ORGANUM
Acute infections of the endometrium, myometrium, fallopian tubes and ovaries are usually the result of ascending infections from the lower genital tract causing PID. PID affects approximately 1.7% of women between 15 and 35 years of age per year in the developed world.
PID affects approximately 1.7% of women between 15 and 35 years of age per year in the developed world. Up to 20% of women with PID will have a further episode within 2 years. The disease is most common between the aged of 15 and 24 years, and particular risk factors include multiple sexual partners and procedures involving transcervical instrumentation. PID is an important cause of infertility - after a first episode, 8% of women will have evidence of tubal infertility; subsequent episodes approximately double this figure. Women with a past history of PID are four times more likely to have en ectopic pregnancy when they conceive.
PID is thought to be the result of polymicrobial infection with primary infection by Chlamydia trachomatis or Neisseria (or both) allowing opportunistic infection with other aerobic bacteria and anaerobes.
C.trachomatis is an obligate, intracellular, Gram-negative bacterium. It is the commonest bacterial STI in Europe, Australia and North America and is thought to be the causative agent in at least 60% of cases of PID in those areas. Prevalence rates vary from 11% to 30% in women attending GUM clinics, with the peak incidence in the UK in women aged between 20-24. The main sites of infection are the columnar epithelium of the endocervix, urethra and rectum, but many women remain asymptomatic. Ascent of infection to the upper genital tract occurs in about 20% of women with cervical infection.
N.gonorrhoeae is a gram-negative, intracellular diplococci. Infection is commonly asymptomatic or associated with vaginal discharge. In cases of PID, it spreads across the cervix and endometrium and causes tubal infection within 1-3 days of contact. It is the principal cause for 14% of cases of PID and occurs in combination with Chlamydia in a further 8%.
The symptoms of acute salpingitis include:
Acute bilateral lower abdominal pain: Salpingitis is almost invariably bilateral; where the symptoms are unilateral, an alternative diagnosis should be considered.
Deep dyspareunia
Abnormal menstrual bleeding
Purulent vaginal discharge
The signs of acute salpingitis include:
Signs of systemic illness with pyrexia and tachycardia
Signs of peritonitis with guarding, rebound tenderness and often localised rigidity. It should be noted that guarding and rigidity rarely are seen if blood is in the peritoneal cavity, such as due to an ectopic pregnancy, whereas tenderness and release tenderness are seen even in the absence of peritonitis).
On pelvic exam, acute pain on cervical excitation and thickening in the vaginal fornices, which may be associated with the presence of cystic tubuals swellings due to pyosalpinges or pus-filled tubes; fullness in the pouch of Douglas suggests the presence of a pelvic abscess.
An acute perihepatitis occurs in 10-25% of women with chlamydial PID, which may cause RUQ pain, deranged liver functions tests and multiple filmy adhesions between the liver surface and the parietal peritoneum, and is known as the Fitz-Hugh-Curtis syndrome.
A pyrexia of 38c or more, sometimes associated with rigors
Nonetheless, many women shown to have chlamydial infection have no symptoms at all.
A STI is not the only cause of PID. It may be secondary to appendicitis or other bowel infections, which sometimes give rise to a pelvic abscess. Perforation of the appendix with pelvic sepsis remains a common cause of tubal obstruction and subfertility. Pelvic sepsis may also occur during the puerperium and after pregnancy termination or after operative procedures on the cervix. Retained placental tissue and blood provide an excellent culture medium for organisms from the bowel, including E.coli, C.welchii, or C.perfringens, Staph A and Strep faecalis.
When the diagnosis of acute salpingitis is suspected, the women should be admitted to hospital. After completion of the history and general examination, swabs should be taken from the vaginal fornices and cervical canal and sent to the laboratory for culture and antibiotic sensitivity. A midstream specimen of urine should also be sent for culture to exclude a possible urinary tract infection. An additional endocervical swab urine sample should be taken for detection of Chlamydia by PCR. Urethral swabs may identify chlamydial infection not detected by endocervical swabs. PCR of urine samples have similar or better sensitivity (90%) compared to genital tract swabs and offer a potential means of screening for chlamydial infection in asymptomatic women.
Examination of the blood for differential white cell count, HB estimation and CRP may help establish the diagnosis. Blood culture is indicated if there is significant pyrexia. The diagnosis of mild to moderate degrees of PID on the basis of the history and examination finding is unreliable, and where the diagnosis is in doubt, laparoscopy is indicated.
Treatment of acute PID typically requires triple antibiotic therapy.
Where the patient in unwell and exhibits peritonitis, high-grade fever, vomiting or a pelvic inflammatory mass, she should be admitted to hospital and managed as follows:
Fluid replacement by IV therapy
When PID is clinically suspected, antibiotic therapy should be commenced. Antibiotic therapy initially prescribed for clinically diagnosed PID should be effective against C.trachnomatis and N.gonorrhoea, and the anaerobes characterising bacterial vaginosis
Pain relief with NSAIDs
If the uterus contains an IUD, it should be removed as soon as antibiotic therapy has been commenced
Bed rest - immobilisation is essential until the pain subsides
Abstain from intercourse
Patients with mild-to-moderate disease who can tolerate oral fluids, do not have a tubo-ovarian abscess and lack other factors for hospitalisation (surgical emergencies cannot be excluded) should be treated with a combination of an IM cephalosporin (ceftriaxone, cefoxitin) plus oral doxycycline plus metronidazole. Probenecid should be used with cefoxitin as it increases mean terminal half-life and decreases renal clearance. Metronidazole is used in combination with doxycycline to provide extended coverage against anaerobic bacteria, as well as the curative effect that metronidazole has on bacterial vaginosis (a common co-infection in women with PID). If a patient does not respond to outpatient antibiotic therapy within 72 hours, hospitalisation and IV antibiotics are indicated. Although fluoroquinolone antibiotics should be avoided as first-line empirical treatment for PID due to the risk of co-existing gonococcal infection/PID (clinically severe disease, partner has gonorrhoea, history of sexual contact abroad), N.gonorrhoeae is an uncommon cause of PID in the UK and they can be used as a second-line empirical treatment among those not at high risk of gonorrhoea. If allergy precludes the use of cephalosporins, if the community prevalence and individual risk for gonorrhoea are low, and follow-up is likely, the use of fluoroquinolone or azithromycin with or without metronidazole can be considered. If mycoplasma genitalium testing is available and detected, guidelines recommend treatment with moxifloxacin. The use of systemic fluoroquinolones antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events.
If the patient is hospitalised - patients with severe PID or surgical emergencies cannot be excluded (patient is pregnant, severe illness precludes outpatient management, patient is unable to follow or tolerate an outpatient oral regimen or patient has not responded to outpatient therapy) we should consider parenteral antibiotic therapy with a cephalosporin plus doxycycline for patients with severe PID. Metronidazole should also be used. Alternative parenteral regimens include ampicillin/sulbactam plus doxycycline, or clindamycin plus gentamicin. Women receiving a parental regimen of clindamycin plus gentamicin who show clinical improvement within 24-48 hours can be switched to an appropriate oral regimen or oral doxycycline to complete the 14 days of therapy. Due to pain associated with IV infusion, doxycycline should be administered orally if possible.
We should also consider removal of IUDs, however evidence is insufficient to recommend this. Caution should be exercised if the IUD remains in place; close clinical follow-up is mandatory, and consideration should be given to removal if symptoms have not resolved within 48 to 72 hours.
In cases of confirmed STI, it is important to treat the partner and arrange appropriate contact tracing.
In most cases, conservative management results in complete remission. Laparotomy is indicated where the condition does not resolve with conservative management and where there is a pelvic mass. In most cases, the mass will be due to a pyosalpin or tubo-ovarian abscess. This can either be drained or a salpingectomy can be performed.
Tubal ectopic pregnancy
Initially pain is unilateral in most cases. Syncopal episodes and signs of diaphragmatic irritiation with shoulder tip pain. WCC high or slightly raised, but Hb is likely to be low depending on the amount of blood lost. In acute salpingitis, WCC is raised and Hb is normal
Acute appendicitis
The most important difference in this diagnosis lies in the unilateral nature of this condition. Pelvic examination does not usually reveal much pain and tenderness, but it must be remembered that the two conditions sometimes co-exist, particularly where the infected appendix lies adjacent to the right fallopian tube
Acute UTI
May produce similar symptoms but rarely produce signs of peritonism and are commonly associated with urinary symptoms
Torsion or rupture of ovarian cyst