Pelvic Inflammatory Disease

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DEFINITION

PID is a spectrum of inflammatory disorders of the upper genital tract including a combination of any of the following:
● Endometritis, salpingitis , tuboovarian abscess, or pelvic peritonitis
● Resulting from an ascending lower genital tract infection
● Not related to obstetric or surgical intervention

PHYSICAL FINDINGS AND CLINICAL PRESENTATION

● Lower abdominal pain
● Abnormal vaginal discharge
● Abnormal uterine bleeding
● Dysuria
● Dyspareunia
● Nausea and vomiting (suggestive of peritonitis)
● Fever
● Right upper quandrant (RUQ) tenderness (perihepatitis): 5% of PID cases
● Cervical motion tenderness and adnexal tenderness
● Adnexal mass
● Laparoscopy may reveal adhesions covering the tubes and ovaries in patients with chronic PID

CAUSE

● Chlamydia trachomatis
● Neisseria gonorrhoeae
● Polymicrobial infection—Bacteroides fragilis, Escherichia coli, Gardnerella vaginalis, Haemophilus infl uenzae, Mycoplasma hominis, U. urealyticum
● Mycobacterium tuberculosis (an important cause in developing countries)
● Cytomegalovirus (CMV)

DIFFERENTIAL DIAGNOSIS

● Ectopic pregnancy
● Appendicitis
● Ruptured ovarian cyst
● Endometriosis
● Urinary tract infection (cystitis or pyelonephritis)
● Renal calculus
● Adnexal torsion
● Proctocolitis

LABORATORY TESTS

● CBC with differential: leukocytosis
● Elevated acute phase reactants: ESR 15 mm/hr, C-reactive protein
● Gram stain of endocervical exudate: 30 PMNs per highpower field correlates with chlamydial or gonococcal
infection
● Endocervical cultures for N. gonorrhoeae and C. trachomatis
● Fallopian tube aspirate or peritoneal exudate culture if laparoscopy performed
● hCG to rule out ectopic pregnancy.
IMAGING STUDIES
● Transvaginal ultrasound to look for adnexal mass has sensitivity for PID of 81%, specifi city 78%, accuracy 80%.
● MRI has sensitivity for PID of 95%, specifi city 89%, accuracy 93%. It is useful not only for establishing the diagnosis of PID, but also for detecting other processes responsible for the symptoms. Disadvantages are its higher cost and unavailability in certain areas.

TREATMENT

● Antibiotic treatment (e.g., ofl oxacin with or without metronidazole as outpatient, cefoxitin plus doxycycline as
inpatient). Most patients are treated as outpatients.
● Criteria for hospitalization (2002, Centers for Disease Control and Prevention) as follows:
1. Surgical emergencies such as appendicitis cannot be excluded.
2. Tuboovarian abscess
3. Pregnant patient
4. Patient is immunodefi cient.
5. Severe illness, nausea, or vomiting precluding outpatient management
6. Patient unable to follow or tolerate outpatient regimens
7. No clinical response to outpatient therapy

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