Pelvic Inflammatory Disease
exp date isn't null, but text field is
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