10.2: PID

Question 1

What causes PID?

Answer 1

An infection that ascends to the upper genital tract spreading from the endocervix

Question 2

Name six diseases/complications that PID can lead to?

Which is considered a surgical emergency

Answer 2

Essentially an infection of every part of the genital tract:

1. Endometritis
2. Salpingitis; inflammation of the Fallopian tubes
3. Parametritis; inflammation of pelvic floor CT
4. Oophoritis; inflammation of ovary
5. Tubo-ovarian abscess; abscess (collection of pus) of the Fallopian tube and/or affecting the ovary
6. Pelvic peritonitis; irritation of peritoneum* surgical emergency

Question 3

What is another name for parametritis?

Answer 3

Pelvic cellulitis

Question 4

Describe the areas that an individual with PID may experience pain
* 5 things

Answer 4

1. Pelvic floor
2. Lower abdominal; usually bilateral but can be unilateral
3. RUQ
4. Deep dyspareunia (especially if recent onset)
5. Secondary dysmenorrhea: pain caused by disordered reproductive organs that starts earlier in the menstrual cycle and lasts longer than menstrual cramps

Question 5

Other than types of pain, what other signs and symptoms might an individual with PID experience?

Answer 5

Abnormal vagina discharge and bleeding

Question 6

List five gynaecological differentials for PID, star the two that are the most severe and must be dealt with quickly

Answer 6

1. Ectopic pregnancy*
2. Ruptured corpus lateral cyst
3. Endometriosis
4. Ovarian cyst rupture
5. Ovarian torsion*

Question 7

Name two potential GI differentials and one renal differential for PID

Other than any gynaecological, GI and renal differentials - what else is a differential for PID?

Answer 7

GI: IBS and diverticular disease

Renal: UTI (particularly if its unilateral pain and there’s associated dysuria)

Other: functional pain and appendicitis (especially if its R iliac fossa pain)

Question 8

What is Mittleshmerz pain?

Answer 8

Another gynaecological differential for PID, its mid-cycle cramping due to ovulation which can be very severe

Question 9

Name four risk factors for a PID specific to sexual behaviour

Answer 9

1. Early age of first sexual intercourse
2. Multiple partners
3. New partner <3 months
4. History of STIs (patient or partner)

Question 10

Name three risk factors for a PID specific to instrumentation of the uterus

Answer 10

1. Termination of a pregnancy
2. IUD insertion within last 4-6 weeks (if so consider removing it after no response to antibiotics within 72 hours)
3. Recent IVF

Question 11

Name four bacterial causes for PID, which is the most common? Is there always a pathogen involved?

Answer 11

1. Chlamydia- most common
2. Gonorrhea
3. Mycoplasma genitalium
4. Overgrowth of natural vaginal flora; anaerobes, gardnerella vaginalis

*But it can also be pathogen negative

Question 12

What would you expect to see in an abdominal, bimanual/pelvic and speculum (to see inside hollow body parts) examination of a patient with PID. What else might the patient present with?

Answer 12

Abdominal: lower (usually bilateral) abdominal tenderness

Bimanual: adnexal, cervical and uterine tenderness

Speculum: abnormal cervical and vaginal mucopurulent discharge

The patient may also have a fever

Question 13

What is the adnexa?

Answer 13

Region adjacent to the uterus that includes the ovary, Fallopian tubes and associated structures

Question 14

Name five major investigations you would do for a patient with suspected PID

Answer 14

1. Pregnancy test
2. Triple swab:
   A) high vaginal swab to rule out bacterial infections and candidiasis
   B) Endocervical swab for chlamydia and gonorrhea
3. Bloods: ESR, CRP, leukocyte count and check for HIV and syphilis
4. Ultrasound: looking for hydrosalpinx (clear serous fluid within the Fallopian tube) or an abscess
5. CT/MRI to exclude any other diagnosis

Question 15

List three major/general things you would do as part of PID treatment

Answer 15

1. GUM referral for advice, contact tracing, and screening current and recent partners within last 6 months
2. Analgesia; i.e paracetamol, ibuprofen
3. Empirical (not waiting for swabs to come back, treat quickly to avoid complications) antibiotics for 14 days
   - outpatient and inpatient regime. The course of antibiotics must be finished even if the swabs come back negative

Question 16

Name three antibiotics used as treatment for PID

Answer 16

Ceftriaxone, doxycycline, metronidazole

Question 17

When would surgery be considered as treatment for PID

Answer 17

1. Patient showing no response to antibiotics
2. Severe disease
3. Tubo-ovarian abscess

Question 18

When should there be significant improvement after giving antibiotics? What should be considered if there isn’t?

Answer 18

Significant improvement should occur 72 hours after, if there isn’t consider admitting for IV antibiotics or further investigations

Question 19

List 5 criteria for admitting a patient with a suspected PDI

Answer 19

1. Ectopic pregnancy cannot be excluded
2. Severe signs and symptoms (febrile, nausea, vomiting, etc)
3. Pelvic peritonitis (SUPER tender)
4. Another surgical emergency cannot be excluded (i.e acute appendicitis)
5. Can’t tolerate oral medications

Question 20

What is a test of cure? List four scenarios where you would perform one

Answer 20

When you retest after completion of antibiotics

To be done if

1. Initial swabs for chlamydia, gonorrhea were positive
2. Symptoms persist after treatment
3. Poor compliance suspected
4. Possibility of reinfection

Question 21

List five complications that prompt empirical antibiotics are given to prevent! What might cause these complications?

Answer 21

1. Tubal infertility
2. Ectopic pregnancy
3. Chronic pelvic pain
4. Development of a tubo-ovarian abscess
5. Fitz-Hugh-Curtis

Can form due to adhesions (scar tissue after inflammation or surgery)

Question 22

What is fitz-Hugh Curtis and why can a PID cause one?

Answer 22

A liver capsular infection that forms without hepatic parenchymal involvement caused by the intra-abdominal spread of a PID (possibly using parabolic gutters, blood or lymph flow)

Question 23

List three characteristics of acute fitz-Hugh Curtis and one characteristic for chronic, is it always symptomatic?

Answer 23

May be asymptomatic

Acute: sharp severe RUQ pain, may have pain in right shoulder tip (due to irritation along the diaphragm), systemically unwell (fever, nausea, vomiting, etc)

Chronic: Persistent dull RUQ pain

Question 24

If a patient with asymptomatic fitz-Hugh-Curtis is sent for surgery what would you find?

Answer 24

Adhesions along the liver (violin string like adhesions)

Question 25

How is Fitz-Hugh-Curtis investigated and what would you expect to see?

Answer 25

If the patient had fitz-Hugh-Curtis.. 1. Bloods: LFT (normal as there’s no hepatic parenchymal involvement), inflammatory markers (would be raised) 2. Ultrasound: to exclude biliary stones, and would see violin string like adhesions

Question 26

How is fitz-Hugh Curtis treated?

Answer 26

Same 2 week course of antibiotics used for PID

Question 27

What does ESR measure and what is an abnormal finding?

Answer 27

Erythrocyte sedimentation rate: measures how quickly erythrocytes settle at the bottom of a test tube. A faster than normal rate may indicate inflammation.