PID

Question 1

PID Definition

Answer 1

Inflammation of the upper genital tract (above cervix) including endometrium, fallopian tubes, ovaries, pelvic peritoneum, ± contiguous structures.

up to 20% of all gynecology-related hospital admissions

Question 2

PID Aetiology

Answer 2

• Non-sexually acquired
  * mixed vaginal flora, including anaerobes, facultative Gram-negative bacteria and Mycoplasma hominid
  * E. coli, Staphylococcus, Streptococcus, Enterococcus, Bacteroides, Peptostreptococcus, H. injluenzae, G. vagina/is
  * cause of recurrent PID
  * associated with instrumentation and IUDs
  * Pelvic Actinomyces species (Gram-positive, non acid-fast anaerobe)
  * 1-4% of PID cases associated with IUDs
  • Sexually acquired
    
    • C. trachomatis
    • N. gonorrhoeae
    • M. genitalium (approximately 10% to 20%)
  • others (TB, Gram-negatives, CMV, U: urealyticum, etc.)

Question 3

PID Risk Factors

Answer 3

• age <30 yrs
  
  • risk factors as for chlamydia and gonorrhoea
  • vaginal douching
  • IUD (within first 10 dafter insertion)
  • invasive gynaecologic procedures (D&C, endometrial biopsy)

Question 4

PID Clinical Presentation

Answer 4

• up to 2/3 asymptomatic: many subtle or mild symptoms
  
  • common
    
    • fever >38.3°C
    • lower abdominal pain and tenderness
    • abnormal discharge: cervical or vaginal
  • uncommon
    
    • nausea and vomiting
    • dysuria
    • AUB
  • chronic disease (often due to chlamydia)
    
    • constant pelvic pain
    • dyspareunia
    • palpable mass
    • very difficult to treat, may require surgery

Question 5

PID Investigations

Answer 5

• blood work
  * ~hCG (must rule out ectopic pregnancy), CBC, blood cultures if suspect septicaemia
  
  • urine R&M
  • speculum exam, bimanual exam
    
    • vaginal swab for Gram stain, C&S
    • cervical cultures for N. gonorrheae, C. trachomatis
    • endometrial biopsy will give definitive diagnosis (rarely done)
  • ultrasound
    
    • maybe normal
    • free fluid in cul-de-sac
    • pelvic or tubo-ovarian abscess
    • hydrosalpinx (dilated fallopian tube)
  • laparoscopy (gold standard)
    
    • for definitive diagnosis: may miss subtle inflammation of tubes or endometritis

Question 6

PID Management

Answer 6

• Non-sexually acquired
  * Mild to Moderate
  * Augmentin PO or Metronidazole PO 12 hours for 14 days
  * Azithromycin PO single dose
  * Azithromycin PO single dose (pregnant or breastfeeding) week later or doxycycline PO every 12 hours for 14 days

  * Severe
     * Amoxy/ampicillin IV
     * Gentamicin IV
     * Metronidazole IV

  • Sexually acquired
    
    • Mild to Moderate
      
      • Ceftriaxone IM
      • Metronidazole PO
      • Azithromycin PO single dose
      • Azithromycin PO single dose (pregnant or breastfeeding) week later or doxycycline PO every 12 hours for 14 day
    • Severe
      
      • Ceftriaxone IV
      • Azithromycin IV
      • Metronidazole IV

Question 7

Complications of Untreated PID

Answer 7

• chronic pelvic pain
  
  • abscess, peritonitis
  • adhesion formation
  • ectopic pregnancy
  • infertility
    
    • 1 episode of PID ~ 13%infertility
    • 2 episodes of PID ~ 36% infertility
  • bacteraemia
  • septic arthritis, endocarditis