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OBSTETRICS & GYNECOLOGY

PELVIC INFLAMMATORY DISEASE

INTRODUCTION
PID
Infection in the upper genital tract not associated with pregnancy or
intraperitoneal pelvic infections
Salpingitis infection of the oviducts; most characteristic & common
component of PID
Primary prevention: prevent exposure & acquisition of STIs safe sex
practices
Secondary prevention:
Universal screening for those at high risk for chlamydia & gonorrhea
Screening for active cervicitis
Sensitive tests for diagnosing lower genital infection
Treatment of sexual partners
Education

Acute PID
Ascending infection from bacterial flora of vagina & cervix
Mucosal surface endometrium & fallopian tubes
Rare in women without menstrual period
Polymicrobial
Most common serious infection of women ages 16-25 years old
May develop from the following procedures: endometrial biopsy,
curettage, IUD insertion, hysterosalpingography, hysteroscopy

Postmenopausal women genital malignancies, diabetes, or concurrent

intestinal diseases
Rate of ectopic pregnancy increases 6-to 10-fold
Chronic pelvic pain increases 4-fold
Infertility depending on severity of infection, number of episodes, &
age
Nonspecific signs & symptoms
Silent/Asymptomatic PID may have tubal infertility without prior
history of signs or symptoms of acute infection

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ETIOLOGY
2 classic sexually transmitted organisms associated with PID:
N. gonorrhoeae
C. trachomatis
N. gonorrhoeae
Transparent colonies on culture medium attach more readily to epithelial
cells -> produce tubal infection more frequently
Ascends to fallopian tube -> selectively adheres to nonciliated mucussecreting cells -> inflammatory response -> cell death & tissue damage > removal of dead cells & fibroblast -> scarring & tubal adhesions

C. trachomatis
intracellular, sexually-transmitted
More prevalent
Remain in the fallopian tubes for months after initial colonization
Primary infections self-limited, with mild symptoms & little permanent
damage
Atypical/silent PID relatively asymptomatic inflammation of the upper
genital tract
Sequelae of repeated infection: tubal infertility & ectopic pregnancy

Mycoplasma hominis
Spread is via the parametria rather than the mucosa
Does not appear to produce damage to the tubal mucosa
Not highly pathogenic

Most common aerobic organisms:

Nonhemolytic Streptococcus
E. coli
Group B Streptococcus
Coagulase-negative Staphylococcus

Most common anaerobic organisms (predominant over aerobic):

Bacteroides spp.
Peptostreptococcus
Peptococcus

Transcervical penetration of the cervical mucus barrier with

instrumentation of the uterus
Genetic variation
SIGNS & SYMPTOMS
Classic triad: (17%)
Fever
Elevated ESR
Adnexal tenderness or mass
Most frequent symptom: new-onset lower abdominal & pelvic pain
diffuse, bilateral, constant, & dull
Exacerbated by motion or sexual activity
May become cramping
Duration: <7 days
Associated endocervical infection or coexistent purulent vaginal
discharge (75%)
Abnormal uterine bleeding (40%)
Nausea & vomiting late symptoms
N. gonorrhoeae rapid onset, pelvic
pain begins a few days after the start of
menstrual period
C. trachomatis slow onset, less pain,
less fever
5-10% - perihepatic inflammation, FitzHugh-Curtis syndrome
RUQ pain
Pleuritic pain
RUQ tenderness when liver is palpated
Elevated liver transaminase levels
Physical Examination findings:
hallmark: lower abdominal & pelvic tenderness
Abdomen: Tenderness to direct palpation in the lower abdomen, &
occasionally rebound tenderness
Pelvic: bilateral tenderness of the parametria & adnexa exacerbated
with movement of cervix & uterus during examination
Edema
Inflammatory adhesions to the small or large intestine
Adnexal complex or abscess

RISK FACTORS
Age at 1st intercourse
Marital status
Number of sexual partners multiple sexual partners increases risk 5fold
Young women, 75% <25 years old
Sexual behavior
Vaginal douching
IUD user
Previous tubal ligation (Acute Salpingitis)
Previous acute PID definite risk factor for future attacks

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OBSTETRICS &
GYNECOLOGY

PELVIC INFLAMMATORY DISEASE

DIAGNOSIS
Direct visualization via the laparoscope most accurate method
Advantage of concurrent operative procedures: lysis of adhesions,
drainage of abscess, & irrigation of pelvic cavity
Temperature >38 deg Celsius unreliable
WBC >10,000 cells/mL - <50%
ESR >15mm/hr 75%
Sensitive test for hCG help in the differential diagnosis of ectopic
pregnancy
Inflammatory test for endocervical mucus
Increased vaginal WBC most sensitive laboratory indicator
Endometrial biopsy for evidence of endometritis
Vaginal ultrasonography adnexal mass
Dilated & fluid-filled tubes
Free peritoneal fluid
MRI sensitive, but expensive & limited availability
TREATMENT
Key issues:
Need for hospitalization
Patient education use of contraceptives
Treatment of sexual partners
Careful follow-up
2 most important goals:
Resolution of symptoms
Preservation of tubal function
Not treated in the 1st 72 hours following symptom onset 3x likely to
develop tubal infertility or ectopic pregnancy

Reexamine within 48 to 72 hours of initiating outpatient therapy

Hospitalize if therapeutic response is not optimal
If responding well, reexamine after 4 to 6 weeks of therapy

Acute PID associated with IUD

More advanced at time of diagnosis due to misinterpretation of early
signs & symptoms
Often caused by anaerobic bacteria
Outpatient therapy leaving the IUD in situ may be attempted if close
follow-up is possible

IV antibiotics continued for at least 24 hours after substantial

improvement
(+) mass add ampicillin to clindamycin & gentamicin
(-) mass oral antibiotics if symptoms have diminished & afebrile for 24
hours
Operative Treatment
life-threatening infections
Ruptured tubo-ovarian abscess
Laparoscopic drainage of pelvic abscess
Persistent masses in those whom future childbearing is not a
consideration
Persistent symptomatic mass
Unilateral removal of tubo-ovarian complex or abscess frequent
conservative procedure
Drainage of abscess if no response to parenteral broad-spectrum
antibiotics
Transvaginal or transabdominal percutaneous aspiration or
drainage of pelvic abscesses under ultrasonic or CT guidance
contraindicated if there is suspicion of infected carcinoma
Laparoscopic aspiration of tubo-ovarian complexes carries more
operative risks than ultrasound-guided aspiration
SEQUELAE
Ectopic pregnancy
Chronic pain
Infertility
Damaged yet patent oviduct
Peritubular and periovarian adhesions -> complete tubular obstruction

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