PELVIC INFLAMMATORY DISEASE ASAL ALQUM CASE A 19

PELVIC INFLAMMATORY DISEASE ASAL ALQUM

CASE: • A 19 year old nulligravida presents to the emergency department with bilateral lower abdominal pelvic pain for 24 hours. She just finished her menses. She is sexually active but using no contraception. Speculum examination reveals mucopurulent cervical discharge. Bimanual pelvic examination shows bilateral adnexal tenderness and cervical motion tenderness. She is afebrile. Qualitative urinary b-h. CG test is negative. Complete blood cell count shows WBC 14, 000. ESR is elevated.

What is PID? • PID is a non specific term for a spectrum of upper genital tract conditions ranging from acute bacterial infection to massive adhesions from old inflammatory scarring.

• The most common initial organisms are chlamydia and gonorrhea. • With persistent infection, secondary bacterial invaders include anaerobes and gram-negative organisms.

PID is an ascending infection Cervicitis Acute salpingo-ophritis Treatme nt Heals without adhesions Normal pelvis No treatment Heals with adhesions Chronic PID Gets worse TOA

Transmission: • • • Sexual transmission via the vagina & cervix. Gynecological surgical procedures. Child birth/ Abortion. A foreign body inside uterus (IUCD). Contamination from other inflamed structures in abdominal cavity (appendix, gallbladder). • Blood-borne transmission (pelvic TB)

Risk factors: • The most common risk factor is female sexual activity in adolescence, with multiple partners. • • Exposure immediately prior to menstruation. Relative ill-health & poor nutritional status. Previously infected tissues (STD/ PID). Frequent vaginal douching.

Cervicitis • The initial infection starts with invasion of endocervical glands chlamydia and gonorrhea. • • • Mucopurulent cervical discharge and friable cervix. No pelvic tenderness. The patient is afebrile. Positive culture for chlamydia or gonorrhea. WBCs and ESR are normal. Management: single dose orally of cefixime and azithromycin.

Acute Salpingo-Oophritis • Bilateral lower abdominal pain may be variable. • Onset may be gradual to sudden. • Nausea and vomiting may be found if abdominal involvement is present. • Mucopurulent cervical discharge, cervical motion tenderness and bilateral adnexal mass tenderness. • Fever, tachycardia, abdominal tenderness, peritoneal signs and guarding may be found depending on the extent of infection progression.

Acute salpingo-ophritis • CLINICAL DIAGNOSIS. • Minimal criteria: 1) Pain: pelvic or lower abdominal. 2) Tenderness: cervix, uterus, adnexa. 3) Sexually active woman. 4) No other identified cause.

Acute salpingo-ophritis • Supportive crieteria: 1) Fever. 2) Mucopus: cervical or vaginal. 3) Leukocytes: vaginal fluid. 4) Elevated WBC or ESR or CRP. 5) Positive GC or Chlamydia testing.

Acute salpingo-ophritis • - Most specific criteria for diagnosis: Endometrial biopsy showing endometritis. Vaginal sono or MRI imaging showing abnormal adnexa. Laparoscopic abnormalities consistent with PID.

Management • - Inpatient criteria: High fever. Nausea and vomiting. Failed outpatient therapy. Severe pain Unsure diagnosis TOA Antibiotics: Cefotetan 2 g IV q 12 h and Doxycycline 100 mg IV q 12 h

Management • Outpatient criteria: - Absence of inpatient criteria. Ceftraxone 250 mg IM x 1 Doxycycline 100 mg bid x 14 d With or without Metronidazole

Differential diagnosis • • • Adnexal torsion Ectopic pregnancy Endometriosis Appendicitis Diverticulitis Crohns disease

Tubo-Ovarian Abcess • Is the accumulation of pus in the adnexa forming an inflammatory mass involving the oviducts, ovaries, uterus or omentum. • The patient will look septic • Lowe abdominal pain is severe • Often there is severe back pain, rectal pain and pain with bowel movements. • Nausea and vomiting are present. • High fever

Tubo-Ovarian Abcess • • • Tachycardia May be in septic shock with hypotension Abdominal exam: peritoneal signs, guarding and rigidity Bilateral adnexal masses may be palpable. Investigative findings: WBCs and ESR are markedly elevated, positive cervical culture for chlamydia or gonorrhea, blood cultures may be positive for gram-negative bacteria and anaerobic organisms. • Sono or CT will show bilateral complex pelvic masses.

Tubo-Ovarian Abcess • Management: Inpatient IV gentamycin and clindamycin If no response or there is rupture of the abcess exposing free pus into the peritoneal cavity then an exploratory laparotomy with possible TAH and BSO or percutaneous drainage may be required.

Tubo-Ovarian Abcess • • Differential diagnosis: Septic abortion Diverticular or appendicular abcess Adnexal torsion

Chronic PID • • Chronic bilateral lower abdominal pain and tenderness Cervical motion tenderness History of infertility, dyspareunia, ectopic pregnancy Nausea and vomiting are absent Normal WBC and ESR No mucopus No fever

Chronic PID • Diagnosis: laparoscopic visualization of diffuse pelvic adhesions • Mild analgesics, lysis, severe unremitting pain may require TAHBSO.