Transcript Pelvic Inflammatory Disease

Pelvic Inflammatory Disease
Corey Kahn, DO
Case Presentation PF 9/23/00

A 37 y/o female with no significant PMH,
presents with 24 hours of LLQ pain.
– Pain started as gradual intermittent, now
with constant with some radiation to groin.
– No bowel changes. No history of ovarian
cyst. No sexual hx documented.



No allergies or meds.
PSH is significant for a tubal ligation.
D/Dx: diverticulitis, UTI, renal stone,
PE





Vitals: T 97.7, HR 74, RR 18, BP 118/68
Abd: Soft, tender LLQ, no rebound, no
guarding.
Rectal: heme neg brown stool.
Pelvic: Tender LLQ, no mass, no CMT,
no discharge. Cervix hard.
Labs: Neg UA. GC/Chlamydia cultures
were sent.
Case Presentation


Abd CT showed no evidence of
urolithiasis or obstruction. Pos relatively
large uterus with prominent
endometrium or fluid.
Pt was observed in the ED.
– Pt was given lortab/motrin and then
demerol for pain relief and d/ced home with
f/u in Ob/Gyn clinic in one week and 24
hours to ED if cont. pain.
Case Presentation

Pt. returned to the emergency dept.
9/25 (two days later).
– + continued pain described as constant
stabbing and sharp, gradual in onset,
increasing with movement, radiating to L
groin and back.
– +Vx1.
– No F, chills, D, C, dysuria, hematuria,
urinary frequency or urgency.
– Pos history of Chamydia/GC.
PE




Vitals: T 96.5, HR 92, RR 20, BP 130/72
Abd: soft, +bs, no G/R/R, + LLQ mild
tenderness, no CVA tenderness.
Pelvic: External:wnl. Speculum: +
yellow purulent d/c from os. Biman:
+CMT, +b/l adnex. tenderness, no
masses.
Labs: + DNA probe for Chlamydia
Trachomatis.
Pelvic Inflammatory Disease

Introduction
– PID includes endometritis, oophorites,
myometritis and peritonitis.
– Costs: 1 million cases/year; $4 billion
annually; 267,000 inpt. hosp admissions;
119,000 operations/year.
– Incidence: Mainly young women(late
teens/early twenties); occurs in 1-2% of
young sexually active females/year.
Pelvic Inflammatory Disease

Causes:
– Sexually transmitted: about 50%
– Non-STD: iatrogenic, frequent douching ,
BV.
– Other Risk Factors: Age<25, multiple sex
partners, lower socioeconomic status,
single, during mentrual period, smoking,
substance abuse, and history of PID,
gonorrhea, chlamydia or herpes infection.
Pelvic Inflammatory Disease

Contraceptive Use
– IUDs: increase risk by creating a sanctuary
for bac. from the body’s defenses. They
establishes a chronic anaerobic
endometritis.
– Barrier Methods (condoms, diaphragm,
sponge and foam) are protective and foam
may be bacteriocidal.
•Pelvic Inflammatory Disease

Oral Contraceptives are protective
because they:
– Decrease menstral flow.
– Decrease the ability of bac. to attach to
endometrium.
– And because there are progestin induced
changes in the cervical mucus that retard
the entrance of bac.
Pelvic Inflammatory Disease

Organisms-often polymicrobial.
– N. gonorrhea: about 50%
– Chlamydia trachomatis: about 25%
– Others include: E. coli, S. viridans,
Enterococci, B. fragilis, Mycoplasma
hominis, Ureaplasma urealyticum, M.
tuberculosis, Actinemyces israelii-15%
assoc with IUD cases, Garnerella
Vaginalis, H. flu, and others.
Pelvic Inflammatory Disease

Symptoms- can be asymptomatic
– Pelvic or lower abdominal pain usu. <2
weeks duration.
– Abnormal vaginal discharge.
– Postcoital bleeding, spotting between
menstrual periods.
– Gastrointestinal symptoms not uncommon.
– Signs of Bacteremia/Sepsis
– Arthritis(dissemimated gonococcal
infection) or Reiter’s Syndrome.
Pelvic Inflammatory Disease

Diagnosis
– Minimum criteria require lower abdominal
tenderness, adnexal tenderness and CMT.
– Additional criteria to increase specificity
include oral temp.>101.8F, abnormal
cervical or vaginal discharge, elevated sed
rate, elevated C-reactive protein level and
lab documentation of cervical infection.
– Elaborate criteria used in severely ill
women with unsure diagnosis include
Pelvic Inflammatory Disease

Complications
– Ectopic Pregnancy: increases six to tenfold
in women with PID. Approx. 50% of all
ectopic preg. are caused by tubal damage
in PID.
– Tubo-ovarian abscess
– Peri-oophoritis
– Chronic pelvic pain- about 20% of patients.
– Fitz-Hugh-Curtis Syndrome (perihepatitis)
Pelvic Inflammatory Disease

Complications cont.
– Disseminated Gonococcemia
– Mortality-rare(neglected cases of abscess)
– Infertility: 6-60% of cases.
• Occurs in 100,000 women/year.
• Tubal obstuction depends on severity and # of
episodes: One - about 11%, two - about 23%,
three - about 54%.
Pelvic Inflammatory Disease



Eschenbach assessed the relationship
between clinical presentation and
laparoscopic observations.
He found that the severity of clinical
manifestations was not associated
positively with tubal occlusion.
This suggests that tubal occlusion may
be as common in the outpt. with mild
clinical findings.
Pelvic Inflammatory Disease

In another report, Hillis showed a delay
in presentation of 3 or more days
beyond the onset of symptoms was
associated with an increased risk of
infertility, and a delay of 10 or more
days was associated with a further
increase.
Pelvic Inflammatory Disease

Outpatient Tx.
– Regimen A: Cefoxitin, 2 g IM plus
probenecid, 1 g PO, or ceftriaxone, 250 mg
IM plus Doxycycline, 100 mg PO BID, x 14
days.
– Regimen B: Ofloxacin, 400 mg PO BID, x
14 days plus Clindamycin, 450 mg PO
QID, or Flagyl, 500 mg PO BID, x 14 days.
Pelvic Inflammatory Disease

Inpatient Tx
– Regimen A: Cefoxitin, 2 g IV Q 6 hours, or
cefotetan, 2 g IV Q 12 hours plus
Doxycycline, 100mg IV or PO Q 12 hours.
– Regimen B: Clindamycin, 900 mg IV Q 8
hours plus Gentamicin, loading dose IV or
IM then a maintenance dose Q 8 hours.
– These regimens should be cont. for at least
48 hours after the pt. shows sig. Clin.
Improvement and then Doxy PO x 14 days.
Pelvic Inflammatory Disease

Tubo-Ovarian Abscess
– Triple-antibiotic therapy is often
recommended(Gram +, Gram -,
anaerobes)
– Amp/Gent/Clinda or
Amp/Ceftriaxone/Clinda
– Surgery is usu. not required.
Pelvic Inflammatory Disease


Pt. requires adequate hydration and
pain management.
Pt. requires close f/u.
– Outpatient: Reexam within 72 hours.
– Inpatient: biman. exam QD.

Remember to discuss treating partners.
Pelvic Inflammatory Disease

Hospitalization? Consider if:
• The dx is uncertain
• Pelvic abscess is suspected
• In severe illness (V, dehydration, fever, or signs
of peritonitis)
• The patient is pregnant
• The patient is an adolescent or if clinical f/u
within 72 hours can’t be arranged
• The pt. has HIV
• Pt is unable to follow or tol. outpatient regimen
or pt. has failed an outpatient course
Pelvic Inflammatory Disease



The threshold for diagnosing PID must
be low.
Patients with mild symptoms may have
severe disease.
Therefore, withholding of antibiotics with
a wait and see approach can lead to
unnecessary infertility.
Pelvic Inflammatory Disease






Eschenbach, Hanssen, Hawes, Pavletic, Paavonen,
Holmes. Obstetrics and Gynecology. Feb., 1997
Tintinalli. Emergency Medicine. Fifth Edition.
McCormack. NEJM. January, 1994.
Newkirk. American Family Physician. March, 1996
Paavonen. Derm. Clinics. Oct. 1998
Hillis, Joesoef, Marchbanks. Am J Ob Gyn. 1993