PID and Pelvic TB

Ina S. Irabon, MD, FPOGS, FPSRM, FPSGE

Obstetrics and Gynecology
Reproductive Endocrinology and Infertility
Laparoscopy and Hysteroscopy
Main reference
¡ Comprehensive Gynecology 7th edition, 2017
(Lobo RA, Gershenson DM, Lentz GM, Valea FA
editors); chapter 23, Genital Tract Infections
Pelvic Inflammatory
Disease (PID)
 Pelvic Inflammatory Disease
(PID)
¡ infection in the upper genital tract not
associated with pregnancy or intraperitoneal
pelvic operations.
¡ polymicrobial infection that is a mixture of
aerobic and anaerobic bacteria, clinically
appearing as a complex infection.
¡ It may include infection of any or all of the
following anatomic locations:
¡ endometrium (endometritis)
¡ Oviducts/fallopian tubes (salpingitis)
¡ ovary (oophoritis)
¡ uterine wall (myometritis)
¡ uterine serosa and broad ligaments (parametritis),
and pelvic peritoneum

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID)
¡ Oviducts are the most commonly
affected

¡ Acute PID results from ascending infection

from the bacterial flora of the vagina and
cervix in more than 99% of cases
¡ Acute PID is rare in the woman without
menstrual periods, such as the pregnant,
premenarcheal, or postmenopausal
woman.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID)
¡ In less than 1% of cases, acute PID results from
transperitoneal spread of infectious material from
a perforated appendix or intraabdominal
abscess.

¡ Hematogenous and lymphatic spread to the

tubes or ovaries is another remote possibility.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID)
¡ PID is extremely rare in women who are
amenorrheic or not sexually active.

¡ When PID is found in the postmenopausal

woman, associated conditions are as follows:
¡ genital malignancies
¡ Diabetes
¡ concurrent intestinal diseases, such as diverticulitis,
appendicitis, or carcinoma

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID): Etiology
¡ In many cases, no causative organism is found.

¡ two classic sexually transmitted organisms

associated with PID: Neisseria gonorrhoea and
Chlamydia trachomatis

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID): Etiology
¡N. gonorrhea

¡ Once the gonococcus ascends to the fallopian

tube, it selectively adheres to nonciliated mucus-
secreting cells.
¡ However, most damage occurs to the ciliated
cells, most likely because of an acute
complement-mediated inflammatory response
with the migration of polymorphonuclear
leukocytes, vasodilation, and transudation of
plasma into the tissues
¡ This robust inflammatory response causes cell
death and tissue damage à SCARRING/ tubal
adhesions
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Paavonen
Paavonen 101101 32 (32%)
32 (32%) 25 (25%)
25 (25%)
Paavonen
Paavonen 228228 69 (30%)
69 (30%) 60 (26%)
60 (26%)
Eilard
Eilard 22 22 6 (27%)
6 (27%) 7 (32%)7 (32%) 1/22 (5%) 1/22 (5%)
Bowi
Bowi 43 43 22 (51%)
22 (51%) 15 (35%)
15 (35%)
Eschenbach
Eschenbach 204204 20/100
20/100 (20%)(20%) 90 (44%)
90 (44%) 7/54 (13%)7/54 (13%)
Sweet
Sweet 39 39 2 (5%)
2 (5%) 18 (46%)
18 (46%) 8/35 (23%)8/35 (23%)

Pelvic Inflammatory Disease

Cunningham
Cunningham 104104 56 (54%)
56 (54%) 30/104 (29%)
30/104 (29%)
Thompson
Thompson 30 30 3 (10%)
3 (10%) 24 (80%)
24 (80%) 10/30 (33%)
10/30 (33%)
Total
Total 1741
1741 400/1365
400/1365 (29%) (29%) 445/1728
445/1728 (26%) (26%) 58/328
58/328 (18%) (18%)

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(PID): Etiology
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In Gynecology
Gynecology and Obstetrics,
and Obstetrics, Philadelphia,
Philadelphia, Harper & Harper & Row,
Row, 1985, p 8. 1985, p 8.

Figure 23-23
Figure 23-23 Acute
Acutesalpingitis with
salpingitis a mixture
with a mixtureof neutrophils,
of neutrophils, FigureFigure
23-24 23-24
Acute salpingitis showing dilation
Acute salpingitis showingof dilation
the fallopian tube
of the fallopian tube
lymphocytes, and
lymphocytes, andplasma
plasmacells in in
cells thethe
fallopian tubetube
fallopian destroying somesomeand blunting
destroying of the papillary
and blunting fronds. (From
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Mosby, 1997, p 107.)
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sensitized studies
sensitized studies havehavedemonstrated
demonstrated thatthat women
women withwithanti- anti-sequelae of repeated
sequelae asymptomatic
of repeated chlamydialchlamydial
asymptomatic infections infections
are are
bodies
bodies to chlamydial
chlamydial
C o m p re h e heat
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itio n , 2 0 1are likely
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t In fe c tio n s be-
severe tubal scarring
severe scarringand andFitz-Hugh–Curtis
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that atypical be themaymore common
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 Pelvic Inflammatory Disease
(PID): Etiology
¡Chlamydia trachomatis

¡ C. trachomatis an intracellular, sexually transmitted

bacterial pathogen.
¡ Chlamydia may remain in the fallopian tubes for
months after initial colonization of the upper genital
tract.
¡ Primary infection appears to be self-limited, with
mild symptoms and little permanent damage.
¡ repeat exposures to Chlamydia, such as may occur
in asymptomatic untreated C. trachomatis cervical
infection, may lead to an autoimmune response
that causes severe tubal damage, even if C.
trachomatis is no longer present.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Pelvic Inflammatory Disease
(PID): Etiology
¡ The most common aerobic organisms are
nonhemolytic Streptococcus, E. coli, group B
Streptococcus, and coagulase-negative
Staphylococcus.
¡ Anaerobic organisms tend to predominate
over aerobes, and the most common
anaerobic organisms are Bacteroides spp.,
Peptostreptococcus, and Peptococcus.
¡ Anaerobic organisms are almost ubiquitous
in pelvic abscesses associated with acute
PID.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID): Risk factors
¡ age at first intercourse
¡ marital status
¡ number of sexual partners

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID): Signs and Symptoms
Box 23-8 CDC Guidelines for Diagnosis of Acute Pelvic
orders Inflammatory Disease: Clinical Criteria for Initiating Therapy

Number Minimum Criteria

Empirical treatment of PID should be initiated in sexually active
24 young women and others at risk for STIs if the following
16 minimum criteria are present and no other causes(s) for the
12 illness can be identified:
11 Lower abdominal tenderness or
7 Adnexal tenderness or
7 Cervical motion tenderness
6
15 Additional Criteria for Diagnosing PID
98 Oral temperature > 38! C
Abnormal cervical or vaginal discharge (mucopurulent)
isease. Am J
Presence of abundant WBCs on microscopy of vaginal secretions
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
e- Laboratory documentation of cervical infection with N. gonorrhoeae
opy/ or C. trachomatis

Definitive Criteria for Diagnosing PID

sis:
Histopathologic evidence of endometritis on endometrial biopsy
umber)
Transvaginal sonography or MRI showing thickened fluid-filled
tubes, with or without free pelvic fluid or tubo-ovarian complex
Laparoscopic abnormalities consistent with PID
Although initial treatment can be made before bacteriologic
diagnosis of C. trachomatis or N. gonorrhoeae infection, such
a diagnosis emphasizes the need to treat sex partners.
PID, Pelvic inflammatory disease; STI, sexually transmitted infection; WBC, white
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
blood cells.
 Pelvic Inflammatory Disease
(PID): Signs and Symptoms
¡ Lower abdominal and pelvic
tenderness during examination is
the hallmark of acute PID.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID): Signs and Symptoms
¡ The most frequent symptom of
acute PID is new-onset lower
abdominal and pelvic pain.
¡ pain is diffuse, bilateral, and usually
described as constant and dull.
¡ It may be exacerbated by motion or
sexual activity.
¡ The duration of pain is usually less than 7
days.

¡ It is important to remember that

up to 50% of women with tubal
damage never experience any
symptoms consistent with PID.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Pelvic Inflammatory Disease
(PID): Fitz-Hugh–Curtis
syndrome

¡ Five percent to 10% of women with acute

PID develop symptoms of perihepatic
inflammation, the Fitz-Hugh–Curtis
syndrome

¡ the liver capsule will appear inflamed, with

classic violin string adhesions to the
parietal peritoneum beneath the
diaphragm.
¡ Persistent symptoms and signs include right
upper quadrant pain, pleuritic pain, and
tenderness in the right upper quadrant
when the liver is palpated
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Pelvic Inflammatory Disease (PID):
Fitz-Hugh–Curtis syndrome
2

DI
¡ develops from transperitoneal or Di

vascular dissemination of the

m
sep

gonococcal or Chlamydia organism to

tia
aro
bu
produce the perihepatic inflammation pr
ab
lap
du
m
les
fer
pe

on
hig
sen
Figure 23-26 Classic violin string sign of Fitz-Hugh–Curtis syndrome ha
in PID. cy
the
perihepatitis have a higher prevalence of moderate to severe pel- (>
vic adhesions and a higher prevalence and titers of antibodies to cal
chlamydial heat shock protein 60. Treatment is the same as the wi
treatment for acute salpingitis. ES
Lower abdominal and pelvic tenderness during examination en
is the hallmark of acute PID. On abdominal examination, pa- tes
tients have tenderness to direct palpation in the lower abdomen, va
and occasionally rebound tenderness. On pelvic examination, bi- ati
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le alateral
FA e d ito rs); c hof
tenderness ap te rparametria
the 2 3 , G e n ita
andl Tra c t Inisfepresent
adnexa c tio n s and sh
may be exacerbated with movement of the uterus or cervix dur- he
ing the pelvic examination. An ill-defined adnexal fullness is fre- ma
 Diagnosis of PID
¡ Direct visualization via laparoscopy
is the most accurate method of
diagnosing acute PID.

¡ The laparoscopy offers the

additional advantage of
concurrent operative procedures
such as lysis of adhesions, potential
drainage of an abscess, and
irrigation of the pelvic cavity.

¡ Acute PID should be included in the

differential diagnosis of any sexually
active young woman with pelvic
pain.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Diagnosis of PID

¡ Examine the endocervical mucus for

inflammatory cells and perform the
NAAT for N. gonorrheae and C.
trachomatis.

¡ The presence of an increased

number of vaginal white blood cells is
the most sensitive laboratory indicator
of acute PID.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Diagnosis of PID

¡Endometrial biopsy (?)

¡Transvaginal ultrasound – useful in
documenting an adnexal mass
¡MRI (?)

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Diagnosis of PID
e Box 23-8 CDC Guidelines for Diagnosis of Acute Pelvic
sorders Inflammatory Disease: Clinical Criteria for Initiating Therapy

Number Minimum Criteria

Empirical treatment of PID should be initiated in sexually active
24 young women and others at risk for STIs if the following
16 minimum criteria are present and no other causes(s) for the
12 illness can be identified:
11 Lower abdominal tenderness or
7 Adnexal tenderness or
7 Cervical motion tenderness
6
15 Additional Criteria for Diagnosing PID
98 Oral temperature > 38! C
Abnormal cervical or vaginal discharge (mucopurulent)
disease. Am J
Presence of abundant WBCs on microscopy of vaginal secretions
Elevated erythrocyte sedimentation rate
Elevated C-reactive protein
se- Laboratory documentation of cervical infection with N. gonorrhoeae
copy/ or C. trachomatis

Definitive Criteria for Diagnosing PID

osis:
Histopathologic evidence of endometritis on endometrial biopsy
Number)
Transvaginal sonography or MRI showing thickened fluid-filled
tubes, with or without free pelvic fluid or tubo-ovarian complex
Laparoscopic abnormalities consistent with PID
Although initial treatment can be made before bacteriologic
diagnosis of C. trachomatis or N. gonorrhoeae infection, such
a diagnosis emphasizes the need to treat sex partners.
C o m p re h e n siv e PID,
G y n ePelvic y 7 th e d itio n , 2 0disease;
c o lo g inflammatory 1 7 (Lo b o STI,
R A , sexually
G e rsh e n so n D M , Le n tzinfection;
transmitted G M , V a le a FA e white
WBC, d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Treatment

¡ The two most important goals of the

medical therapy of acute PID:
1. resolution of symptoms
2. preservation of tubal function.

¡ Antibiotic therapy should be started as

soon as the diagnosis has been made.
¡ Early diagnosis and early treatment will
help reduce the possibility of long-term
sequelae of the disease.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Treatment

¡ Women who are not treated in the first

72 hours following the onset of symptoms
are three times as likely to develop tubal
infertility or ectopic pregnancy
¡ In the management of acute PID, DO
NOT FORGET the treatment and
education of the male partner for the
prevention of the disease, including the
use of proper contraceptives, which help
reduce the rate of upper genital tract
infection.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Treatment

¡ Because most cases of PID are

polymicrobial, broad-spectrum antibiotic
coverage is indicated.
¡ Empirical antibiotic protocols should
cover a wide range of bacteria,
(includes: N. gonorrhoeae, C. trachomatis,
anaerobic rods and cocci, gram-negative aerobic
rods, and gram-positive aerobes )

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 estimate of the need for anaerobic coverage. Importantly, if
the woman has bacterial vaginosis, adding prolonged coverage
with metronidazole, 500 mg orally twice daily for 14 days, is
Treatment: Outpatient
preferable.

Box 23-9 CDC Recommendations for Ambulatory Management

of Acute Pelvic Inflammatory Disease
Ceftriaxone, 250 mg IM, single dose
or
Cefoxitin, 2 g IM, single dose, and probenecid, 1 g PO administered
concurrently in a single dose
or
Other parenteral third-generation cephalosporin (e.g., ceftizoxime,
cefotaxime)
plus
Doxycycline, 100 mg PO bid for 14 days
with or without
Metronidazole, 500 mg PO bid for 14 days
Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC):
Sexually transmitted diseases treatment guidelines, MMWR 59(RR-2):66,
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
2010.
 Treatment: Outpatient

¡ It is important to reexamine women

within 48 to 72 hours of initiating
outpatient therapy to evaluate the
response of the disease to oral
antibiotics.
¡ If the disease is responding well,
approximately 4 to 6 weeks after therapy
the woman should be reexamined to
assess the resolution of clinical symptoms
and establish a post-treatment baseline.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 women misinterpret the early signs and symptoms of an infec-
tion as being related to the IUD. Pelvic infections with an PI
IUD in place and pelvic infections following operative or diag- pr
Treatment: Inpatient
nostic procedures often are caused by anaerobic bacteria. Outpa- tio
tient therapy leaving the IUD in situ may be attempted if close of
C
Box 23-10 Indications for Hospitalizing Patients with Acute 24
Pelvic Inflammatory Disease w
ta
Surgical emergencies (e.g., appendicitis) cannot be excluded.
an
The patient is pregnant.
The patient does not respond clinically to oral antimicrobial
ha
therapy. co
The patient is unable to follow or tolerate an outpatient oral
regimen. It
The patient has severe illness, nausea and vomiting, or high fever. an
The patient has a tubo-ovarian abscess. C
Adapted from Workowski KA, Berman S; Centers for Disease Control and
C
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
Prevention (CDC): Sexually transmitted diseases treatment guidelines, MMWR 59 Pe
 Treatment: Inpatient
cillin– Box 23-11 Inpatient Management of Acute Pelvic Inflammatory
n may Disease
symp-
ness in Parenteral Regimen A
bined Cefotetan, 2 g IV every 12 hr
n, 1 g or
Cefoxitin, 2 g IV every 6 hr
, con-
plus
nisms Doxycycline, 100 mg PO or IV every 12 hr
ll also NOTE: Because of pain associated with infusion, doxycycline should
olone- be administered orally when possible, even when the patient is
ended hospitalized. PO and IV administration of doxycycline provide
phalo- similar bioavailability.
olones
00 mg Parenteral Regimen B
, may Clindamycin, 900 mg IV every 8 hr
al risk plus
Gentamicin, loading dose IV or IM (2 mg/kg of body weight)
orrhea
followed by a maintenance dose (1.5 mg/kd) every 8 hr. Single
daily dosing may be substituted.
urs of
he dis- Alternative Parenteral Regimens
when Limited data support the use of other parenteral regimens. The
pond- following regimen has been investigated in a least one clinical
oman trial, and has broad-spectrum coverage:
symp- Ampicillin-sulbactam, 3 g IV every 6 hr
plus
nullip- Doxycycline, 100 mg PO or IV every 12 hr
One trial has demonstrated high short-term clinical cure rates with
onger
azithromycin, either as monotherapy for 1 wk (500 mg IV " one
found or two doses followed by 250 mg PO, 5-6 days) or combined
e PID with a 12-day course of metronidazole.
n over
g y 7 th e d itio n
ber Cof
o m p re h eAdapted
n siv e G y nfrom
e c o loWorkowski , 2 0Berman
KA, 1 7 (Lo b o S;
R ACenters
, G e rsh e nfor
so nDisease
D M , Le nControl
tz G M , Vand
a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Treatment: Inpatient
regimens
¡ With IV protocols, the CDC recommends that
IV antibiotics be continued for at least 24 hours
after substantial improvement in the patient.

¡ When the woman has a mass, we add

ampicillin to clindamycin and gentamicin.

¡ For patients without a mass, we switch to oral

antibiotics when the symptoms have
diminished and the woman has been afebrile
for 24 hours.

¡ In both regimens, doxycycline is continued for

a total of 14 days.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Treatment: Inpatient
Regimen A
¡ Regimen A is a combination of doxycycline
and IV cefoxitin.

¡ It is excellent for community-acquired

infection.

¡ Doxycycline and cefoxitin provide excellent

coverage for N. gonorrhoeae, C.
trachomatis, and penicillinase-producing N.
gonorrhoeae.

¡ Cefoxitin is an excellent antibiotic against

Peptococcus and Peptostreptococcus spp.
and E. coli.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Treatment: Inpatient
Regimen B
¡ Regimen B is a combination of clindamycin and an
aminoglycoside (gentamicin).

¡ provides excellent coverage for anaerobic

infections and facultative gram- negative rods.

¡ it is preferred for patients with an abscess, IUD-

related infection, and pelvic infection after a
diagnostic or operative procedure.

¡ Parenteral antibiotic therapy may be discontinued

when the woman has been afebrile for 24 hours,
and oral therapy with doxycycline (100 mg twice
daily) should continue to complete 14 days of
therapy.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Surgical management
¡ Operations are restricted to the
following:

¡ life-threatening infections
¡ ruptured tubo-ovarian abscesses
¡ laparoscopic drainage of a pelvic abscess
¡ persistent masses in some older women for
whom future childbearing is not a
consideration
¡ removal of a persistent symptomatic mass.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Abscess vs Tubo-ovarian
complex
¡ an abscess is a collection of pus within a
newly created space.
¡ Tubo-ovarian complex is a collection of
pus within an anatomic space created by
the adherence of adjacent organs.

¡ Since Clindamycin is stable in the abscess

environment, a combination of clindamycin and
an aminoglycoside is considered the standard for
treatment of a tubo-ovarian abscess.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Sequelae

Adhesion
Scarring
formation

Ectopic
pregnancy,
chonic
pelvic pain,
infertility

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic Inflammatory Disease
(PID): Sequelae
¡ Following acute PID:

¡ the rate of ectopic pregnancy

increases 6- to 10-fold
¡ chance of developing chronic pelvic
pain increases fourfold.
¡ incidence of infertility varies widely (6%
to 60%), depending on the severity of
the infection, number of episodes of
infection, and age of the woman.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Sequelae: ectopic pregnancy
and infertility
¡ Approximately 10% to 15% of
pregnancies will be ectopic after
laparoscopically mild to moderate
PID, and almost 50% after severe PID.

¡ 4% and 13% of women are infertile or

undergo an operative procedure
secondary to acute PID.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Frequency Relative Risk and 95% Multivariate
Sequela (No. and %) Risk Factor P Confidence Interval Analysis P Value
Involuntary 17/42 History of pelvic inflammatory 0.05 1.8 (1.0-3.3) 0.05
infertility (40%) disease (PID)
Age at time of first sex 0.04 0.39 0.07
! 2 days of pain before therapy 0.02 2.0 (1.1–3.6)
Chronic pelvic pain 12/51 History of PID 0.03 1.5 (1.0-2.2)

Sequelae: chronic pelvic pain

(24%)
PID after index 22/51 History of PID 0.06 1.7 (0.9-3.1) 0.02
episode (43%) Mean no. of days of pain 0.04 — 0.04
before therapy
Age at time of first sex 0.0008 — 0.01
Ectopic pregnancy 2/51 (2.4%) *
*Risk analysis not performed because of small numbers involved.

¡ Chronic pelvic pain may be caused

From Safrin S Schacter J, Dahrouge D, Sweet RL: Long-term sequelae of acute inflammatory disease. A retrospective cohort study. Am J Obstet Gynccol 166:1300, 1992.

by a hydrosalpinx, a collection of Table 23-18 Standardized (Indirect Standardization) First Event

Rates Per 1000 Woman-Years for Specified Outcomes*

sterile watery fluid in the fallopian Women

Women
with Control

tube. Outcome
Condition
with PID
(N ¼ 1,200)
Conditions
(N ¼ 10,507)
Relative
Risk
Nonspecific 16.7 (155) 1.7 (158) 9.8

¡ A hydrosalpinx is the end-stage

abdominal pain
Gynecologic pain 3.6 (38) 0.8 (70) 4.5
Endometriosis 2.2 (18) 0.4 (34) 5.5

development of a pyosalpinx. Hysterectomy

Ectopic pregnancy
18.2 (152)
1.9 (19)
2.3 (204)
0.2 (14)
7.9
9.5
*After admission with acute pelvic inflammatory disease or a control event in

¡ The pain may result from adhesions

cohorts of women in the Oxford Record Linkage Study followed from 1970 to
1985. Number of women shown in parentheses.
From Buchan H, Vessey M, Goldacre M, Fairweather J: Morbidity following pelvic

and the resultant fixation or tethering

inflammatory disease. Br J Obstet Gynaecol 100:558, 1993.

Figure 23-33 Hydrosalpinx with marked dilation of the fallopian tube

of organs intended to have freedom

and blunting of the fimbriated end. (From Voet RL: Color Atlas of
Obstetric and Gynecologic Pathology. St. Louis, Mosby, 1997, p 107.)

of movement during physical activity, Table 23-19 Associations among History of Acute Pelvic Inflammatory Disease and Adnexal Adhesions, Distal Tubal Occlusion, and/or
Perihepatic Adhesions
coitus, and ovulation. Laparoscopic
Pelvic Inflammatory Disease
Findings Yes (N ¼ 22) No (N ¼ 90) OR 95% CI P

Distal tubal occlusion 4 (18.2%) 7 (7.8%) 2.6 0.7-10.0 0.14

Tubal adhesions 8 (36.4%) 21 (23.3%) 1.9 0.7-5.1 0.16
Ovarian adhesions 9 (40.9%) 21 (23.3%) 2.3 0.9-6.5 0.08
th Perihepatic adhesions 3/21 (14.3%) 2/84 (2.4%) 6.8 1.1-43.9 0.05
C o m p re h e n siv e G y n e c o lo g y 7 e d itio n , 2Any
0 1 adhesions
7 (Lo b o R A , G e rsh e n so n
11D(50.0%)
M , Le n tz G M , V a le25
a (27.8%)
FA e d ito rs); c h a p te
2.6r 2 3 , G e n ita l Tra c t In fe c tio n s
1.0-6.8 0.04
CI, Confidence interval; OR, odds ratio.
 Pelvic
Tuberculosis
 Pelvic TB
¡ Mycobacterium tuberculosis or
Mycobacterium bovis.

¡ Early in the course of pulmonary infection,

the bacteria spread hematogenously and
the infection becomes located in the
oviducts, which are the primary and
predominant site of pelvic tuberculosis.

¡ Subsequently, the bacilli usually spread to

the endometrium and, less commonly, to the
ovaries.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic TB

¡ clinical symptoms and signs of pelvic Tuberculosis

are similar to the chronic sequelae of acute PID.

¡ The predominant presentations of this chronic

infection are infertility and abnormal uterine
bleeding.
¡ Mild to moderate chronic abdominal and pelvic
pain occur in 35% of women with the disease.

¡ Advanced cases are often accompanied by

ascites.

¡ Some women may be asymptomatic.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Pelvic TB: diagnosis

¡ Tuberculous salpingitis may be

suspected when a woman is not
responding to conventional
antibiotic therapy for acute
bacterial PID.
¡ Results of a tuberculin skin test
will be positive.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic TB: diagnosis
23 Infections of the Lower and Upper Genital Tracts 55

¡ The diagnosis may be

established by performing an
The diagnosis may be established by performing an endometrial
biopsy late in the secretory phase of the cycle. A portion of the
endometrial biopsy should be sent for culture and animal inoc-

endometrial biopsy late in the ulation and the remaining portion should be examined
histologically. The findings of classic giant cells, granulomas,

secretory phase of the cycle.

and caseous necrosis confirm the diagnosis (Fig. 23-34). Ap-
proximately two of three women with tuberculous salpingitis
will have concomitant tuberculous endometritis. Pelvic tubercu-
losis may not be diagnosed until laparotomy or celiotomy, when
the characteristic changes may be visualized. The distal ends of

¡ classic findings: giant cells, the oviduct remain everted, producing a tobacco pouch appear-
ance. When the diagnosis has been established, the woman

granulomas, and caseous

should have a chest radiographic examination, IV pyelography,
serial gastric washings, and urine cultures for tuberculosis.
Approximately 10% of women with pelvic tuberculosis have

necrosis confirm the diagnosis.

concomitant urinary tract tuberculosis.
The treatment of pelvic tuberculosis is medical. Not uncom-
monly, patients will be admitted to the hospital for initiation of
therapy, for observation, and to ensure appropriate compliance.
Figure 23-34 Tuberculous salpingitis—Langerhans’ giant cell

¡ The distal ends of the oviduct

Initial therapy in a woman with newly diagnosed tuberculosis
granuloma. (From Gompel C, Silverberg SG (eds): Pathology in
usually will include five drugs because of the emergence of Gynecology and Obstetrics, 2nd ed. Philadelphia, JB Lippincott, 1977,

remain everted, producing a

multidrug-resistant organisms. Multidrug-resistant (MDR) p 258.)
tuberculosis is defined as infection from a strain of M. tuber-
culosis that is resistant to two or more agents, including isoni-

tobacco pouch appearance.

azid. The mortality rate in HIV-negative patients who develop usually kept on a five-drug regimen. Operative therapy for pel-
MDR infection may be as high as 80%. Often, health care vic tuberculosis is reserved for women with persistent pelvic
workers become infected during outbreaks of MDR tuberculo- masses, some women with resistant organisms, women older
sis. The CDC has recommended starting a woman on a multi- than 40 years, and women whose endometrial cultures remain
th drug
C o m p re h e n siv e G y n e c o lo g y 7 e d itio n , regimen until
2 0 1 7 (Lo b o the
R A ,culture
G e rshresults
e n so nyield
D M specific
, Le n tz sensitivity.
G M , V a le a positive.
FA e d itoAlthough
rs); c h a pthe
te rmajor
2 3 , Gsequela
e n ita l of
Trapelvic tuberculosis
c t In fe c tio n s is
At that time, medications may be decreasedto two or three infertility, occasionally a woman will become pregnant after
 Pelvic TB: diagnosis

¡ When the diagnosis has been

established, the woman should have:
chest radiographic examination, IV
pyelography, serial gastric washings, and
urine cultures for tuberculosis.
¡ Approximately 10% of women with pelvic
tuberculosis have concomitant urinary
tract tuberculosis.

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Pelvic TB: Treatment

¡ The treatment of pelvic tuberculosis is mainly medical.

¡ Initial therapy in a woman with newly diagnosed

tuberculosis usually will include five drugs because of
the emergence of multidrug-resistant organisms.
(Isoniazid, Rifampicin, Ethambutol, Pyrazinamide +
Bedaquiline SIRTURO® )

¡ Multidrug-resistant (MDR) tuberculosis is defined as

infection from a strain of M. tuberculosis that is resistant
to two or more agents, including isoniazid

¡ The CDC has recommended starting a woman on a

multi- drug regimen until the culture results yield specific
sensitivity.

¡ Patients who have infection from MDR strains are

usually kept on a five-drug regimen.
C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s
 Pelvic TB: Surgical Treatment

¡ Operative therapy for pelvic

tuberculosis is reserved for women
with:

¡ persistent pelvic masses

¡ resistant organisms
¡ Age >40 years
¡ endometrial cultures remain positive

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

 Summary
PID PELVIC TB
¡ Definition ¡ Etiology

¡ Etiology ¡ Signs and symptoms

¡ Risk factors ¡ Diagnosis

¡ Signs/symptoms ¡ treatment

¡ Diagnosis

¡ Treatment

¡ Sequelae

C o m p re h e n siv e G y n e c o lo g y 7 th e d itio n , 2 0 1 7 (Lo b o R A , G e rsh e n so n D M , Le n tz G M , V a le a FA e d ito rs); c h a p te r 2 3 , G e n ita l Tra c t In fe c tio n s

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