Pelvic Inflammatory Disease

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Introduction

  • Ascending pelvic infection involving the upper genital tract
  • Usually involves sexually transmitted organisms e.g. Neisseria gonorrhoeae and Chlamydia trachomatis
  • It may also be caused by organisms endogenous to the lower genital tract.
  • In severe cases, organisms may migrate via the peritoneum to the upper abdomen causing perihepatic adhesions: the so- called "violin strings" (Fitz-Hugh-Curtis syndrome)

Risk factors

  • Age:
    • Peak incidence between 15 - 25 years
  • Sexual activity:
    • Multiplicity of sexual partners
  • Use of intrauterine contraceptive devices:
    • Usually within the first 4 months of use
  • Previous episode(s) of PID

Clinical features

Major criteria (the Westrom triad):

  • Lower abdominal pain and tenderness
  • Cervical excitation tenderness
  • Adnexal tenderness

Minor criteria

  • Fever (38oC)
  • Leucocytosis
  • Purulent vaginal discharge
  • Adnexal mass

Diagnosis

  • Based on the presence of the Westrom triad of symptomatology plus one of the minor criteria
  • Confirmation by demonstration of causative organism(s) on microscopy, culture and sensitivity testing

Differential diagnoses

  • Acute appendicitis
  • Ovarian cyst accident
  • Endometriosis
  • Urinary tract infections
  • Renal disorders (e.g. nephrolithiasis)
  • Pelvic adhesions
  • Lower lobe pneumonia
  • Ectopic gestation

Complications

  • Pelvic abscess
  • Septicaemia
  • Chronic pelvic pain
  • Ectopic gestation
  • Infertility
  • Fitz-Hugh-Curtis syndrome
  • Recurrence (about 25% rates)

Investigations

  • FBC
  • Haemoglobin genotype
  • Blood Group
  • Electrolyte, Urea and Creatinine
  • Midstream urine microscopy, culture and sensitivity
  • Endocervical swab
  • High vaginal swab culture: to exclude trichomoniasis, bacterial vaginosis
  • Urethral swab
  • Ultrasound scan: to exclude cyesis, ectopic gestation, adnexal mass (e.g. ovarian mass)

Indications for admission

  • Uncertain diagnosis
  • Intolerance of oral medication or non-response to outpatient therapy
  • Presence of a pelvic mass
  • Presence of an intrauterine device
  • Upper abdominal pain
  • Non-adherence to therapy
  • Pregnancy
  • Nulliparity

Treatment goals

  • Rehydrate adequately
  • Eradicate the infecting organism(s)
  • Prevent complications

Drug treatment

Appropriate antibiotics for an adequate period

  • The antibiotic chosen should cover all possible causative organisms while awaiting culture/sensitivity results
  • In the absence of culture /sensitivity result, local frequently sensitive drugs can be commenced, but as outpatient therapy while awaiting culture results can include:
  • Ceftriaxone (or equivalent cephalosporin) - 1g intramuscularly stat

Plus:

  • Doxycycline - 100 mg orally every 12 hours for 14 days

Plus or minus:

  • Metronidazole - 400 mg orally every 12 hours for 14 days

If no response in 48 - 72 hours - Admit, re-evaluate and give appropriate intravenous therapy

Inpatient triple therapy:

  • Ceftriaxone/doxycycline/metronidazole

Or:

  • Clindamycin/gentamicin/metronidazole

Triple antibiotic regimen to be continued for 48 hours after the patient improves clinically

Subsequently, the patient should continue therapy with:

  • Doxycycline - 100 mg orally every 12 hours

Plus:

  • Metronidazole - 400 mg orally every 8 hours for 10-14 days

Prevention

  • Encourage the use of barrier contraceptive with spermicides
  • Modify risky sexual behaviour: avoid multiplicity of sexual partners
  • Contact tracing: to break the existing chain of infection and prevent recurrence
  • Prompt diagnosis and treatment to prevent long-term complications