PELVIC INFLAMMATORY DESEASE

Voloceai Victoria
 Definition
 Pelvic Inflammatory Disease (PID) comprises a
spectrum of inflammatory disorders of the upper
female genital tract, including any combination of
endometritis, salpingitis, tubo-ovarian abscess, and
pelvic peritonitis.

Center for Disease Control & Prevention (CDC)

Treatment Guidelines 2010
International-Infectious Disease Society for Obstetrics and
Gynecology-USA (I-IDSOG-USA) Definition of PID

 The membership of I-IDSOG-USA strongly

recommends eliminating the term PID and replacing it
with the term “upper genital tract infection”
(UGTI), followed by the name of the etiological agent,
followed by the stage of disease
(e.g., UGTI, Neisseria gonorrhoeae, stage III)
International-Infectious Disease Society for Obstetrics and
Gynecology-USA (I-IDSOG-USA) Definition of PID

 Anatomical designations. The term PID indicates an

inflammatory process of infectious etiology involving,
at the least, the endometrium and fallopian tubes.
International-Infectious Disease Society for Obstetrics and
Gynecology-USA (I-IDSOG-USA) Definition of PID

 Etiological and epidemiological designation. The

members of the I-IDSOG-USA concur with the
designation of Neisseria gonorrhoeae and Chlamydia
trachomatis as initiating cytological agents.
 General classification of pelvic infections:

Pelvic inflammatory desease:

-acute salpingitis
(gonococcalnegonococical)
-Pelvic cellulitis
-Tubo-ovarian abcess
-Pelvic abcess
Puerperal infections: Abortion-associated infections:
-Cesarean section (common) -Post-abortal cellulitis
-Vaginal delivery (uncommon) -Incomplete septic abortion

Postoperative Secondary to other infections:

gynecological surgery:
-Cellulitis and parametritis - Appendicitis
-Vaginal cuff abcess
-Tubo-ovarian abcess
Pelvic -Diverticulitis
-Tuberculosis
infections
Pelvic inflammatory desease

Endometritis

Salpingitis
Oophoritis

Pelvic cellulitis

Tubo-ovarian abcess

Pelvic peritonitis
Pelvic inflammatory disease
Other pelvic infections caused by surgery,
during pregnancy or due to other abdominal
processes are not, strictly considered, ‘PID’.
 Epidemiology: International statistics
 No specific international data are available for PID incidence
worldwide.

 In2005, the World Health Organization (WHO) estimated that

approximately 448 million new cases of curable STIs occur
annually in individuals aged 15-49 years.

 The annual rate of PID in high-income countries has been

reported to be 10-20 per 1000 women of reproductive age.

Centers for Disease Control and Prevention. Morb Mortal Wkly Rep.
2010;59:413-17.
 Epidemiology - CDC

 TheCDC has estimated that more than 1 million women

experience an episode of PID every year.

 Among sexually active women: Incidence is 1-2 % per

year

Centers for Disease Control and Prevention. Morb Mortal Wkly

Rep. 2010;59:413-17.
 Epidemiology:
 Factors contributing to the difficulty of determining the actual
worldwide incidence and prevalence of PID:

 Non recognition of disease

 Difficulties in obtaining access to care
 Often subjective method of disease diagnosis
 The lack of diagnostics and laboratory facilities
 Underfunded and overstretched public health systems

Centers for Disease Control and Prevention. Morb Mortal Wkly

Rep. 2010;59:413-17.
 Microbial Etiology
 Most cases of PID are  Secondary organisms:
polymicrobial (25-60%)  Non-hemolytic
 Primary organisms: streptococcus group B
Sexually transmitted  E. Coli
 Gardnerella
 Staphylococcus
 Klebsiella
 Haemophilus Influentzae
 Bacteroides species
Causes
 Risk factors
ACCEPTED PROPOSED
(strong evidence) (weak evidence)
1. Prior infection with Chlamydia or
1. Low socio-economic status
Gonorrhea

2. Young age at onset of sexual activity 2. Intercourse during menstruation

3. Prior PID 3. Urban living

4. Sexually Transmitted Infection 4. High frequency of coitus

5. Non-use of barrier contraceptive 5. Use of IUCD

6. Cigarette smoking
6. Multiple sex partners
7. Substance abuse

8. Douching
 Provocative agents

 Menses
 Intercourse
 Iatrogenic:
 Abortion
 Curettage of uterine cavity
 Hysterosalpingography
 IUD insertion
 In vitro fertilization
 Protective factors

1. Barrier methods: Specially condom with spermicidal

chemicals
2. Oral steroidal contraceptives:
 Thick mucus plug (preventing ascend of sperm and
bacterial penetration)
 Decrease in duration of menstruation (Short interval of
bacterial colonization of the upper tract)
3. Monogamous partner
4. Pregnancy
5. Menopause
 Mode of transmission:

 Ascending infection (most often): ascend of organisms

by surface extension from the lower genital tract
through the cervical canal by way of the endometrium to
the fallopian tubes

 Hematogenous

 Lymphatic

 Direct spread
 Pathogenesis

PID – Ascending infection Peritonitis

Salpingitis/
oophoritis/ tubo-
ovarian abscess

Endometritis

Cervicitis
18
 Pathology
1. Involvment of fallopian tubes is almost bilateral
2. Pathological process is initiated primarely in the endosalpinx

3. Gross distruction of epithelial cells, cilia and microvilli

4. Acute inflammatory reaction: all layers are involved (from

muscular layer to the serosa)

5. Edema and hyperemia of tubes. Exfoliated cells and exudate into

the lumen agglutinate mucosal folds

6. Abdominal ostium of tubes is closed by edema and inflammation

7. Uterine end of tubes is closed by congestion

 Pathology

Hydrosalpinx and piosalpinx

Possibilities: Oophoritis
Tubo-ovarian abcess
Peritonitis
Pelvic abcess
or resolution in 2-3 weeks with/without chronic sequelae
 Pathology

 The diagnosis of an isolated ovarian purulent

inflammatory process is practically impossible, since in
most cases it is associated with piosalpinx, as an
inflammatory adnexal tumor
 Lymphatic spread of bacterial infection
- Mycoplasma
- Secondary organisms

Specific for postpartum, postabortal, and some IUD-related

infections, results in extraperitoneal parametrial cellulitis

[Link]
 Hematogenous spread of bacterial infection

In rare cases, certain diseases (ex, tuberculosis) may gain

access to pelvic structures by hematogenous routes

[Link]
Direct spread from contaminated structures in the
abdominal cavity

- appendicitis, cholecystitis, etc.

[Link]
Clinical classification of PID

Brunham RC et al. N Engl J Med 2015;372:2039-2048.

Center for Disease Control and Prevention criteria for the
diagnosis of pelvic inflammatory disease (PID).

David L. Hemsel et al. Clin Infect Dis. 2001;32:103-107

 acute PID

Triad of lower abdominal pain, adnexal tenderness,

and tender cervical movements are considered to
be the most important clinical features of acute
PID
Clinical presentation
 I-IDSOG-USA staging of acute PID
 Stage I
 Women who fulfill the CDC major diagnostic criteria and >1 of minor
criteria but who do not have overt peritonitis (absence of rebound
tenderness) and who have not had any prior documented STD upper
tract infections
 Stage II
 The above criteria, with peritonitis
 Stage III
 Women with demonstrable tubo-ovarian complex or tubo-ovarian
abcess evident on either physical or USG examination
 Stage IV
 Women with ruptured tubo-ovarian abcess
 Laparoscopic staging of acute PID

3 grades of severity based on laparoscopic findings:

 Grade 1 PID means there is either endometritis or

erythema of the salpinx, or a combination of both
 Grade 2 PID, the salpinges are dark red and swollen
(edema)
 Grade 3 PID the salpinx is filled with pus (pyosalpinx) and
exudation is found in the pelvis

Tubo-ovarian abcess (TOA) is also PID grade 3 according

to the definition
 Diagnosis of PID
History Physical examination
 Lower abdominal and  Abdominal and pelvic
pelvic dull aching pain examination
 Fever >38,3  Bilateral abdominal
 Abnormal vaginal tenderness
discharge  Adnexal mass and adnexal
 Dysuria tenderness
 Previous abdominal/pelvic  Cervical motion tenderness
surgery  Uterine tenderness
 Previous gynecological  Vaginal muco-purulent
problems discharge
 IUD insertion
 Sexual and STD history
 Investigations
 Complete blood count
 Erythrocyte sedimentation rate  Imaging:
 Vaginal wet mount  transvaginal/transabdominal
 Vaginal/cervical culture for USG – imaging of choice
gonorrhea and chlamydia  Abdominal CT or MRI
 C-reactive protein
 Urine pregnancy test
 Urinanalysis
 Urine culture
 Tests for TBC, syphilis, HIV
 Diagnostic procedures

Culdocenthesis
Endometrial biopsy
Diagnostic laparoscopy – gold standard
 Deferential diagnosis
 Gastrointestinal:  Gynecologic:
 Appendicitis  ectopic pregnancy
 Bowel obstruction  Adenomyosis
 Gastritis  Endometriosis
 Diverticulitis  Mittelschmertz
 Inguinal hernia  Ovarian cyst
 Mesenteric venous thrombosis  Ovarian torsion
 Peri-rectal abscess, etc.  Postpartum endometritis,
 Urinary: etc.
 Cystitis
 Pyelonephritis  Other: dissecting aortic
 Ureterolythiasis, etc.
anevrysm, etc.
 Complications and sequelae
1. Dyspareunia
2. Infertility
3. Ectopic pregnancy
4. Adhesions, hydrosalpinx, pyosalpinx, tubo-ovarian
abcess
5. Chronic pelvic inflammation
6. Chronic pelvic pain
 Fitz-Hugh–Curtis syndrome
 Consists in right upper quadrant  The major symptom: acute onset
pain resulting from ascending of right upper quadrant
pelvic infection and inflammation abdominal pain, aggravated by
of the liver capsule or diaphragm, breathing, coughing or laughing,
leading to creation of adhesions which may be referred to the
 Is a rare complication of PID right shoulder
  Tenderness on palpation of the
Typically associated with acute
salpingitis right upper abdomen and
 tenderness to percussion of the
It is usually caused by Gonorrhea
lower ribs which protect the liver
(acute gonococcal perihepatitis) or
 There is often no or only
Chlamydia
minimal pelvic pain, vaginal
discharge or cervical motion
tenderness

[Link]
 Tubo-ovarian abcess
A tubo-ovarian complex is a name used for oedema of the
salpinx which is adherent to the ovary, uterus, pelvic wall,
and/or bowel, but without abscedation.

A tuboo-varian abscess is an inflammatory mass

(collection of pus) involving the fallopian tube, ovary, and
other adjacent pelvic organs (ex: bowel, bladder)

[Link]
 Tubo-ovarian abcess
 Usually a complication  Polymicrobial infection
of pelvic inflammatory (aerobic and anaerobic)
disease  The most common
 Serious and potentially
microorganisms isolated
life-threatening from tubo-ovarian
condition abscess are Escherichia
 Mortality rate: 5-10% Coli and Bacteroides
 Chlamydia trachomatis
and Neisseria
gonorrhoeae are rarely
isolated from tubo-
ovarian abscess

[Link]
Acute PID : diagnostic approach

[Link]
disease-24890282
Acute PID : diagnostic approach

[Link]
disease-24890282
Flow chart Showing Clinical Diagnosis of PID

Infectious Diseases in Obstetrics and Gynecology

Volume 2011 (2011), Article ID 753037, 6 pages
[Link]
 Management
 Regimens used to treat PID should be effective against N.
gonorrhoeae, C. trachomatis and anaerobic microbes

 Treatment should be initiated as soon as presumptive

diagnosis has been made, for prevention of long-term
sequelae
 Management

Outpatient treatment
 Acute salpingitis, but temperature <39 C
 Minimal lower abdominal findings
 Non toxic patient

 Mild or moderate clinical severity - oral regimens

 Management

Hospitalisation
 surgical emergencies (e.g., appendicitis) cannot be
excluded
 tubo-ovarian abscess
 severe illness, nausea and vomiting, or high fever
 pregnancy
 unable to follow or tolerate an outpatient oral regimen
 no clinical response to oral antimicrobial therapy

CDC -2010 criteria

 Management
Recommended Parenteral Regimens

Cefotetan 2 g IV every 12 hours PLUS Doxycycline 100 mg orally or IV every

12 hours

Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every

12 hours

Clindamycin 900 mg IV every 8 hours PLUS Gentamicin loading dose IV or

IM (2 mg/kg), followed by a maintenance dose (1.5 mg/kg) every 8 hours.
Single daily dosing (3–5 mg/kg) can be substituted.

CDC. 2015 STD Treatment Guidelines

 Management

 Parenteral therapy can be discontinued 24 hours after

clinical improvement, but oral therapy should continue to
complete 14 days of treatment

 Limited data are available to support use of other parenteral

second- or third-generation cephalosporins (ex: ceftizoxime,
cefotaxime, and ceftriaxone)

CDC. 2015 STD Treatment Guidelines

 Management
Alternative Parenteral Regimens

Ampicillin/Sulbactam 3 g IV every 6 hours

PLUS
Doxycycline 100 mg orally or IV every 12 hours

azithromycin, either as monotherapy for 1 week (500 mg IV daily for 1 or 2

doses followed by 250 mg orally for 5–6 days) or combined with a 12-day
course of metronidazole

CDC. 2015 STD Treatment Guidelines

 Management
Recommended Intramuscular/Oral Regimens

Ceftriaxone 250 mg IM in a single dose

PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH* or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
Other parenteral third-generation cephalosporin (e.g., ceftizoxime or
cefotaxime)
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH* or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days

CDC. 2015 STD Treatment Guidelines

 Management
Alternative Intramuscular/Oral Regimens

Azithromycin has demonstrated short-term clinical effectiveness in one

randomized trial when used as monotherapy (500 mg IV daily for 1–2 doses,
followed by 250 mg orally daily for 12–14 days) or in combination with
metronidazole (745),

and in another study, it was effective when used 1 g orally once a week for 2
weeks in combination with ceftriaxone 250 mg IM single dose

CDC. 2015 STD Treatment Guidelines

 Management

 As a result of the emergence of quinolone-resistant N.

gonorrhoeae, regimens that include a quinolone agent are
no longer routinely recommended for the treatment of PID.

CDC. 2015 STD Treatment Guidelines

 Other Management Considerations

 Abstinence from sexual intercourse until therapy is

completed, and symptoms have resolved.

 All women who received a diagnosis of acute PID should

be tested for HIV, as well as GC and chlamydia, using
NAAT.

 Men who have had sexual contact with a woman with PID
during the 60 days preceding her onset of symptoms
should be evaluated, tested, and presumptively treated for
chlamydia and gonorrhea, regardless of the etiology of
PID or pathogens isolated from the woman.

CDC. 2015 STD Treatment Guidelines

 Follow-Up
 Women should demonstrate clinical improvement within
3 days after initiation of therapy.

 If no clinical improvement has occurred within 72 hours

after outpatient IM/oral therapy, hospitalization,
assessment of the antimicrobial regimen, and additional
diagnostics (including consideration of diagnostic
laparoscopy for alternative diagnoses) are recommended.

 All women who have received a diagnosis of chlamydial

or gonococcal PID should be retested 3 months after
treatment, regardless of whether their sex partners were
treated.

CDC. 2015 STD Treatment Guidelines

[Link]
disease-24890282
 Indications for surgery
1. Ruptured abcess
2. Failed response to medical treatment
3. Uncertain diagnosis
 Types of surgeries

1. Colpotomy
2. Percutaneous drainage/aspiration
3. Laparoscopy – GOLD STANDARD
4. Exploratory laparotomy
 Extend of surgeries

1. Conservation – if fertility desired

(salpingolysis, salpingostomy)
2. Oophorectomy ± Histerectomy
3. Drainage of abcess
 Prevention
Primary prevention
 Sexual counseling (safe sex, limit number of sexual
partners, avoid contact with risk partners, etc).
 Barrier methods of contraception

Secondary prevention
 Screening for infection in high risk population
 Early diagnosis and treatment of STD

Tertiary prevention
 Early treatment of PID
 References
 2012 European Guideline for the Management of Pelvic Inflammatory
Disease.
 CDC. 2015 STD Treatment Guidelines.
 Center for Disease Control & Prevention (CDC)
Treatment Guidelines 2010.
 Centers for Disease Control and Prevention. Morb Mortal Wkly Rep.
2010;59:413-17.
 Brunham RC et al. N Engl J Med 2015;372:2039-2048
 [Link]
24890282
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