of the above

79. The correct answer is #D. All of the above

80. Question
Which of the following conditions is not a risk factor for pelvic inflammatory disease (PID)?
A. Smoking B. Multiple sexual partners C. Young age at first intercourse D. Hepatitis B E. Intrauterine device (IUD) insertion

81. The correct answer is D:
Hepatitis B is not a known risk factor for PID.

82. A: Azithromycin B: Ceftriaxone C: Ampicillin D: Ofloxacin E: Cefoxitin
Question:
4.) Which of the following is not used to treat symptoms associated with pelvic inflammatory disease (PID)?
A: Azithromycin B: Ceftriaxone C: Ampicillin D: Ofloxacin E: Cefoxitin

83. The correct answer is A:
No data suggest that Azithromycin is an appropriate oral regimen for the tx of PID.
Most patients are now managed as outpatients.
One outpatient regimen is Cefoxitin and probenecid taken orally in a single dose.
Alternatively, ceftriaxone (less active against anaerobic bacteria compared to Cefoxitin) can be taken once IM with doxycycline orally twice daily for 14 days.
Another regimen is ofloxacin taken orally for 14 days with either clindamycin or metronidazole, which also are taken orally for 14 days.

84. elevated C-reactive protein (CRP)
Question
5.) (T/F): The major criteria for the diagnosis of pelvic inflammatory disease (PID) include
Leukocytosis
elevated C-reactive protein (CRP)
elevated erythrocyte sedimentation rate (ESR)
fever.

85. The correct answer is False:
The major criteria for the diagnosis of PID include:
Cervical motion tenderness
Adnexal tenderness
Lower abdominal tenderness.
ESR, CRP, and laboratory documentation of Neisseria gonorrhea or Chlamydia trachomatis cervical infection, among others, can aid in increasing the specificity of diagnosis

86. failed outpatient therapy Inability to tolerate oral therapy Pregnancy
Question:
6.) (T/F): All of the following are indications for hospitalization for treatment of pelvic inflammatory disease (PID):
failed outpatient therapy
Inability to tolerate oral therapy
Pregnancy
pelvic abscess.

87. The correct answer is True:
These are circumstances in which women should be hospitalized for treatment of PID.
Other conditions that may require hospitalization are:
uncertain diagnosis
severe illness
Severe N & V
Immunodeficiency (HIV, immunosuppressive medications).

88. Question:
7.) (T/F): In the initial workup, laparoscopy should be used to confirm the diagnosis of pelvic inflammatory disease (PID).

89. The correct answer is False:
Laparoscopy is costly and not always available.
It should be used if the diagnosis is in doubt

90. Question
8.) (T/F): Consider hospitalizing patients who do not improve clinically after 72 hours with outpatient therapy for pelvic inflammatory disease (PID).

91. The correct answer is True:
While most patients are now treated on an outpatient basis, these patients should be admitted to the hospital and treated appropriately

92. Any Questions???

93. THANK YOU FOR YOUR ATTENTION !!