PID

• Pelvic Inflammatory Disease (PID)


  Acute and subclinical infection of the upper genital tract in women, involving any or all of the uterus, fallopian tubes, and ovaries; often accompanied by involvement of the neighboring pelvic organs
• PID


  • Results in endometritis, salpingitis, oophoritis, peritonitis, perihepatitis, and/or tubo-ovarian abscess
• The majority of PID cases (85 percent) are caused by sexually transmitted pathogens or bacterial vaginosis-associated pathogens
• Fewer than 15 percent of acute PID cases are not sexually transmitted and instead are associated with enteric or respiratory pathogens that have colonized the lower genital tract
• Post-operative pelvic cellulitis and abscess, pregnancy-related pelvic infection, injury or trauma-related pelvic infection, and pelvic infection secondary to spread of another infection can also produce a similar clinical picture to PID
• Most commonly identified pathogens in PID among sexually active pre-menopausal females

  • Neisseria gonorrhoeae
  • Chlamydia trachomatis
• Mycoplasma genitalium is a rare agent in the pre-menopausal group
• Most commonly identified pathogens in PID among post-menopausal women

  • E. coli
  • Colonic anaerobes
• Very rare pathogens identified in PID include Mycobacterium tuberculosis and the agents of Actinomycosis
• In most cases, the precise microbial etiology of PID is unknown
• Regardless of the initiating pathogen, PID is clinically considered a mixed infection
• Up to 10% of women with untreated gonorrhea and 20% of women with untreated chlamydia infection may go on to develop PID
• Patients at risk for PID

  • Any sexually active female
  • Those with multiple sexual partners
  • Age younger than 25
  • Partner with a sexually transmitted infection
  • History of prior PID or STD
  • Those who do not use barrier contraception
• PID is rare during pregnancy because the mucus plug and decidua seal off the uterus from ascending bacteria, but can occur in the first 12 weeks of gestation before this occurs
• Women who undergo instrumentation of the cervix are at higher risk of infection ascending to cause PID
• Older women less commonly present with PID, but when they do, the cause is more likely to be non-STI-related
• Spectrum of PID


  • Acute presentation over several days
  • Indolent presentation over weeks to months
  • Some women do not present with symptoms but are later suspected to have had PID due to tubal factor infertility
  • Acute symptomatic PID represents a spectrum from mild, vague pelvic symptoms to tubo-ovarian abscess and rarely fatal intra-abdominal sepsis
  • Inflammatory process can extend to the liver capsule to cause perihepatitis (Fitz-Hugh Curtis syndrome)
• Acute symptomatic PID


  • Characterized by acute onset of lower abdominal or pelvic pain, pelvic organ tenderness, and evidence of inflammation of the genital tract
  • Majority have mild to moderate disease, only minority develop peritonitis or pelvic abscess
  • Abnormal uterine bleeding (post-coital, inter-menstrual, menorrhagia) occurs in one-third or more of patients
  • Other non-specific complaints include urinary frequency and abnormal vaginal discharge
• Examination findings in PID

  • Abdominal tenderness on palpation, greatest in lower quadrants
  • In severe PID: rebound tenderness, fever, decreased bowel sounds
  • Uterine and adnexal tenderness on bimanual pelvic exam
  • Purulent endocervical or vaginal discharge
• Laboratory findings in PID

  • Peripheral blood leukocytosis, elevated ESR, elevated CRP - all nonspecific and rare
• Perihepatitis (Fitz-Hugh Curtis Syndrome)

  PID with inflammation of the liver capsule and peritoneal surfaces of the anterior right upper quadrant, with minimal stromal hepatic involvement

  
• Perihepatitis


  • Occurs in approximately 10% of women with acute PID
  • Characterized by right upper quadrant abdominal pain with pleuritic component
  • Marked tenderness in right upper quadrant
  • Aminotransferases usually normal or only slightly elevated
  • Manifests as patchy purulent and fibrinous exudate ("violin string" adhesions) on liver surface
  • First associated with gonococcal salpingitis and Chlamydia trachomatis

  
• Tubo-ovarian abscess


  An inflammatory mass involving the fallopian tube, ovary, and occasionally other adjacent pelvic organs
• Subclinical PID


  • Subclinical infection of the upper reproductive tract that does not prompt a woman to present for care but is severe enough to produce significant sequelae
  • Relatively common, often identified in women with tubal factor infertility or endometrial biopsy findings
  • Lower genital tract infection with gonorrhea, chlamydia, or bacterial vaginosis is a risk factor
  • May occur more frequently in oral contraceptive users
• Chronic PID


  Indolent presentation with low-grade fever, weight loss, and abdominal pain, reported with actinomycosis and tuberculosis
• An association between an indwelling IUD and risk of actinomycosis has been suggested, although this relationship remains unclear
• Evaluation of suspected PID


  • PID should be suspected in any young or sexually active female with lower abdominal pain and pelvic discomfort
  • Goal is to establish a presumptive clinical diagnosis, assess for additional findings, and evaluate for other causes of pelvic pain
  • Presumptive diagnosis can be made on history and physical exam alone, empiric treatment should not be delayed awaiting test results
  • Additional diagnostic tests like pelvic imaging may be useful for acutely ill patients, those not improving with empiric therapy, or when diagnosis remains uncertain
• History for suspected PID

  • Should focus on potential risk factors, including sexual history
• Index of suspicion for PID

  Should be high, especially in adolescents
• Goals of initial evaluation of women with suspected PID

  • Establish a presumptive clinical diagnosis of PID
  • Assess for additional findings that increase the likelihood of the diagnosis
  • Evaluate for other potential causes of pelvic pain
• A presumptive clinical diagnosis of PID can be made on the basis of history and physical exam findings alone
• Empiric treatment should not be delayed while awaiting results of supportive tests
• For women who are acutely ill and may have complications of PID, who do not improve with empiric therapy for PID, or in whom the diagnosis remains uncertain, additional diagnostic tests, such as pelvic imaging, can be useful
• History


  • Focus on potential risk factors for PID
  • Sexual history assessing for new sexual partners and consistent use of condoms
  • Onset (usually recent)
  • Character of pelvic pain (usually constant and aching)
  • Subtle and mild symptoms can be consistent with PID
  • Other symptoms of the differential diagnosis
• Physical and pelvic exam

  • Bimanual exam to evaluate for cervical motion, uterine, or adnexal tenderness
  • Speculum exam to evaluate for cervical mucopurulent discharge
  • Pelvic organ tenderness is the defining characteristic of acute symptomatic PID
  • Other diagnoses should also be considered if uterine and adnexal tenderness are not prominent
  • Presence of a palpable adnexal mass may suggest a tubo-ovarian abscess complicating PID, but it could also reflect other disease processes
• Point-of-care and laboratory tests

  • Pregnancy test
  • Microscopy of vaginal discharge
  • Nucleic acid amplification tests (NAATs) for C. trachomatis and N. gonorrhoeae
  • HIV screening
  • Serologic testing for syphilis
• Pregnancy test


  To rule out ectopic pregnancy and complications of an intrauterine pregnancy
• Saline microscopy of vaginal discharge

  To assess for increased white blood cells (WBC) in vaginal fluid which is sensitive for PID
• Microscopy


  Can also identify coexisting bacterial vaginosis and trichomoniasis
• Positive NAATs for C. trachomatis or N. gonorrhoeae


  Support the diagnosis of PID, but negative NAATs do not rule out PID