Pelvic inflammatory disease (PID)

كلية الطب ? جامعة بابل المرحلة الخامسة
د-نسرين مالك
Gynaecology
Pelvic inflammatory disease (PID)
Is an infectious and inflammatory disorder of the upper female genital tract, including the uterus, fallopian tubes, and adjacent pelvic structures. Infection and inflammation may spread to the abdomen, including perihepatic structures (Fitz-Hugh?Curtis syndrome).
Risk factors of pelvic inflammatory disease include:-
1-Having sex and being under the age of 25.
2-Sex with more than one person.
3-Having sex without a condom.
4-Using an intrauterine device (IUD).
5-Vaginal douching.
6- History of pelvic inflammatory disease.
PID is initiated by infection that ascends from the vagina and cervix into the upper genital tract. Chlamydia trachomatis is the predominant sexually transmitted organism associated with PID. Other organisms implicated in the pathogenesis of PID include Neisseria gonorrhoeae, Gardnerella vaginalis, Haemophilus influenzae, and anaerobes such as Peptococcus and Bacteroides species ,Mycobacterium tuberculosis,and others. Laparoscopic studies have shown that in 30-40% of cases PID is polymicrobial.
Clinical features:- Clinical manifestations of PID vary widely,
Some women with pelvic inflammatory disease don’t have symptoms. For the women who do have symptoms, these can include:-
1-Pain in the lower abdomen (the most common symptoms).
2-Pain in the upper abdomen.
3-Fever.
4-Dyspareunia( painful sex).
5-Painful urination.
6-Irregular bleeding.
7-Increased or foul-smelling vaginal discharge.
8-Tiredness

Some women have severe pain and symptoms, such as
1-Sharp pain in the abdomen.
2-Vomiting.
3-Fainting.
4- High fever.
If there are severe symptoms, the patient should be refer to the emergency room. The infection may have spread to the bloodstream or other parts of the body. Once again, this can be a life-threatening. PID may produce tubo-ovarian abscess (TOA) and may progress to peritonitis and Fitz-Hugh?Curtis syndrome (perihepatitis) is a rare but life-threatening complication. The acute rupture of a TOA may result in diffuse peritonitis and necessitate urgent abdominal surgery.
On physical examination:-There is cervical motion tenderness( often called cervical excitation)with or without uterine and adnexal tenderness.
The differential diagnosis :-includes
1-Ovarian cyst torsion or rupture. 2-Ectopic pregnancy
3- Urinary tract infection. 4- Endometriosis.
6- Adnexal tumors. . 5- Cervicitis.
7- Appendicitis. 8-Irritable bowel syndrome.
9-Inflammatory bowel diseases. 10-Psuchosomatic pain.
Diagnosis of PID :-
1-Pelvic exam to check pelvic organs.
2-Cervical culture to check cervix for infections.
3-Urine test to check for signs of blood, cancer, and other diseases.
4-Pelvic ultrasound.
5-Endometrial biopsy.
6-Laparoscopy.

Laparoscopy is the current criterion standard for the diagnosis of PID. Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome) can be seen by laproscopy.)
No single laboratory test is highly specific or sensitive for the disease, but studies that can be used to support the diagnosis include the erythrocyte sedimentation rate (ESR), the C-reactive protein (CRP) level, and chlamydial and gonococcal DNA probes and cultures. Imaging studies (eg, ultrasonography, computed tomography [CT], and magnetic resonance imaging [MRI]) may be helpful in unclear cases.
Treatment:-
Most patients with PID are treated in an outpatient setting. In selected cases, however, physicians should consider hospitalization.
Antibiotics to treat PID:- usually give two different types of antibiotics to treat a variety of bacteria.Within a few days of starting treatment, symptoms may improve or go away. However, medication should finish, even if feeling better. Stopping the medication early may cause the infection to return.
Out patient antibiotic regimens :All regimens should complete 14 days of therapy, use one of the following regimens:-
Regimen 1:- Ofloxacin 400 mg twice daily plus metronidazole 400 mg twice daily.
Regimen 2:- Moxifloxacin 400 mg once daily.
Regimen 3:- Ceftriaxone 500 mg intramuscularly, plus doxycycline 100 mg twice daily, plus metronidazole 400 mg twice daily.

Inpatient antibiotic regimens:-fore those who are severely ill ,use one of the following regimens:-
Regimen 1 :- I.v Ceftriaxone 2 g daily, plus i.v or oral doxycycline 100 mg twice daily,followed by oral doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily.
Regimen 2 :- I.v Clindamycin 900 mg three times daily, plus i.v gentamycine 2 mg\kg loading dose followed by 1.5mg\kg three times daily(a single daily dose may also used),followed by oral doxycycline 100 mg twice daily, plus metronidazole 400 mg twice daily.
Regimen 3:- I.v Ofloxacin 400 mg twice daily plus i.v metronidazole 500 mg three time daily, followed by oral Ofloxacin 400 mg twice daily plus metronidazole 400 mg twice daily.
Regimen 4:- I.v Ciprofloxacin 200 mg twice daily,plus i.v or oral doxycycline 100 mg twice daily, plus i.v metronidazole 500 mg three time daily followed by oral doxycycline 100 mg twice daily, plus metronidazole 400 mg twice daily.

For all regimens parenteral therapy should be continued until 24 h after clinical improvement. Oral therapy should be continue to complete 14 days of antibiotics in total.
Pelvic inflammatory disease may require surgery. This is rare and only necessary if an abscess in the pelvis ruptures or there is suspicion that an abscess will rupture. It can also be necessary if the infection does not respond to treatment.
Management of the male partners of women with pelvic infection:-
1-Test for gonorrhea and Chlamydia.
2- Give empirical therapy for gonorrhea and Chlamydia if testing is not available .
3-Advice to avoid intercourse until index patient and male partner have both completed antibiotic therapy.

Prevention:-Ways to Prevent Pelvic Inflammatory Disease:-
1-Practicing safe sex.
2-Getting tested for sexually transmitted infections.
3-Avoiding vaginal douches.
4-Wiping from front to back after using the bathroom or after defecation to stop bacteria from entering the vagina.

Complications:- Long-term complications of pelvic inflammatory disease are:-
1-Infertility.
2-Ectopic pregnancy.
3-Chronic pelvic pain: pain in the lower abdomen caused by scarring of the fallopian tubes and other pelvic organs.
4-The infection can also spread to other parts of the body if it spreads to the blood.