GYNECOLOGY

Topic: Upper Genital Tract Infections

Lecturer: Dr. Abeleda (LRA)

ENDOMETRITIS PELVIC INFLAMMATORY DISEASE (PID)

 Nonpuerperal endometritis – infection of the uterine lining  Infection in the upper genital tract not associated with pregnancy or
 Commonly coexists with salpingitis intraperitoneal pelvic operations
 It may include infection of any or all of the following anatomic locations:
Risk Factors: o Endometrium (endometritis)
 Douching in past 30 days o Oviducts (salpingitis)
 Current intrauterine device (IUD) in place o Ovary (oophoritis)
 Douching in days 1-7 of the menstrual cycle o Uterine wall (myometritis)
During menstruation, the cervix is open such that nobody should be o Uterine serosa and broad ligaments (parametritis)
doing douching during that time o and Pelvic peritoneum
Old Notes:
What is Douching?  Infection of the oviducts – most characteristic and most
common component of PID
 Most long term sequelae result from destruction of the tubal
architecture by the infection

 Reduction of the medical impact of acute PID requires:

1. Aggressive therapy for lower genital tract infection
2. Early diagnosis and treatment of upper genital tract infection
If we see a patient comes to you with abnormal discharge  treat
them immediately to prevent ascending infection

(+) Association: Public Health Emphasis:

 Young age (20-22 years old)  Primary Prevention – involving attempts to prevent exposure and
 Abnormal uterine bleeding (menorrhagia or metrorrhagia) acquisition of STIs
 Menstrual cycle day <14 o Teaching adolescents sex practices
 Douching in past 30 days o Promoting the use of condoms and chemical barrier methods
 History of prior PID  Secondary prevention
o Universal screening of women at high risk for chlamydia and
Sublinical Endometritis gonorrhea
 No symptoms or signs of acute salpingitis (no cervical motion or adnexal o Screening for active cervicitis
or uterine tenderness) o Increasing use of sensitive tests to diagnose lower genital
infection
Diagnosis: o Treatment of sexual partners
 Endometrial biopsy – GOLD STANDARD o Education to prevent recurrent infection
 Histopathologic criterion:
o At least one plasma cell/x120 field of endometrial stroma Acute PID
o Five or more neutrophils in the superficial endometrial  Rare among Women without menstrual periods:
epithelium/x400 field o Pregnant
o Severe cases: Diffuse lymphocytes and plasma cells in the o Premenarcheal
endometrial stroma or stromal necrosis  present in chronic o Postmenopausal woman
conditions Why is it rare? Because if they are not menstruating, the cervix
is closed
Etiology:
 C. trachomatis  99% - ascending infection
 N. gonorrhoeae Occurs along the mucosal surface, resulting in bacterial colonization
and infection of the endometrium and fallopian tubes. The process
 Bacterial vaginosis
sometimes extends to the surface of the ovaries and nearby
 M. genitalium
peritoneum, and rarely into the adjacent soft tissues, such as the
 T. vaginalis broad ligament and pelvic blood vessels
 Mucupurulent cervicitis – this is due to Chlamydia or Gonorrhea
 1% - transperitoneal spread of infectious material from a perforated
Treatment: appendix or intraabdominal abscess
 Antimicrobial therapy – effective
o Cefixime, 400 mg orally Occurrence:
o Azithromycin, 1000 mg  Annually, acute PID occurs in 1% to 2% of all young, sexually active
With or without women.
o Metronidazole, 500 mg orally twice daily for 7 days  It is the most common serious infection of women ages 16 to 25
years.
 85% -- spontaneous in sexually active females.
Sequelae of endometritis distinct from salpingitis – difficult to determine  15% -- develop following procedures that break the cervical mucus
barrier, allowing the vaginal flora the opportunity to colonize the
upper genital tract. These procedures include:
 Endometrial biopsy, Curettage, IUD insertion
 Hysterosalpingography, Hysteroscopy

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 GYNECOLOGY
Topic: Upper Genital Tract Infections
Lecturer: Dr. Abeleda (LRA)

Acute PID continued….. Risk Factors:

Etiology:  Age at first intercourse
Acute PID is usually a polymicrobial infection that is a mixture of aerobic and o 75% of cases occurring in women younger than 25 years
anaerobic bacteria, clinically appearing as a complex infection. o Teenagers
The two classic sexually transmitted organisms associated with PID:  Lack of contraception
1. N. gonorrhoeae  Comparative lack of antibody protection and the
2. C. trachomatis wider area of cervical columnar epithelium
These two organisms may frequently coexist in the same individual. This is the reason why anticervical cancer vaccine
can be given as early as 9 years old
N. gonorrhea
 Ascends to the fallopian tube, it selectively adheres to nonciliated  Marital status
mucus-secreting cells  Multiple sexual partners
 Most damage occurs to the ciliated cells – due to an acute  Social factors
complement-mediated inflammatory response with the migration of o Involvement with a child protective agency, prior suicide
polymorphonuclear leukocytes, vasodilation, and transudation of attempt, and alcohol use before intercourse
plasma into the tissues  Use of contraceptives
 Cell death and tissue damage  scarring and tubal adhesions o Barrier methods – mechanical obstructive devices and as
 Remains in the tubes for few days in untreated patients chemical barriers
 Rapid onset, and the pelvic pain usually begins a few days after the start  Bactericidal and viricidal
of a menstrual period o IUD – occurs only at the time of insertion of the IUD and in the
first 3 weeks after placement
C. trachomatis  8 years = 1.4/1000
 More prevalent than gonorrhea  20 years = 9.7/1000
 Increases the risk of an ectopic pregnancy by three to six times An analysis from the World Health Organization (WHO)
has found the rate of PID to be:
compared with women without chlamydial infection
 9.7/1000 woman-years for the first 20 days
 Remains in the tubes for months, even years after insertion compared with
 Cell-mediated immune mechanisms – important in tissue destruction  1.4/1000 woman-years for the next 8 years of
 Primary infection appears – self-limited; with mild symptoms and little follow-up
permanent damage
 May lead to an autoimmune response that causes severe tubal damage  Previous PID – 25%
Atypical or Silent PID o Definite risk factor for future attacks of the disease
 Is an asymptomatic, or relatively asymptomatic o Prior infection causes an immunologic priming effect
o The sequelae of repeated asymptomatic chlamydial infections o Untreated male partner
are tubal infertility and ectopic pregnancy  Transcervical penetration of the cervical mucus barrier with
 Indolent course with slow onset, less pain, and less fever instrumentation of the uterus
 (+) Chlamydial heat shock protein antibodies, more likely to have: o Iatrogenic acute PID – happens when there is failure of giving
o Severe tubal scarring of prophylactic antibiotic when doing instrumentation
o Fitz-Hugh-Curtis syndrome – adhesions (violin string adhesions) o Give Prophylactic antibiotics – to decrease the incidence of
between the liver and the diaphragm indicating prior associated acute PID
peritonitis  Virulence factors of an organism
o Virulence factor  hemolysin enzymes and proteases, and
Mycoplasma hominis (4-17%) and Ureaplasma urealyticum (2-20%) bacterial defense mechanisms that inhibit host responses may
 Young, sexually active women become activated in varying microenvironments
 Route of spread: via parametria rather than the mucosa  Genetic variation
 Primary upper genital tract infection – parametria and the tissues
surrounding the tubes, not in the tubal lumen Signs and Symptoms:
 Does not appear to produce damage to the tubal mucosa  Wide range of nonspecific clinical symptoms and signs
 High false-positive and high false-negative rates
M. genitalium
 Associated with cervicitis, endometritis and tubal factor infertility

Endogenous aerobic and anaerobic flora of the vagina

 Aerobic organisms – nonhemolytic Streptococcus, E. coli, group B
Streptococcus and coagulase-negative Staphylococcus
 Anaerobic organisms – Bacteroides spp., Peptostreptococcus, and
Peptococcus

Regardless of the initiating event, the microbiology of PID should be treated

as mixed  treatment should be a broad-spectrum antibiotic

False Positive  diagnosis was PID but it was another disease (listed above)

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 GYNECOLOGY
Topic: Upper Genital Tract Infections
Lecturer: Dr. Abeleda (LRA)

Laparoscopy  gold standard for diagnosing PID

 Direct visualization via the laparoscope – most accurate

Advantages:
o Lysis of adhesions
o Potential drainage of abscess
o Irrigation of the pelvic cavity
 Indications for Surgery (laparoscopy/ laparotomy)
o Impending septic shock
o Acute surgical abdomen
o Complicated differential diagnosis in a postmenopausal
woman
 Elevated temperature is an unreliable diagnostic sign because only
one of three women with acute PID present with a temperature
higher than 38° C.
 Laboratory tests may be ordered but are also insensitive and
False Negative  diagnosis was any disease listed above, but upon laparoscopy it was PID nonspecific.
o Less than 50% =WBC higher than 10,000 cells/mL.
o Leukocytosis does not correlate with the need for
hospitalization or the severity of tubal inflammation.
o The ESR is elevated (>15 mm/hr) in approximately 75% of
women with laparoscopically confirmed acute pelvic
infection. 53% of women with pelvic pain and visually normal
pelvic organs have an elevated ESR.
o C-reactive protein levels have been used but are not reliable
enough to guide clinical management.
 Ultrasonography is of limited value for patients with mild or
moderate PID because of its low sensitivity, but vaginal
ultrasonography is helpful in documenting an adnexal mass.

Treatment:
 More than just prescribing the appropriate antimicrobial regimen
How to assess the tenderness?
 Abdominal examination  Determining:
o Tenderness to direct palpation; occasionally rebound tenderness o Need for hospitalization
 Pelvic Examination o Patient education
o Grasp the cervix and wiggle it o Treatment of sexual partners
o Wriggling tenderness; ill-defined fullness o Careful follow – up
 The most frequent symptom of acute PID is new-onset lower  Most important goals
abdominal and pelvic pain o Resolution of symptoms
o diffuse, bilateral, and usually described as constant and dull o Preservation of tubal function
o may be exacerbated by motion or sexual activity and, on
occasion, the pain may become cramping. Early diagnosis and early treatment:
o usually less than 7 days.  Early diagnosis and early treatment will help reduce the number of
o If the pain has been present for longer than 3 weeks, it is unlikely women who suffer from the long-term sequelae of the disease.
that the woman has acute PID  Women who are not treated in the first 72 hours following the
onset of symptoms are three times as likely to develop tubal
Diagnosis: infertility or ectopic pregnancy as those who are treated early in the
disease process

NAAT Test  best for testing the infection (but not available in the Philippines)

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 GYNECOLOGY
Topic: Upper Genital Tract Infections
Lecturer: Dr. Abeleda (LRA)

 When are we going to shift to oral medication?

o If there is improvement in the condition of patient (ex. Afebrile
for 12 hours, pain already subsided)

This table just shows the etiologic agents of PID Operative Treatment:
 Restricted to life- threatening infections
 Ruptured tubo- ovarian abscess
 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
 Perform conservative surgery and preserve ovarian and uterine
function
o unilateral removal of a tubo- ovarian complex or an abscess
o drainage of a cul-de-sac abscess via percutaneous drainage or
a colpotomy incision

ABSCESS Is a collection of pus within a newly created space

TUBO-OVARIAN Is a collection of pus within anatomic space
Failure of Outpatient Oral Therapy: COMPLEX created by the adherence of adjacent organ
1. Non compliance
2. Reinfection Sequelae:
3. Inadequate antibiotic coverage for peniciliinase-producing gonorrhea  Ectopic pregnancy
o Mild to moderate PID – 10-15%
o Severe PID – almost 50%
 Chronic Pain
o Involuntary infertile, deep dyspareunia
o Caused by a hydrosalpinx, a collection of sterile watery fluid in
the fallopian tube (end-stage of pyosalpinx)
 Infertility
o Damaged yet patent oviduct, peritubular and periovarian
adhesions that may hinder ovum pickup, and finally complete
tubal obstruction

ACTINOMYCES INFECTION
 Actinomyces israelii
o Gram-positive anaerobic bacterium
o Needs 2-3 weeks to culture
 In women chronically wearing an IUD for an average of 8 years
 Cervical smear with Actinomyces
o No need prompt antibiotic therapy or IUD removal UNLESS
with fever, abdominal pain, or AUB
 May produce a chronic endometritis, with an associated foul-smelling
discharge  widespread adhesions, induration and fibrosis
- usually given if patient has tubo-ovarian abscess
Histology:
 Classic sulfur granules
 Gram- positive filaments

Treatment:
 Oral Penicillin, Doxycycline, or a Fluoroquinolone
o Given for 12 weeks (3 months)

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 GYNECOLOGY
Topic: Upper Genital Tract Infections
Lecturer: Dr. Abeleda (LRA)

TUBERCULOSIS
 Frequent cause of chronic PID and infertility- Asia, the Middle East and
Latin America
 Mycobacterium tuberculosis or Mycobacterium bovis
 Primary site of infection for tuberculosis is usually the LUNG
 Bacteria spread hematogenously  oviducts (Primary and
predominant site of pelvic tuberculosis)  endometrium  ovaries
 Extrapulmonary Tuberculosis may present as an insidious or rapidly
progressing disease

Predominant Presentations:
 Infertility
 Abnormal Uterine bleeding
 But most cases would be Asymptomatic
 35% - Mild to moderate chronic abdominal and pelvic pain
 Ascites - in advanced cases
 Pelvic examination
o 50% normal
o Mild adnexal tenderness and bilateral adnexal masses, with an
inability to manipulate the adnexa because of scarring and
fixation
 Tuberculous Salpingitis - suspected when a woman is not responding
to conventional antibiotic therapy for acute bacterial PID
 Tuberculin Test  positive
 1:3 women does not have evidence of pulmonary tuberculosis on chest
radiographic films
It does not mean that if the chest x-ray is negative for TB, you will
already rule out pelvic TB. Still consider pelvic TB because 1 out of 3
women present (-) on CXR

Diagnosis:
 Endometrial Biopsy late in the secretory phase of the cycle
 Histology:
o Classic giant cells, granulomas, and caseous necrosis confirm
the diagnosis
 2:3 women with tuberculous salphingitis will have concomitant
tuberculous endometritis
 Laparoscopy
o 50% simple tubal blockage
o 15% tubo- ovarian masses
o 24% a frozen pelvis

Treatment:
 MEDICAL
o Five drugs because of the emergence of multidrug – resistant
(MDR) organisms
o Whether the TB is in the lungs or pelvic area  TB must be
treated medically
 Operative Therapy is reserved for:
o persistent pelvic masses
o some women with resistant organisms
o women older than 40 years
o women whose endometrial cultures remain positive

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