CASE 12: UPPER GENITAL INFECTION
UPPER GENITAL INFECTION
 MOT: Ascending of Lower Genital Infection
 Organs involved: Uterus, Fallopian tube, Ovaries
Uterus:
 Endometrial lining - Mucosal spread not vascular or
Lymphatic
 Endometrium - Endometritis
 Fallopian tube: Salpingitis
 Spills out from the fimbriated end: "oopohirits or
salphingooophporitis"
IF everything else is involved: PID (Irritation of Peritoneal
surface)
Symptoms:
 Abdominal pain,
 Fever, general malaise
 GI irritation (peritoneal irritation): nausea & vomiting
sometimes diarrhea
 Bleeding due to endometritis
 Genitourinary symptoms: dysuria frequency, dribbling
(UTI symptoms, Note the proximity to the bladder)
o Remember: UTI cannot cause PID
 Abnormal discharge
 IF Chronic Stage: Pelvic or Lower abdominal mass as TOA
(Ultimate End Stage of PID)
Risk Factors:
Sexual HX:
 Use of barrier devices (IUD, Cervical diaphragms/cuff,
condoms, family planning devices
 If had ligation (metal clips inserted on the fallopian tube)
 Diagnosed to have STID,
 # of sexual partners
PMH:
 Minor surgical procedures that enter the uterine cavity
(endometrial biopsy, curettage, hysteroscopy, HSG) with
introduction of medias such as water, saline or dye
producing microorganisms to infect the endometrium
causing endosalpinx from DX of AUB or infertility cases
 Recent abdominal surgery or pelvic surgery in the form
of oophorecystectomy for infected ovarian cyst causing
post op morbidity in the form of pelvic infection
(secondary not primary)
 Primary: a direct mucosal infection, ascending infection
from the lower genital tract
What other structures aside from the ovary might involve the
tubes forming or notorious for forming secondary infections?
 Appendix: Perforated appendicitis or Peri-appendicial
abscess
 Cancer or Malignancy with Necrosis (serosal spread
before mucosal spread)
PE: (Confirmatory)
 Abdominal tenderness (inguinal area or lower quadrant
area)
 Cervical motion tenderness (elicited by IE from moving to
the sides),
If (+) due to peritoneal irritation: Ectopic pregnancy, TOA
 Uterine Tenderness
 Adnexal Tenderness
Speculum Exam: Abnormal cervical discharge, erythematous
If Salpingitis: Inflammation can lead to abscess
 Mass can be elicited represented as TOA or
Hematosalpinx, Hydrosalpinx or Pyosalpinx (bulbous,
edematous mass due to fluid inside)
Other PE Finding:
 If there is leakage of the pus, it would gravitate on the
most dependent portion: FORNICES which would be
manifested as FULLNESS or BULGING
Do IE: presence of fluid accumulating in the cul de sac
which pushes the fornix downwards (Remember thin
mucosa & if you have any accumulation of fluid/ blood/
pus then it will be full or bulging)
 Chronic PID: Long standing infection or inflammation
causing fibrosis/adhesions felt as thickened uterosacrals
 Dyspareunia (Chronic PID)
Triad:
 Abdominal pain, Cervical motion tenderness, & Adnexal
tenderness
DDX:
 Acute appendicitis: Progression of the pain from
periumbilical to RLQ pain + nausea
 Ectopic pregnancy: LMP (Missed period, Delay, + PT)
 Ureterolithiasis: Colicky pain (Squeezing) Spasmodic,
Intermittent
 Ovarian cyst (rupture or leak): ask for risk factors
Laboratory Test:
 CBC: Leukocytosis (PMN: Inflammation)
 Gram stain/ culture:
What if there is no discharge, where is the ideal site?
ENDOCERVICAL CANAL & not from the pooling of the
discharge (remember it has crypts wherein bacteria hide:
commensalism)
 Urinalysis
 TVS: TOA (complex mass filled with fluid, pus presenting
as hypoechoic & hyperechoic within the tube), fluid,
bulbous tube, hydrosalpinx or blunted end of the tube
wherein fimbriae cannot be appreciated anymore.
 LAPAROSCOPY: GOLD STANDARD, Can determine the
severity of the disease, visualize the pelvis
DX: gross inspection (erythema, adhesions (acute -
flimsy, chronic - dense), aspirate the pus for gram stain
TX: drain the abscess, washing or peritoneal
Etiology: Polymicrobial
 Peculiar in developing countries: TB (take a look at the
physique: thin tuberculous looking)
 Work up: CXR, endometrial sampling to see the (+)
tubercle bacilli
TX:
 Antibiotic Regimen for PID
 Quadruple Anti-Kochs Regimen
Treatment: Medical or Surgical
Medical: Ambulatory or Outpatient/ Inpatient
Indications for admitting a patient:
1. Unsure diagnosis
2. Unable to tolerate or unresponsive treatment (have to
give it parenteral form)
3. Presence of TOA
4. Acute abdomen, direct & rebound tenderness, rigidity or
board like
5. Pregnant
6. Systemic or full blown?
How long is the antibiotic treatment? 2 WEEKS
How much time for the medical TX to take effect before
giving surgical intervention or shift to another medication &
when do you expect resolution of the symptoms? 48 – 72
hours
For both gram (+) & (-) organisms: 2nd Gen Cephalosporin
For chlamydial infection: Tetracycline, Doxycycline  it will take a while for the abscess to dissolve but if there
is resolution of the SX continue the antibiotics & do UTZ
CDC Regimen A: at the end of 2 weeks (no point in stopping 3 days)
 How long would be the IV route? 48 - 72 hours where in  Less IE the better 
observe for resolution of symptoms: ↓ abdominal pain,
lysis of fever, ↓ WBC (PMN) If with TOA:
 If responsive in IV: Shift to oral preparation & continue  For the anaerobes: Clindamycin + Gentamycin +
for 1 - 2 weeks. Metronidazole
 For the chlamydia: + Tetracycline
What is important in PID & should be remembered?
 Not only the choice of antibiotics, but ALWAYS TREAT If there is no resolution for the TOA by progression of pain &
THE PARTNER (to prevent recurrence or development ↑ WBC:
into chronic PID)  Do surgical intervention by draining the abscess via
aspiration in laparoscopy, or laparotomy, or UTZ.
If the patient had TOA 48 - 72 hours can you expect
resolution?
Case 12
th
24 y/o nulligravid consults because of abdominal pain accompanied by fever of 3 days duration. Today is the 6
O
day of her menstrual cycle. PPE: BP – 110/70 PR 100/min full RR – 20/ min Temp – 39.2 C. Heart & lungs
unremarkable; Abdomen: flat, soft, (+) direct tenderness on the hypogastric area & both lower quadrants.
Speculum exam: Cervix – pink with purulent discharge at the cervical os. IE: Cervix – firm, long, closed, (+) cervical
motion tenderness. Uterus – normal sized anteverted tender. Adnexa – could not be assessed due to guarding

DX: Acute PID

 If chronic PID, there is minimal systemic symptoms & IE:
thickening of the parametria representing adhesions
secondary to infections

D6 of menstrual period & abdominal pain happen 3 days ago:

 It is typical after menstruation to have presence of pain.
The cervix is open which gives easy access to bacteria
going upwards to the endometrium, tubes & the blood
coming out consisting of proteins is a good medium for
the cultivation of bacteria.

Work-up:
 CBC: Leukocytosis (systemic illness can cause anemia)
 UTZ: check for TOA
 UA: check for UTI

Management:
 Admission due to tenderness, fever, tachycardia &,
presence of peritoneal irritation (e.x. Fitz-High-Curtis
syndrome: Liver)
 Give IV fluids, monitor VS (patient can go to septic shock)
& antibiotics
 Do gram stain & culture of the purulent discharge

 IF UTZ result is presence of normal size bulbous tubes

bilateral &swollen edematous tubes but ovaries are
normal: Give REGIMEN A
 If UTZ result is presence of TOA: Give REGIMEN B
 If there is no improvement: Drain the abscess, do
Fowler’s position to drain in the pelvic area & not spread
to other areas

 If 52 year old G3P3 with the same PE in the case either

with TOA or swollen tube & after 3 days no resolution:
Do clean up by TAHBSO (but do not do in septic
environment)
 If young: USO (Affected side only)