Tutorial 14: Pelvic Inflammatory Disease

Question 1

What is Pelvic Inflammatory Disease?

Answer 1

Pelvic inflammatory disease (PID) is an acute, ascending, polymicrobial infection of the upper female reproductive tract.

PID is frequently associated with Neisseria gonorrhoeae or Chlamydia trachomatis.

It is a spectrum of inflammatory disorders including any combination of endometritis, salpingitis, parametritis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis.

Question 2

What types of infection is PID and what are the most common causative organisms?

Answer 2

PID is a polymicrobial infection.

1. Sexually transmitted organisms (common): Neisseria gonorrhoeae and Chlamydia trachomatis
2. Micro-organisms of the vaginal flora (e.g., anaerobes, Gardnerella vaginalis, Haemophilus influenzae, enteric gram-negative rods, and Streptococcus agalactiae)
3. Other organisms: Cytomegalovirus (CMV), Mycoplasma hominis, Mycoplasma genitalium, and Ureaplasma urealyticum.

Question 3

What is the epidemiology of Pelvic Inflammatory Disease?

Answer 3

It most commonly affects young, single, sexually active women with a history of sexually transmitted diseases.

No actual prevalence is known. The rate of diagnosed Chlamydia infection is increasing in NZ, having risen by 27.7% from 3363 diagnosed cases in 2002 to 4295 in 2006.

Question 4

What is the pathophysiology behind pelvic inflammatory disease?

Answer 4

Infection of the cervix, usually caused by Neisseria gonorrhoeae and Chlamydia trachomati, if left untreated, may ascend to the upper genital tract.

Epithelial damage leads to a disruption of protective cervical barrier which allows entry of other micro-organisms, which ultimately leads to an ascending polymicrobial infection.

Spreading to the upper genital tract may also occur by insertion of instrumentations to the cervix such as D&C, TOP termination of pregnancy, or insertion of an IUD.

Question 5

What are some complications of Pelvic Inflammatory Disease?

Answer 5

Long term complications of untreated or incompletely treated PID may lead to:

1. Tuboovarian Abscess (TOA)
2. Tubal scarring and obstruction: leading to infertility or ectopic pregnancy
3. Chronic pelvic pain
4. Reactive arthritis
5. Perihepatitis (Fitz-Hugh-Curtis syndrome).

Question 6

What are some risk factors for Pelvic Inflammatory Disease?

Answer 6

1. Prior infection with chlamydia or gonorrhoea
2. Prior Hx of PID
3. Young age at onset of sexual activity
4. Unprotected sexual intercourse with multiple sexual partners
5. Instrumentation (eg. IUD insertion, D & C, surgical TOP termination of pregnancy)
6. Lifestyle Factors: Smoking, low SES, linked with sex trade and drug use,
7. Sexual Habits: intercourse during menstruation, vaginal douching

Question 7

What are some symptoms of Pelvic Inflammatory disease?

Answer 7

1. Asymptomatic (85% of women)
2. Unspecific and may vary widely (mild to absent)
3. Bilateral lower abdominal pain
4. Fever/chills
5. Nausea and vomiting
6. Back pain
7. Dysuria
8. Dyspareunia (deep)
9. Cervical or vaginal discharge
10. Abnormal vaginal odour, bleeding, or discharge
11. Abnormal vaginal bleeding, including post-coital, inter-menstrual, and menorrhagia

Question 8

What are some signs of Pelvic Inflammatory Disease?

Answer 8

1. Vitals: High temperature
2. Abdo exam: Bilateral lower abdominal tenderness
3. Speculum: mucopurulent cervical (cloudy or yellow discharge) and vaginal
4. Friable cervix : Cervix bleeds easily with friction from a Dacron swab (uncommon)
5. Bimanual to reveal: uterine tenderness, cervical motion tenderness, adnexal tenderness

Question 9

What Investigations would you want to perform if a patient had suspected pelvic inflammatory disease?

Answer 9

1. FBC (WBC count), CRP, ESR
2. Swabs – NAAT Chlamydia and gonorrhoea from cervix. HVS for trichomonas vaginalis (rectal swab if anal sex)
3. Nucleic acid amplification test (NAAT): Polymerase chain reaction, transcription mediated amplification, strand displacement amplification

Question 10

What investigations would you consider for an uncertain clinical diagnosis of Pelvic Inflammatory disease?

Answer 10

1. Transvaginal USS: primary imaging modality and may be normal in early stages or uncomplicated cases to confirm uncertain diagnosis. Use of c_olour or power Doppler_ can improve detection of subtle abnormalities of endometritis, salpingitis, and, oophoritis.
2. Pelvic CT: indicated in patients with diffuse pelvic pain, peritonitis, or difficult or equivocal ultrasound. It should be performed with both oral and intravenous contrast, as un-opacified bowel may be mistaken for an abscess.
3. Pelvic MRI: considered superior to USS at diagnosing PID when there is a tubo-ovarian abscess, pyosalpinx, fluid-filled tube, and/or enlarged polycystic ovaries with free intrapelvic fluid. Rarely used due to cost effectiveness.
4. Laparoscopy: enables specimens to be taken from the fallopian tubes and pouch of Douglas. It will not detect endometritis or subtle inflammation of the fallopian tubes. Not be used as a routine diagnostic tool, especially when symptoms are mild or vague.
5. Endometrial biopsy (endometritis) : Endometrial biopsy should not be used as a routine diagnostic test. It is indicated in women undergoing laparoscopy who do not have visual evidence of salpingitis.

Question 11

What are some differentials for Pelvic Inflammatory Disease?

Answer 11

1. Ectopic Pregnancy
2. Acute appendiciis
3. Ruptured Ovarian cyst
4. Ovarian cyst torsion
5. Haemorrhagic ovarian cyst
6. Endometritis

Question 12

How do you differentiate between an ectopic pregnancy and PID?

Answer 12

Lower abdominal pain, adnexal tenderness, fever, and other symptoms of acute abdomen (nausea, vomiting, diarrhoea) may be present.

May resemble severe case of PID. PID can exist concurrently with ectopic pregnancy.

A positive pregnancy test: hCG hormone level is high in serum and urine.

USS may reveal an empty uterus and may show a mass in the fallopian tubes.

Question 13

How do you differentiate between acute appendicitis and PID?

Answer 13

Nausea and vomiting. Cervical motion tenderness will occur in about 25% of women with appendicitis while this sign is usually present in all patients with PID.

Abdominal USS shows aperistalic or non-compresible structure with diameterof >6mm.

Abdominal and pelvic CT may show calcified appendicolith seen in association with periappendiceal inflammation.

Laparoscopy will be diagnostic and therapeutic

Question 14

How do you differentiate between ruptured ovarian cyst and PID?

Answer 14

Rupture usually spontaneous, can follow history of trauma; mild chronic lower abdominal discomfort may suddenly intensify.

Signs of peritonism (guarding, rebound tenderness, rigid abdomen) may be present in lower abdomen and pelvis; size of the adnexal mass may be unremarkable due to collapsed cyst.

Pelvic ultrasound confirms diagnosis.

Question 15

How can you differentiate between ovarian cyst torsion and PID?

Answer 15

Sudden, acute, unilateral, lower quadrant abdominal pain, severe and colicky in nature; two thirds of patients have nausea and vomiting.

Lowgrade fever usually correlates with necrosis;

Tender adnexal mass palpated in 90%; localised peritoneal irritation.

Pelvic ultrasound confirms diagnosis.

Question 16

How can you differentiate between haemorrhagic ovarian cyst and PID?

Answer 16

Localised abdominal pain, nausea, and vomiting.
Clinical examination may be unremarkable.

Rarely, and depending on size of cyst, hypovolaemic shock may be present; abdominal tenderness and peritonism; pelvic mass may be palpated.

Pelvic ultrasound confirms diagnosis.

Question 17

How do you differentiate between endometritis and PID?

Answer 17

Adnexal enlargement, cervical stenosis, or lateral displacement of uterus;

Cyclic pain that is exacerbated by onset of menses and during the luteal
phase; or dyspareunia. Cyclic pain is not a feature of PID.

Transvaginal ultrasound may show ovarian endometrioma or evidence of deep pelvic endometriosis e.g. uterosacral ligament involvement.

Laparoscopy confirms diagnosis by direct visualisation of peritoneal implants with biopsy-confirmed endometrial glands or stroma outside of uterine cavity.

Question 18

What is the treatment for Pelvic Inflammatory Disease?

Answer 18

1. Medication:
   
   • Ceftriaxone 250 to 500mg IM STAT
   • Doxycycline 100mg bd for 14days OR Azithromycin 1g per week for two weeks
   • Metronidazole 400mg bd for 14days
2. Contact Tracing: Sexual partners who have had sexual contact with a woman diagnosed with PID 60 days prior to her onset of symptoms should be consulted and treated also
3. Analgesia
4. Avoid sexual intercourse until completion of treatment

Empirical treatment of PID should be initiated in women high risk and physical findings suggestive of PID. This is to prevent long term complication of PID.

Question 19

What preventative measures can be put in place for pelvic inflammatory disease?

Answer 19

1. Counselling and education should be given to the patient and the partner on the basis of safe sex, risk of STI and future use of barrier contraception.
2. HIV Testing may be applicable in high risk patients.

Question 20

What are some facts about chlamydia?

Answer 20

• Females are asymptomatic in 79-90% in up to 73% in males.
• If symptomatic, symptoms and signs are similar to PID and require prompt treatment to prevent PID and further complications.
• Transmission to sexual partner at 45-68%. Untreated Chlamydia infection can remain culture positive for over 60days.

Question 21

What opportunisitic testing is available for chlamydia testing?

Answer 21

1. In NZ, offer testing for women aged 15-24years, who have:
   
   1. two or more partners in the last year and/or
   2. recent partner change, pregnant and not consistently used condoms.
2. Asymptomatic women: low vaginal swab either by health care practitioner or self collected. Cervical swab for NAAT with speculum examination.
3. Asymptomatic men: first 10-20mL void urine most accurate. Urethral swab not recommended. NB: There is not enough evidence for routine testing for asymptomatic sexually active young men.

Question 22

What is the treatment for chlamydia?

Answer 22

Treatment for male and non-pregnant female

1. Doxycycline 100mg BD for 7days OR
2. Azithromycin 1g stat

Treatment pregnant female

1. Azithromycin 1g stat OR
2. Amoxicillin 500mg TDS for 7days OR
3. Erythromycin stearate 500mg qid for 7days