Submitted by : Dr Preeti Krishna

PELVIC INFLAMMMATORY Ds.

Aetiology

  •  Result of infection ascending from the endocervix causing endometritis, salpingitis, parametritis, oophoritis, tuboovarian abcess and/or pelvic peritonitis.

Causative agents

  • Neisseria gonorrhoeae and Chlamydia trachomatis – only a quarter of cases in the UK
    Other organisms commonly found – Gardnerella vaginalis, anaerobes (including Prevotella, Atopobium and Leptotrichia) & Mycoplasma genitalium has also been associated with upper genital tract infection in women

Clinical Features

Symptoms suggestive of a diagnosis of PID

  • lower abdominal pain which is typically bilateral
  • deep dyspareunia
  •  abnormal vaginal bleeding, including post coital, inter-menstrual and menorrhagia
  • abnormal vaginal or cervical discharge which is often purulent

Signs

  •  lower abdominal tenderness which is usually bilateral
  •  adnexal tenderness on bimanual vaginal examination
  • cervical motion tenderness on bimanual vaginal examination
  • fever (>38°C)

Complications

  • HIV may have more severe symptoms associated with PID but respond well to standard antibiotic therapy
  • Fitz-Hugh-Curtis syndrome comprises right upper quadrant pain associated with perihepatitis which occurs in some women with PID
  • Removal of the IUD may be associated with better short term clinical outcomes. The decision to remove the IUD needs to be balanced against the risk of pregnancy, if UPSI – Hormonal emergency contraception may be appropriate

Diagnosis

  • may be symptomatic or asymptomatic. clinical symptoms and signs lack sensitivity and specificity (the positive predictive value of a clinical diagnosis is 65-90% )
  • Testing for gonorrhoea and chlamydia in the lower genital tract is recommended
  • Elevated ESR or C reactive protein also supports the diagnosis but is non-specific
  • absence of endocervical or vaginal pus cells – good negative predictive value (95%) , but their presence is non-specific (poor positive predictive value – 17%)

Differential diagnosis

  • ectopic pregnancy
  • UTI
  • Ovarian cyst complications
  • Appendicitis
  •  Functional pain
  •  Endometriosis

Management

  • delaying treatment increases the risk of long term sequelae such as ectopic pregnancy, infertility and pelvic pain.
  • low threshold for empiric treatment of PID is recommended.
  • Broad spectrum antibiotic therapy is required to cover N. gonorrhoeae, C. trachomatis and a variety of aerobic and anaerobic
  •  PEACH study – women were treated with cefoxitin followed by doxycycline – pregnancy rates after 3 years were similar or higher than those in the general population

General Advice

  • Rest is advised for severe disease.
  • Appropriate analgesia
  • IV therapy is recommended for severe clinical disease e.g. pyrexia > 38 C, clinical signs of tubo-ovarian abcess, signs of pelvic peritonitis.
  • avoid unprotected intercourse until they, and their partner(s), have completed treatment and follow-up
  • repeat episodes of PID are associated with an exponential increase in the risk of infertility
  •  earlier treatment is given the lower the risk of future fertility problems.
  •  future use of barrier contraception will significantly reduce the risk of PID
  •  the need to screen her sexual contacts for infection to prevent her becoming reinfected
  •  Women taking the oral contraceptive pill who present with breakthrough bleeding should be screened for genital tract infection, especially C. trachomatis

Outpatient treatment for mild to moderate cases

Inpatient care considered in the following situations:

  •  a surgical emergency cannot be excluded
  • lack of response to oral therapy
  •  clinically severe disease
  • presence of a tuboovarian abcess
  • intolerance to oral therapy
  •  pregnancy

Further Investigation

All sexually active patients should be offered:

  • a pregnancy test
  • screening for STI including HIV

Outpatient Regimens

  1. I.M. ceftriaxone* 500mg single dose followed by oral doxycycline 100mg twice daily plus metronidazole 400mg twice daily for 14 days
  2. oral ofloxacin 400mg twice daily plus oral metronidazole 400mg twice daily for 14 days

Alternative Regimens

  1.  IM ceftriaxone 500 mg immediately, followed by azithromycin 1 g/week for 2 weeks
  2.  oral moxifloxacin 400mg once daily for 14 days

POINTS TO CONSIDER

  • Anaerobes are of relatively greater importance in patients with severe PID
  • metronidazole may be discontinued in mild or moderate PID who are unable to tolerate it.
  •  Ofloxacin and moxifloxacin should be avoided in – high risk of gonococcal PID because of increasing quinolone resistance in the UK .
  •  Quinolones should also be avoided as first line where >5% of PID is caused by quinolone resistant Neisseria gonorrhoeae.
  •  Levofloxacin is the L isomer of ofloxacin and has the advantage of once daily dosing (500mg OD for 14 days). It may be used as a more convenient alternative to ofloxacin.
  •  Replacing intramuscular ceftriaxone with an oral cephalosporin (e.g. cefixime) is not recommended

Inpatient Regimens

IV therapy should be continued until 24 hours after clinical improvement and then switched to oral

  1. IV. ceftriaxone 2g daily + IV doxycycline 100mg twice daily (oral doxycycline may be used if tolerated) followed by oral doxycycline 100mg twice daily + oral metronidazole 400mg twice daily for a total of 14 days
  2. IV clindamycin 900mg 3 times daily plus IV gentamicin (2mg/kg loading dose) followed by 1.5mg/kg 3 times daily [a single daily dose of 7mg/kg may be substituted]) followed by either oral clindamycin 450mg 4 times daily or oral doxycycline 100mg twice daily plus oral metronidazole 400mg twice daily to complete 14 days

ALTERNATE REGIMEN

  1.  i.v. ofloxacin 400mg BD plus i.v. metronidazole 500mg TID for 14 days
  2.  i.v. ciprofloxacin 200mg BD plus i.v. (or oral) doxycycline 100mg BD plus i.v. metronidazole
    500mg TID for 14 days

Pregnancy and Breastfeeding + PID

  •  increase in both maternal and fetal morbidity – parenteral therapy is advised
  •  insufficient data to recommend a specific regimen and agents effective against gonorrhoea, chlamydia and Anaerobic infections should be considered .

Surgical Management

  •  Laparoscopy – dividing adhesions and draining pelvic abscesses
    ultrasound guided aspiration of pelvic fluid collections is less invasive and may be equally effective.
  • adhesiolysis in cases of perihepatitiS

Sexual Partners

  • male partners of women with PID – screening for gonorrhoea and chlamydia and treated broad spectrum empirical therapy should also be offered to male partners e.g. azithromycin 1g single dose
  • screening – tracing of contacts within a 6 month period of onset of symptoms is recommended
  • If screening for gonorrhoea is not available – antibiotics effective against Neisseria gonorrhoeae should be offered e.g. i.m. ceftriaxone 500mg single dose
  •  avoid intercourse until they and the index patient have completed the treatment course

Follow Up

  • Review at 72 hours is recommended – moderate or severe clinical presentation — if no improvement – further investigation, parenteral therapy and/or surgical intervention.
  • Further review after 2 – 4 weeks
  • If persisting symptoms, antibiotic resistance pattern (gonorrhoea only), compliance with antibiotics and/or tracing of sexual contacts indicate the possibility of persisting or recurrent infection -Repeat testing for gonorrhoea or chlamydia after 2 to 4 weeks