Pelvic Inflammatory Disease

Upper Genital Tract Infections

The Cervix is considered the boundary between the lower and upper genital tracts. Upper genital tract infections affect primarily the cervix, uterus, or fallopian tubes Severe infections may affect one or both ovaries.

Topic Defined: Pelvic Inflammatory Disease (PID)

Infection of the upper female genital tract. Refers to the clinical syndrome among women resulting from infection Includes endometritis (infection of the uterine cavity) Salpingitis (infection of the fallopian tubes) Mucopurulent Cervicitis (infection of the cervix), Oophoritis (infection of the ovaries).

Pathologic Processes of PID

PID has a broad clinical spectrum that includes a) acute PID b) chronic/silent PID c) - stage of exacerbation d) - following reaction e) - toxic course

PID Specifically defined:

Individual cases of PID can also be more specifically defined by a) the site (s) of disease (i.e., endometritis, salpingitis, salpingooophoritis) b) the etiologic agent (s) involved (those that cause chlamydial endometritis, gonococcal salpingitis, nonchlamydial/nongonococcal salpingo-oophoritis).

Relevance to Womens Health:

Commonly occurs in women <35 years. Rarely occurs before menarche, after menopause or during pregnancy. About 1.2 million women are treated for PID. Over 100,000 women with PID are hospitalized each year. About 15% are acutely ill that require intensive inpatient treatment. Approximately 85,000 women with mild or moderate PID who currently are being hospitalized, treating them as outpatients may save around $500 million each year.

Relevance to Womens Health

Is one of the major causes of gynecologic morbidity Infertility Ectopic pregnancy Chronic pelvic pain Diagnosis and treatment must be prompt to avoid these conditions.

PID: Etiology
PID results from microorganisms transmitted during intercourse. Certain procedures that open the cervix and allow possible bacteria to pass through (abortion, cesarean birth, miscarriage, I.U.D. insertion) The infection is usually multifactorial, involving aerobic and anaerobic organisms

PID: Risk Factors

Multiple sexual partners or partner with multiple sexual partners Intercourse with partner with untreated urethritis Previous history of PID Use of an IUD Presence of bacterial vaginosis or an STD Nulliparity Recent instrumentation of the uterus Douching Cigarette smoking Sex with menses

Causative Agents of PID

Neiserria Gonorrhoeae and Chlamydia trachomatis are the 2 major causative organisms. Chlamydia trachomatis is the predominant STD organism causing PID. The role of Neisseria Gonorrhoeae as the primary cause of PID has decreased. Other agents: Mixed infection caused by both aerobic and anaerobic organisms Recent studies demonstrate the presence of Bacterial Vaginosis and trichomoniasis in cases of confirmed PID

Causative Agents of PID

Cytomegalovirus (CMV) has been found in the upper genital tracts of women with PID. Enteric gram-negative organisms (E-coli) Peptococcus species Streptococcus agalactiae Bacteroides fragilis Mycoplasma hominis Gardnerella vaginalis Haemophilus influenzae

Signs & Symptoms of PID

The patient presents with lower abdominal pain, fever, vaginal discharge, and/or abnormal uterine bleeding. Symptoms frequently occur during or after menses. Peritoneal irritation produces marked abdominal pain with or without rebound tenderness The abdomen should be palpated gently to prevent abscess rupture

Chlamydial Pyosalpinx
Pelvic inflammatory disease, proven Chlamydial Pyosalpinx. Right tube is swollen and tortuous (arrow)

(Holmes, 1999, Plate 17; reprinted with permission from McGraw Hill.)

Cervicitis
The cervix appears red and bleeds easily when touched with a spatula or cotton swab. Mucopurulent discharge is yellowgreen Contains >10 polymorphonuclear WBCs per oil immersion field (using Gram stain)

Acute Salpingitis
Onset is usually shortly after menses. Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness, and cervical motion tenderness. Involvement is usually bilateral. Nausea and vomiting occur with severe infection. In the early stages, acute abdominal signs are often absent

Acute Salpingitis (PID)

Bowel sounds are present unless peritonitis with ileus has developed. Fever, leukocytosis, and mucopurulent cervical discharge are common Irregular bleeding and bacterial vaginosis often accompany the pelvic infection.

Acute Salpingitis (PID)

Pelvic infection due to N. Gonorrhoeae is usually more acute than that due to C. trachomatis Onset is rapid, and pelvic pain develops shortly after menses starts. Although the pain is often localized to one side, both tubes are probably infected. The infection produces a diffuse exudate, leading to agglutination, adhesions, and tubal occlusion. Peritonitis may occur, causing upper abdominal pain and adhesions

Acute Salpingitis: Chlamydia & Gonorrhea

C. trachomatis produces symptoms that often seem mild, but it can cause more damage than N. Gonorrhoeae in the long term. Chlamydial organisms may remain in tubal mucosa for many months before clinical manifestations of acute disease appear. Untreated or inadequately treated acute infection can lead to chronic salpingitis, with tubal scarring and possible adhesion formation. Chronic pelvic pain, menstrual irregularities, and infertility are long-term sequelae

Complications of PID
Tubo-ovarian abscess develops in about 15% of women with salpingitis. It can accompany acute or chronic infection The tube and ovary can become completely matted together. May require prolonged hospitalization, sometimes with surgical percutaneous drainage. Rupture of the abscess is a surgical emergency Rapidly progressing from severe lower abdominal pain to N & V, generalized peritonitis, and septic shock

Tubo-ovarian abscess
Pyosalpinx, in which one or both fallopian tubes are filled with pus, may also be present.
Hydrosalpinx (fimbrial obstruction and tubal distention with nonpurulent fluid) develops if treatment is late or incomplete. The consequent mucosal destruction leads to infertility. Hydrosalpinx is generally asymptomatic but can cause pelvic pressure, chronic pelvic pain, or dyspareunia. Women with HIV infection are more likely to have tubo-ovarian abscess

Tubo-ovarian abscess
Here at least the ovaries, tubes and uterus can still be recognized as separate structures

Fitz-Hugh-Curtis syndrome
Can be a complication of gonococcal or chlamydial salpingitis. Characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis. Acute cholecystitis may be suspected, but signs and symptoms of PID are present or develop rapidly.

Diagnostic Studies:
CBC with differential Erythrocyte Sedimentation Rate Cervical cultures Blood Cultures Urine Pregnancy Test Rapid Plasma Reagin (RPR) Cervical infection due to N. Gonorrhoeae can also be diagnosed by Gram stain showing intracellular gram-negative diplococci

Diagnostic studies
Leukocytosis is typical. Pelvic ultrasonography may be used when a patient cannot be adequately examined because of tenderness or pain When a pelvic mass may be present, or when no response to antibiotic therapy occurs within 48 to 72 h. - Laparoscopy should be performed only if the diagnosis is uncertain or if the patient does not promptly improve with medical therapy

Minimum Criteria for Empiric Treatment of PID

Lower Abdominal Tenderness & Rebound Adnexal Tenderness Cervical Motion Tenderness

Diagnosis
And one or more minor criteria Temperature over 100.9F or 38.3 C White Blood Cell count > 10,000 Elevated ESR Elevated C-reactive protein Pus in cul-de-sac Pelvic abscess or inflammatory complex Cervical Mucus findings Gram Stain: Gram Positive diplococci Intracellular parasites

Diagnosis
ESR and C-reactive protein are elevated in many disorders and are therefore not specific for PID. Endometrial biopsy with aerobic and anaerobic culture may assist in the diagnosis. All three major criteria and at least one minor criterion must be present to diagnose PID.

Differential Diagnosis
Condition
Acute Appendicitis

Characteristic Signs/Symptoms
Anorexia, N & V, decreased or absent bowel signs, unilateral pain limited to right or left lower quadrant Unilateral pain; missed menstrual period usually warrants hCG test Unilateral pain

Ectopic Pregnancy Ruptured Ovarian Cyst

Endometriosis
Urinary Tract Infection Renal calculus

Constant pain begins 2-7 days before menses

Dysuria, abnormal urinalysis. No cervical motion tenderness Severe unilateral pain, hematuria

Adnexal torsion
Proctocolitis Hemorrhaging corpus luteum

Unilateral pain
Anorectal pain, tenesmus, rectal discharge or bleeding Unilateral pain

Treatment Goals & Benefits

Therapeutic goals include complete resolution of the infection and prevention of infertility and ectopic pregnancy.

Management Outpatient
Regimen A:
Initial Treatment at Diagnosis Ofloxacin 400 mg orally BID for 14 days (95% cure) Or Levofloxacin 500 mg orally once daily for 14 days With or without: Metronidazole 500 mg orally twice a day for 14 days.

Management Outpatient: Regimen B

Ceftriaxone 250 mg IM in a single dose Or Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose Or Other parenteral third-generation cephalosporin (ceftizoxime or cefotaxime) Plus Doxycycline 100 mg PO BID for 14 days (75% cure) With or without Metronidazole 500 mg PO BID for 14 days

Management Inpatient

Toxic appearance Unable to take oral fluids Unclear DX Appendicitis Ectopic Pregnancy Ovarian torsion

Pelvic abscess Pregnancy HIV positive Adolescents Outpatient TX failure Unreliable patient

Inpatient Treatment Regimens:

General: Treat for at least 48 hours IV Regimen A Cefotetan 2g IV q12 hours OR Cefoxitin 2g IV q6 hours Plus Doxycycline 100 mg orally or IV every 12 hours

Inpatient Treatment
Regimen B Clindamycin 900 mg IV q8 hours Plus Gentamicin 2 mg/kg IV loading dose, then 1.5 mg/kg IV q8h Discharge Regimen (after IV antibiotics) Doxycycline 100mg PO BID for 10 days or Clindamycin 450mg PO QID for 14 days

Alternative Parenteral Regimens

Ofloxacin 400 mg IV q 12 hours Or Levofloxacin 500 mg IV once daily With or without Metronidazole 500 mg IV every 8 hours Or Ampicillin/Sulbactam 3 g IV every 6 hours Plus Doxycycline 100 mg orally or IV every 12 hours

Prognosis
Therapy using antibiotics alone is successful in 33-75% of cases. If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage and copious irrigation or unilateral adnexectomy, if possible. Further surgical therapy is needed in 1520% of cases so managed.

Prognosis
Chronic pelvic pain occurs in approximately 25% of patients with a history of PID. This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or Hydrosalpinx. Impaired fertility is a major concern in women with a history of PID. The rate of infertility increases with the number of episodes of infection. The risk of ectopic pregnancy is increased in women with a history of PID. Ectopic pregnancy is a direct result of damage to the fallopian tube.

Prevention
Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID. Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide. Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs. Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended

Relevance of topic for clinical NP Practice

NPs can help reduce the risk for PID and its sequelae. Timely diagnosis and appropriate treatment of lower-genital-tract chlamydial and gonococcal infection among both men and women can reduce the risk of adverse consequences among infected individuals and can reduce the risk of further transmission to others.

Relevance of topic for clinical NP Practice

Also, NPs can influence men's and women's risk of infection by providing effective counseling about their sexual behavior, health- care-seeking behavior, and contraceptive practice, and by convincing them to comply with management instructions. Finally, by ensuring timely and effective treatment of patients' sex partners, NPs can reduce risk of reinfection.

Relevance of topic for clinical NP Practice

Because the partners' infections may be asymptomatic, interviewing and treating these persons will help reduce further transmission of infection in the community and may facilitate identifying other infected persons.

Management of Sex Partners

Treatment for sex partners of women with PID is imperative. The management of women with PID should be considered inadequate unless their sex partners have been appropriately evaluated and treated. Failure to manage her sex partner (s) effectively places a woman at risk for recurring infection and related complications. Moreover, untreated sex partners often unknowingly transmit STD in a community because of asymptomatic infection.

Surveillance
At all levels, PID surveillance is affected by four main constraints: PID is difficult to diagnose accurately. PID is diagnosed in a wide variety of clinical settings. Microbiology test results are needed to determine the etiology of PID.

Patient Education
The NPs role as a health educator is central to effective management. NPs should explain to women the nature of their disease and should encourage them to comply with therapy and prevention recommendations. Specifically, NPs should: Emphasize the need for taking all the medication, regardless of symptoms.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Patient Education
Review contraindications and potential side effects. Identify and discuss potential compliance problems. Review the medical purpose of follow-up evaluation. Emphasize the need to avoid sex until treatment is completed. Emphasize the need to refer sex partners for evaluation and treatment.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Patient Education
When medical-care messages are clear, explicit, relevant, and rigorously delivered by providers, patients are likely to comply. Reinforcement of these messages can be achieved by providing written information. Information on written materials for patient distribution can be obtained from CDC or local and state health departments
http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

Controversies Surrounding PID

The exact incidence of PID is unknown The disease cannot be diagnosed reliably from clinical signs and symptoms. Laparoscopy exam of the pelvic organs continues to be the "gold standard" approach to diagnosis of PID. But, because this is a surgical procedure which requires an incision in the abdomen, the high priority is to design and development of non-invasive techniques, with smaller costs and fewer risks. OC may reduce the risk of PID that is not attributable to C. trachomatis.

Relevant Research Findings

Recently, a study conducted at the University of Washington School of Medicine confirmed that regular douching is associated with pelvic inflammatory disease. An earlier study had shown a significant association between vaginal douching and ectopic pregnancy. Pelvic inflammatory disease is also a major factor in ectopic pregnancy.

Research Findings
In a comparison of 100 women with confirmed pelvic inflammatory disease (PID) and 762 randomly selected controls, at Harborview Medical Center in Seattle The investigators report that women who douche once or twice a month were 2.5 times more likely to have PID than those who douched less than once a month. However, the risk of PID does not appear to increase with more frequent douching.

Relevant Research Studies on PID

It is thought that douching increases the risk of PID by wiping out beneficial vaginal bacteria making it possible for disease producing bacteria to get the upper hand. Another theory is that douching flushes vaginal and cervical bacteria back into the uterine cavity where they cause trouble.

Research Study
According to a study funded by the Agency for Healthcare Research and Quality (AHRQ), women with mild to moderate PID who are treated as outpatients have recovery and reproductive outcomes similar to those for women treated in hospitals. The PID Evaluation and Clinical Health (PEACH) study was a randomized clinical trial designed to compare the effectiveness of inpatient and outpatient treatment strategies in preserving fertility and preventing PID recurrence, chronic pelvic pain and ectopic pregnancy for women with mild to moderate PID.

Research Study
Women treated as outpatients received a single injection of Cefoxitin and an oral dose of probenecid, followed by a 14-day supply of oral doxycycline. Those treated in a hospital were given multiple intravenous doses of Cefoxitin plus doxycycline during a minimum inpatient stay of 48 hours. The womens care then was followed for 35 months to document long-term outcomes

Research Study
The short-term clinical improvements were similar for women treated in inpatient and outpatient settings. After 35 months of follow-up, pregnancy rates were nearly equal between the groups, as was the amount of time it took to become pregnant. There also were no statistically significant differences between the proportion of women with ectopic pregnancy, chronic pelvic pain or PID recurrence .

Relevant Research Questions

Should suspected PID be treated empirically or should treatment be delayed until results of microbiological investigations are known?
Do parental antibiotic treatment provide optimal effectiveness than oral antibiotic treatment for PID?

Question:

1. Pelvic inflammatory disease (PID) in women is most commonly caused by: A) Leptotrichia buccalis B) Treponema pallidum C) Chlamydia trachomatis D) Bacillus anthracis E) Borelia burgdorferi

Answer

The correct answer is #C. Chlamydia Trachomatis

Question:

2. IUD use has been linked with: A. pelvic inflammatory disease B. tubal infections C. uterine infections D. all of the above E. none of the above

Answer

The correct answer is #D. All of the above

Question

3. Which of the following conditions is not a risk factor for pelvic inflammatory disease (PID)?

A. Smoking B. Multiple sexual partners C. Young age at first intercourse D. Hepatitis B E. Intrauterine device (IUD) insertion

Answer

The correct answer is D: Hepatitis B is not a known risk factor for PID.

Question:

4.) Which of the following is not used to treat symptoms associated with pelvic inflammatory disease (PID)?

A: Azithromycin B: Ceftriaxone C: Ampicillin D: Ofloxacin E: Cefoxitin

Answer

The correct answer is A: No data suggest that Azithromycin is an appropriate oral regimen for the tx of PID. Most patients are now managed as outpatients. One outpatient regimen is Cefoxitin and probenecid taken orally in a single dose. Alternatively, ceftriaxone (less active against anaerobic bacteria compared to Cefoxitin) can be taken once IM with doxycycline orally twice daily for 14 days. Another regimen is ofloxacin taken orally for 14 days with either clindamycin or metronidazole, which also are taken orally for 14 days.

Question

5.) (T/F): The major criteria for the diagnosis of pelvic inflammatory disease (PID) include Leukocytosis elevated C-reactive protein (CRP) elevated erythrocyte sedimentation rate (ESR) fever.

Answer

The correct answer is False: The major criteria for the diagnosis of PID include: Cervical motion tenderness Adnexal tenderness Lower abdominal tenderness. ESR, CRP, and laboratory documentation of Neisseria gonorrhea or Chlamydia trachomatis cervical infection, among others, can aid in increasing the specificity of diagnosis

Question:

6.) (T/F): All of the following are indications for hospitalization for treatment of pelvic inflammatory disease (PID): failed outpatient therapy Inability to tolerate oral therapy Pregnancy pelvic abscess.

Answer

The correct answer is True: These are circumstances in which women should be hospitalized for treatment of PID. Other conditions that may require hospitalization are: uncertain diagnosis severe illness Severe N & V Immunodeficiency (HIV, immunosuppressive medications).

Question:

7.) (T/F): In the initial workup, laparoscopy should be used to confirm the diagnosis of pelvic inflammatory disease (PID).

Answer

The correct answer is False: Laparoscopy is costly and not always available. It should be used if the diagnosis is in doubt

Question

8.) (T/F): Consider hospitalizing patients who do not improve clinically after 72 hours with outpatient therapy for pelvic inflammatory disease (PID).

Answer

The correct answer is True: While most patients are now treated on an outpatient basis, these patients should be admitted to the hospital and treated appropriately

Any Questions???