Pelvic Inflammatory Disease (PID) Max Brinsmead PhD FRANZCOG July 2011

This talk What is Pelvic Inflammatory Disease? Why it is important How it is spread Diagnosis Treatment Prevention

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

Anatomy

PID comes in two forms... Acute Chronic 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)

Why PID is important Affects up to 1:4 women in PNG 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

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

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

Etiology 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

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

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

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)

Pathology

Uterus, Bilateral Fallopian Tubes, and Ovaries C F O M U: Uterus C: Cervix F: Fallopian Tube O: Normal Ovary M: Inflamed Tubo- Ovarian Mass Note 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.

Normal Fallopian Tube - Low Power M: Mucosal Folds L: Lumen W: Wall of Tube Note the delicate mucosal folds lined by epithelium and a vascularized stroma. There are no inflammatory cells in the lumen or in the mucosa.

Fallopian Tube – from a PID W M L W: Muscular Wall M: Inflamed Mucosa L: Lumen with Inflammatory Cells Notice the inflammatory infiltrate in the mucosa and muscular wall. Inflammatory cells have nearly obscured the lumen.

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

Fitz-Hugh-Curtis

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

Endometritis (thickened heterogenous endometrium)

Hydrosalpinx (anechoic tubular structure)

Hydrosalpinx.

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

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 >40% ~ 3 episodes Recurrence of acute PID at least 25% Male genital disease in 25%

Treatment of PID Antibiotics Surgical Rest and analgesia 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

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.

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

Criteria for hospitalization

Special Situations 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

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

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

Any Questions? Thank you