Pelvic Inflammatory Disease CDC, 2010 European Guidelines, 2012

1. Pelvic
Inflammatory
Disease
CDC, 2010
European Guidelines, 2012
Prof. Aboubakr Elnashar
Benha University Hosp. Egypt
ABOUBAKR ELNASHAR

2. Definition
Inflammatory disorders of the upper
FGT
Any combination of
endometritis,
salpingitis,
tubo-ovarian abscess&
pelvic peritonitis.
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3. Pathophysiology
I. Ascending: common, from the LGT
1. Through sperm, TV, along surfaces
traveling from the cervix to the endometrium,
through the salpinx, and into the peritoneal
cavity
2. Through the lymphatic systems:
infection of the parametrium from IUCD
II. Lateral:
Rare, from infected appendix
III. Through hematogenous routes
Rare: tuberculosis
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4. Factors associated with PID:
I. Factors related to sexual behaviour
•young age
•multiple partners
•recent new partner (within previous 3 months)
•past history of (STIs) in the patient or their partner
II. Instrumentation of the uterus / interruption of the
cervical barrier
• termination of pregnancy
• insertion of IUCD within the past 6 w
• HSG
• IVF
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5. Types
Primary
No precipitating
cause
STD
Secondary
Precipitating
cause
IUCD,
HSG,
abortion or
infection
elsewhere in the
body;
appendicitis
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6. Aetiology
ST organisms:
N. Gonorrhoeae (NG), C. trachomatis (CT)
Vaginal flora:
Anaerobes, G. vaginalis,
H influenzae, enteric Gram- rods
Streptococcus agalactiae
Rare
M. hominis, U. urealyticum, M. genitalium.
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7. Diagnosis
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8. •Difficult:
1. No single historical, physical, or lab finding
is both sensitive & specific
Combinations of diagnostic findings to
improve sensitivity &specificity
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9. 2. Clinical Diagnosis
PPV: 65%– 90% compared with laparoscopy.
a.Wide variation in S & S.
b. Sym:
± No
±Subtle, mild, non specific e.g.
AUB
Dyspareunia
VD
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10. 3. Laparoscopy:
accurate diagnosis of salpingitis
bacteriologic diagnosis.
not readily available
not easy to justify when sym are mild or vague.
not detect endometritis
might not detect subtle inflammation of FT.
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11. Grading (Soper,1991):
Mild: erythema, edema, exudates, tubes are patent & mobile,
Moderate: purulent discharge & fixed tubes
Severe: TO abscess, pyosalpinx
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12. bilateral pyosalpinx.
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13. Hager criteria (Hager et al,1983)
1. Abdominal pain & tenderness,
2. Cervical movement tenderness &
3. Adenxal tenderness + 1 or more of the following
1. T >38.3°C,
2. Discharge: mucopurulent
3. Saline microscopy: WBC 6-10/HPF
4. ESR: elevated (> 15 mm/h)
5. CRP: elevated
6. laboratory documentation of NG or CT. {Gram –ve
intracellular diplcocci, I.F. stain: CT}
7. Leucocytosis > 10000
8. U/S: adenxal mass
9. Culdocentesis: purulent discharge
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14. CDC (2010)
Minimum criteria: one is enough
1. Cervical motion tenderness
2. Uterine tenderness
3. Adnexal tenderness
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15. •One or more of the following minimum criteria must
be present on pelvic examination to diagnose PID:
•The requirement that all 3 minimum criteria be
present before the initiation of empiric tt: insufficient
sensitivity for the diagnosis of PID.
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16. Supportive criteria:
Improving the specificity of the minimum criteria
1. T >38.3°C,
2. Discharge: mucopurulent
3. Saline microscopy: WBC 6-10/HPF
4. ESR: elevated
5. CRP: elevated
6. laboratory documentation of NG or CT.
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17. Specific criteria:
1. TVS or MRI showing
thickened, fluid-filled tubes with or without free pelvic
fluid or tubo-ovarian complex, or
Doppler studies suggesting pelvic infection (e.g.,
tubal hyperemia)
2. Laparoscopic abnormalities consistent with PID
3. Endometrial biopsy with histopathologic evidence of endometritis
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18. Ovarian abscess
Pelvic abscessABOUBAKR ELNASHAR

19. PID & tubo-ovarian complex
Tubo-ovarian abscess: an echo poor
septated process close to the uterus
(U).
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20. Complications
• Tuboovarian abscesses and pelvic peritonitis:
Acute lower abdominal pain and fever are usually
present.
US: confirm a pelvic abscess
CT: rule out other peritonitis.
• The Fitz-Hugh-Curtis syndrome:
Rt upper quadrant pain associated with Perihepatitis
±dominant symptom.
treatment for PID
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21. • In pregnancy PID
Uncommon
: increase maternal and fetal morbidity
parenteral therapy effective against gonorrhoea,
chlamydia and anaerobic infections
(e.g. i.v. cefoxitin 2g three times daily plus i.v.
erythromycin 50mg/kg continuous infusion, with the
possible addition of i.v. metronidazole 500mg three
times daily)
(Evidence level III, B)
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22. Differential Diagnosis
lower abdominal pain in a young woman:
• ectopic pregnancy
• acute appendicitis
• endometriosis
• irritable bowel syndrome
• complications of an ovarian cyst i.e. rupture,
torsion
• functional pain (pain of unknown physical origin)
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23. Treatment
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24. Empiric treatment of PID
WHY?
1. Diagnosis is difficult
2. Delay in diagnosis & tt: inflam sequelae in upper
FGT.
3. Empiric antimicrobial tt of PID:
Not impair Diagnosis & management of other causes of
lower abd pain: ectopic pregnancy
ac appendicitis
functional pain
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25. Recommendation
{lack of definitive clinical diagnostic criteria}
a low threshold for empirical tt of PID is
recommended
(RCOG, 2003, B)
Outpatient antibiotic tt should be commenced as
soon as the diagnosis is suspected.
(RCOG, 2003, A)
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26.  When?
1. Sexually active young women and other
women at risk for STDs
2. Pain: pelvic or lower abd
3. Other causes are excluded
4. Tenderness on pelvic examination
(minimum criteria):
a) cervical motion OR
b) uterine OR
c) adnexal.
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27. Treatment should be initiated as soon
as the presumptive diagnosis has been
made {prevention of long-term
sequelae}
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28. Indication of hospitalization
1. Surgical emergencies (appendicitis) cannot
be excluded
2. Pregnant
3. No response to oral antimicrobial therapy
4. Unable to follow or tolerate an outpatient
oral regimen
5. Severe illness (N&V, or high fever)
6. Tubo-ovarian abscess.
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29. General measures include:
• Rest is advised for those with severe disease
(Evidence level C)
• If there is a possibility that the patient could be
pregnant, a pregnancy test should be
performed
(Evidence level C)
• Appropriate analgesia should be provided
(Evidence level C)
• Intravenous therapy is recommended for patients
with more severe clinical disease
(Evidence level IV, C)
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30. In inpatients the tt response can be monitored by changes in C
reactive protein and WBC .
In severe cases and cases with failure of the initial tt tuboovarian
abcess should be excluded by TVS, CT or MRI
All patients should be offered screening for STD
(Evidence level IV, C) .
It is likely that delaying treatment increases the risk of long term
sequelae such as ectopic pregnancy, infertility and pelvic pain 15.
Because of this, and the lack of definitive diagnostic criteria, a low
threshold for empiric treatment of PID is recommended (Evidence
level IV, C).
In cases with suspected repeat PID, especially if it is of mild
severity, other causes should be sought and treated accordingly,
especially functional pain, pain originating in the ileopsoas
muscles, the pelvic floor and urinary tract (Evidence level IV, C).
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31. Choice of treatment regime should be influenced
by the following:
• Mild and moderate cases should be treated as
outpatients with oral therapy16 (Evidence
level Ib, A).
• Intravenous therapy, when given, should be
continued until 24 hours after clinical improvement
and then switched to oral (Evidence level IV, C).
• Dosage recommendations may need to be
adjusted slightly depending on local licensing
regulations and the availability of drug formulations.
• The optimal duration of treatment is not known but
most clinical trials report a response to 10-14 days
of therapy.
• No difference in efficacy has been demonstrated
between the recommended regimensABOUBAKR ELNASHAR

32. Selection of antibiotics
1. Effective against N. G&C. T.
{negative endocervical screening does not rule out PID}.
The need to eradicate anaerobes has not
been determined definitively.
Regimens with anaerobic activity should be considered
{a. Anaerobic bacteria have been isolated
b. BV is present in many women who have PID}
2. Consider
availability
cost
patient acceptance.
3. Parenteral & oral therapy have similar
efficacy in mild or moderate PIDABOUBAKR ELNASHAR

33. Recommended Parenteral Regimen A
(RCOG, 2003, B)
I. Initial:
Cefotetan (Cefotan) 2 g IV/12 h
OR
Cefoxitin (Mefoxin) 2 g IV/ 6 h
PLUS
Doxycycline 100 mg orally or IV*/12 h
*Oral and IV administration of doxycycline provide similar bioavailability.
II. Continued
24 h after a patient improves clinically
doxycycline (100 mg twice a day) to complete 14
days ABOUBAKR ELNASHAR

34. Recommmended Parenteral Regimen B
I. Initial
Clindamycin 900 mg IV/8 h
PLUS
Gentamicin loading dose IV or IM (2 mg/kg),
followed by a maintenance dose (1.5 mg/kg)/8
h.
Single daily dosing may be substituted. Although use of a single daily dose of
gentamicin has not been evaluated for the treatment of PID, it is efficacious in
analogous situations.
II. Continued:
24 h after a patient improves clinically
doxycycline 100 mg orally twice a day or
clindamycin 450 mg orally four times a day to complete a total
of 14 days of therapy. ABOUBAKR ELNASHAR

35. •Bevan CD, Ridgway GL, Rothermel CD. Efficacy and safety of
azithromycin as monotherapy or combined with metronidazole compared
with two standard multidrug regimens for the treatment of acute PID. (J Int
Med Res 2003;31:45–54).
•Azithromycin (Zithromax)
500 mg/d IV for 1 day or 2 days
followed by 250 mg/d orally for a total
of 7 days, alone or with
Metronidazole
400 mg tds or 500 mg IV then
orally for a total of 14 days.
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36. •Rates of clinical success for
Azithromycin alone: 97.1%
with metronidazole: 98.1%
Conclusion:
Azithromycin, alone or with metronidazole,
provides a shorter, simpler treatment option for
the successful management of acute PID.
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37. Recommended Regimen A (RCOG, 2003,
B)
Levofloxacin (levaquin) 500 mg orally once
daily for 14 days*
OR
Ofloxacin (floxin) 400 mg orally once daily
for 14 days*
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day
for 14 days
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38. Azithromycin: 250 mg daily for 7 days
Plus
Metronidazole: 500 mg tds for 14 d
{effective against anaerobes and BV}
(Bevan et al, 2003).
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39. Surgical treatment should be
considered in severe cases or where
there is clear evidence of a pelvic
abscess (RCOG, 2003,B)
1. Hospitalization: at least 24 h
2. Laparotomy/laparoscopy:
a. division of adhesions & drainage of pelvic
abscesses.
b. adhesiolysis in cases of perihepatitis
although there is no evidence as to whether
this is superior to antibiotic therapy alone.
3. US-guided aspiration:
less invasive and may be equally effective.ABOUBAKR ELNASHAR

40. Tubo-ovarian abscess:
I. Initial
II. Contiued:
Clindamycin or metronidazole with
doxycycline {more effective anaerobic
coverage}.
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41. Management of Sex Partners
•Examined and treated if they had sexual contact
with the patient during the 60 days preceding the
patient’s onset of symptoms.
{ a. Risk for reinfection of the patient
b. strong likelihood of urethral gonococcal or
chlamydial infection in the sex partner}.
•With regimens effective against both of these
infections
Patients should be advised to avoid unprotected
intercourse until they, and their partner(s),
have completed treatment and follow-up (Evidence
level IV, C)
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42. IUD
•Risk of PID
confined to the first 3 w after insertion
uncommon thereafter.
A Cochrane review:
Doxycycline or azithromycin (Zithromax) before
IUD insertion confers little benefit.
•PID in IUD users:
No evidence that IUDs should be removed
Close clinical follow-up is mandatory.
IUCD may be left in mild PID but should be
removed in severe cases (RCOG, 2003,B)
In women with an intrauterine contraceptive device (IUD) in situ, consider removing the IUD
since this may be associated with better short term improvement in symptoms and signs.
(Evidence level Ib, A) ABOUBAKR ELNASHAR

43. Role of Prophylactic Antibiotics (2014)
Recommendation
Routine use of prophylactic antibiotics is not
recommended prior to IUD insertion, although it may
be used in certain high-risk situations. (I-C)
Management of PID with IUD In Situ
Recommendation
In treating mild to moderate PID, it is not necessary to
remove the IUD during treatment unless the patient
requests removal or there is no clinical improvement
after 72 hours of appropriate antibiotic treatment. In
cases of severe PID, consideration can be given to
removing the IUD after an appropriate antibiotic
regimen has been started. (I-B)
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44. HSG:
{Postoperative PID is an uncommon but
potentially serious complication.
Patients with dilated fallopian tubes are at
greater risk}.
1. Dilated fallopian tubes: 100 mg of
doxycycline twice daily for 5 d.
2. History of pelvic infection: doxycycline
before the procedure & continued if dilated
fallopian tubes are found (ACOG, 2006).
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45. Surgical Abortion/D&C
{periabortal antibiotics had a 42% overall
decreased risk of infection}.
ACOG: antibiotic prophylaxis is effective,
regardless of risk.
Doxycycline: 100 mg orally 1 h before
procedure & 200 mg after procedure
Metronidazole: 500 mg orally twice daily
for 5 d
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46. COC and PID
BTB: screen for C. trachomatis (RCOG, 2003,
C)
COC has been regarded as protective
against symptomatic PID.
Increased risk of CT.
may mask endometritis.
Effectiveness may be reduced when
taking antibiotic
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47. Recent data suggest that few antibiotics
(azithromycin and moxifloxacin, mainly) are
effective against Mycoplasma genitalium
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48. Syndromic Management of Pelvic Inflammatory Disease
(for use where initial investigations are not available)
lower abdominal pain +/- abnormal vaginal/cervical discharge
with adnexal tenderness or cervical motion tenderness on
bimanual examination
missed or overdue period
sudden onset severe pain
bowel symptoms or signs
intermittent cyclical abdominal pain
positive pregnancy test
screen for STD if possible
treat with recommended regimen (see below)
educate patient about PID
treat partner(s) with ceftriaxone 500mg i.m. single dose
plus azithromycin 1g single dose
(or an alternative regimen locally effective against N.
gonorrhoeae and C. trachomatis)
review after 3 days to ensure clinical improvement
Refer for
further
investigation
No
Yes
No
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49. PID is a polymicrobial infection of the upper genital
tract. It primarily affects young, sexually active
women.
The diagnosis is made clinically; no single test or
study is sensitive or specific enough for a definitive
diagnosis.
PID should be suspected in at-risk patients who
present with pelvic or lower abdominal pain with no
identified etiology, and who have cervical motion,
uterine, or adnexal tenderness.
Chlamydia trachomatis and Neisseria gonorrhoeae
are the most commonly; however, other
microorganisms may be involved.
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50. The spectrum of disease ranges from
asymptomatic to life-threatening tubo-ovarian
abscess.
Patients should be treated empirically, even if they
present with few symptoms. Most women can be
treated successfully as outpatients with a single
dose of a parenteral cephalosporin plus oral
doxycycline, with or without oral metronidazole.
Delay in treatment may lead to major sequelae,
including chronic pelvic pain, ectopic pregnancy,
and infertility.
Hospitalization and parenteral treatment are
recommended if the patient is pregnant, has
human immunodeficiency virus infection, does not
respond to oral medication, or is severely ill.ABOUBAKR ELNASHAR

51. No single clinical finding or laboratory test is
sensitive or specific enough to definitively
diagnose PID.
Empiric antibiotic treatment should be initiated at
the time of presentation in patients with symptoms
suspicious for PID, even if the diagnosis has not
been confirmed. B
Women with mild to moderate PID may receive
outpatient oral medical treatment without
increased risk of long-term sequelae.
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52. ABOUBAKR ELNASHAR