Pelvic Inflammatory Disease

1. Pelvic Inflammatory Disease By: Ana Corona, FNP-Student University of Phoenix December 2002

2. Upper Genital Tract Infections • The Cervix is considered the boundary between the lower and upper genital tracts. • Upper genital tract infections affect primarily the cervix, uterus, or fallopian tubes • Severe infections may affect one or both ovaries.

3. Topic Defined: Pelvic Inflammatory Disease (PID) • Infection of the upper female genital tract. • Refers to the clinical syndrome among women resulting from infection • Includes endometritis (infection of the uterine cavity) • Salpingitis (infection of the fallopian tubes) • Mucopurulent Cervicitis (infection of the cervix), • Oophoritis (infection of the ovaries).

4. Pathologic Processes of PID • PID has a broad clinical spectrum that includes • acute PID • silent PID • atypical PID • the PID residual syndrome or chronic PID and • postpartum/postabortal PID

5. PID Specifically defined: • Individual cases of PID can also be more specifically defined by • a) the site (s) of disease (i.e., endometritis, salpingitis, salpingo-oophoritis) • b) the etiologic agent (s) involved (those that cause chlamydial endometritis, gonococcal salpingitis, nonchlamydial/nongonococcal salpingo-oophoritis).

6. Relevance to Women’s Health: • Commonly occurs in women <35 years. • Rarely occurs before menarche, after menopause or during pregnancy. • About 1.2 million women are treated for PID. • Over 100,000 women with PID are hospitalized each year. • About 15% are acutely ill that require intensive inpatient treatment. • Approximately 85,000 women with mild or moderate PID who currently are being hospitalized, treating them as outpatients may save around $500 million each year.

7. Relevance to Women’s Health • Is one of the major causes of gynecologic morbidity • Infertility • Ectopic pregnancy • Chronic pelvic pain • Diagnosis and treatment must be prompt to avoid these conditions.

8. PID: Etiology • PID results from microorganisms transmitted during intercourse. • Certain procedures that open the cervix and allow possible bacteria to pass through (D&C, abortion, cesarean birth, miscarriage, I.U.D. insertion) • The infection is usually multifactorial, involving aerobic and anaerobic organisms

9. PID: Risk Factors • Multiple sexual partners or partner with multiple sexual partners • Intercourse with partner with untreated urethritis • Previous history of PID • Use of an IUD • Presence of bacterial vaginosis or an STD • Nulliparity • Recent instrumentation of the uterus • Douching • Cigarette smoking • Sex with menses

10. Causative Agents of PID • Neiserria Gonorrhoeae and Chlamydia trachomatis are the 2 major causative organisms. • Chlamydia trachomatis is the predominant STD organism causing PID. • In the U.S., the role of Neisseria Gonorrhoeae as the primary cause of PID has decreased. • Other agents: Mixed infection caused by both aerobic and anaerobic organisms • Recent studies demonstrate the presence of Bacterial Vaginosis and trichomoniasis in cases of confirmed PID

11. Causative Agents of PID • Cytomegalovirus (CMV) has been found in the upper genital tracts of women with PID. • Enteric gram-negative organisms (E-coli) • Peptococcus species • Streptococcus agalactiae • Bacteroides fragilis • Mycoplasma hominis • Gardnerella vaginalis • Haemophilus influenzae

12. Signs & Symptoms of PID • The patient presents with lower abdominal pain, fever, vaginal discharge, and/or abnormal uterine bleeding. • Symptoms frequently occur during or after menses. • Peritoneal irritation produces marked abdominal pain with or without rebound tenderness • The abdomen should be palpated gently to prevent abscess rupture

13. Chlamydial Pyosalpinx • Pelvic inflammatory disease, proven Chlamydial Pyosalpinx. • Right tube is swollen and tortuous (arrow) (Holmes, 1999, Plate 17; reprinted with permission from McGraw Hill.)

14. Cervicitis • The cervix appears red and bleeds easily when touched with a spatula or cotton swab. • Mucopurulent discharge is yellow-green • Contains >10 polymorphonuclear WBCs per oil immersion field (using Gram stain)

15. Acute Salpingitis • Onset is usually shortly after menses. • Lower abdominal pain becomes progressively more severe, with guarding, rebound tenderness, and cervical motion tenderness. • Involvement is usually bilateral. • Nausea and vomiting occur with severe infection. • In the early stages, acute abdominal signs are often absent

16. Acute Salpingitis (PID) • Bowel sounds are present unless peritonitis with ileus has developed. • Fever, leukocytosis, and mucopurulent cervical discharge are common • Irregular bleeding and bacterial vaginosis often accompany the pelvic infection.

17. Acute Salpingitis (PID) • Pelvic infection due to N. Gonorrhoeae is usually more acute than that due to C. trachomatis • Onset is rapid, and pelvic pain develops shortly after menses starts. • Although the pain is often localized to one side, both tubes are probably infected. • The infection produces a diffuse exudate, leading to agglutination, adhesions, and tubal occlusion. • Peritonitis may occur, causing upper abdominal pain and adhesions

18. Acute Salpingitis: Chlamydia & Gonorrhea • C. trachomatis produces symptoms that often seem mild, but it can cause more damage than N. Gonorrhoeae in the long term. • Chlamydial organisms may remain in tubal mucosa for many months before clinical manifestations of acute disease appear. • Untreated or inadequately treated acute infection can lead to chronic salpingitis, with tubal scarring and possible adhesion formation. • Chronic pelvic pain, menstrual irregularities, and infertility are long-term sequelae

19. Complications of PID • Tubo-ovarian abscess develops in about 15% of women with salpingitis. • It can accompany acute or chronic infection • The tube and ovary can become completely matted together. • May require prolonged hospitalization, sometimes with surgical percutaneous drainage. • Rupture of the abscess is a surgical emergency • Rapidly progressing from severe lower abdominal pain to N & V, generalized peritonitis, and septic shock

20. Tubo-ovarian abscess • Pyosalpinx, in which one or both fallopian tubes are filled with pus, may also be present. • Hydrosalpinx (fimbrial obstruction and tubal distention with nonpurulent fluid) develops if treatment is late or incomplete. • The consequent mucosal destruction leads to infertility. • Hydrosalpinx is generally asymptomatic but can cause pelvic pressure, chronic pelvic pain, or dyspareunia. • Women with HIV infection are more likely to have tubo-ovarian abscess

21. Tubo-ovarian abscess • Here at least the ovaries, tubes and uterus can still be recognized as separate structures

22. Fitz-Hugh-Curtis syndrome • Can be a complication of gonococcal or chlamydial salpingitis. • Characterized by right upper quadrant pain in association with acute salpingitis, indicating perihepatitis. • Acute cholecystitis may be suspected, but signs and symptoms of PID are present or develop rapidly.

23. Diagnostic Studies: • CBC with differential • Erythrocyte Sedimentation Rate • Cervical cultures • Blood Cultures • Urine Pregnancy Test • Rapid Plasma Reagin (RPR) • Cervical infection due to N. Gonorrhoeae can also be diagnosed by Gram stain showing intracellular gram-negative diplococci

24. Diagnostic studies • Leukocytosis is typical. • Pelvic ultrasonography may be used when a patient cannot be adequately examined because of tenderness or pain • When a pelvic mass may be present, or when no response to antibiotic therapy occurs within 48 to 72 h. -- • Laparoscopy should be performed only if the diagnosis is uncertain or if the patient does not promptly improve with medical therapy

25. CDC’s Minimum Criteria for Empiric Treatment of PID • Lower Abdominal Tenderness & Rebound • Adnexal Tenderness • Cervical Motion Tenderness

26. Diagnosis • And one or more minor criteria • Temperature over 100.9F or 38.3 C • White Blood Cell count > 10,000 • Elevated ESR • Elevated C-reactive protein • Pus in cul-de-sac • Pelvic abscess or inflammatory complex • Cervical Mucus findings • Gram Stain: Gram Positive diplococci • Intracellular parasites

27. Diagnosis • ESR and C-reactive protein are elevated in many disorders and are therefore not specific for PID. • Endometrial biopsy with aerobic and anaerobic culture may assist in the diagnosis. • All three major criteria and at least one minor criterion must be present to diagnose PID.

28. Differential Diagnosis

29. Treatment Goals & Benefits • Therapeutic goals include complete resolution of the infection and prevention of infertility and ectopic pregnancy.

30. Management Outpatient • Regimen A: • Initial Treatment at Diagnosis • Ofloxacin 400 mg orally BID for 14 days • (95% cure) • Or • Levofloxacin 500 mg orally once daily for 14 days • With or without: • Metronidazole 500 mg orally twice a day for 14 days.

31. Management Outpatient: Regimen B • Ceftriaxone 250 mg IM in a single dose • Or • Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose • Or • Other parenteral third-generation cephalosporin (ceftizoxime or cefotaxime) • Plus • Doxycycline 100 mg PO BID for 14 days (75% cure) • With or without • Metronidazole 500 mg PO BID for 14 days

32. Toxic appearance Unable to take oral fluids Unclear DX Appendicitis Ectopic Pregnancy Ovarian torsion Pelvic abscess Pregnancy HIV positive Adolescents Outpatient TX failure Unreliable patient Management Inpatient

33. Inpatient Treatment Regimens: • General: Treat for at least 48 hours IV • Regimen A • Cefotetan 2g IV q12 hours • OR • Cefoxitin 2g IV q6 hours • Plus • Doxycycline 100 mg orally or IV every 12 hours

34. Inpatient Treatment • Regimen B • Clindamycin 900 mg IV q8 hours • Plus • Gentamicin 2 mg/kg IV loading dose, then 1.5 mg/kg IV q8h • Discharge Regimen (after IV antibiotics) • Doxycycline 100mg PO BID for 10 days • or • Clindamycin 450mg PO QID for 14 days

35. Alternative Parenteral Regimens • Ofloxacin 400 mg IV q 12 hours • Or • Levofloxacin 500 mg IV once daily • With or without • Metronidazole 500 mg IV every 8 hours • Or • Ampicillin/Sulbactam 3 g IV every 6 hours • Plus • Doxycycline 100 mg orally or IV every 12 hours

36. Prognosis • Therapy using antibiotics alone is successful in 33-75% of cases. • If surgical therapy is warranted, the current trend in therapy is conservation of reproductive potential with simple drainage and copious irrigation or unilateral adnexectomy, if possible. • Further surgical therapy is needed in 15-20% of cases so managed.

37. Prognosis • Chronic pelvic pain occurs in approximately 25% of patients with a history of PID. • This pain is thought to be related to cyclic menstrual changes, but it also may be the result of adhesions or Hydrosalpinx. • Impaired fertility is a major concern in women with a history of PID. • The rate of infertility increases with the number of episodes of infection. • The risk of ectopic pregnancy is increased in women with a history of PID. • Ectopic pregnancy is a direct result of damage to the fallopian tube.

38. Prevention • Randomized controlled trials suggest that preventing chlamydial infection reduces the incidence of PID. • Other methods of preventing PID and STD include reducing the number of sexual partners, avoiding unsafe sexual practices, and using condoms with spermicide. • Use of mechanical barriers with spermicide also decreases the risk of acquiring STDs. • Notification of the female sex partners of men infected with Chlamydia trachomatis is recommended

39. Relevance of topic for clinical NP Practice • NPs can help reduce the risk for PID and its sequelae. • Timely diagnosis and appropriate treatment of lower-genital-tract chlamydial and gonococcal infection among both men and women can reduce the risk of adverse consequences among infected individuals and can reduce the risk of further transmission to others.

40. Relevance of topic for clinical NP Practice • Also, NPs can influence men's and women's risk of infection by providing effective counseling about their sexual behavior, health- care-seeking behavior, and contraceptive practice, and by convincing them to comply with management instructions. • Finally, by ensuring timely and effective treatment of patients' sex partners, NPs can reduce risk of reinfection.

41. Relevance of topic for clinical NP Practice • Because the partners' infections may be asymptomatic, interviewing and treating these persons will help reduce further transmission of infection in the community and may facilitate identifying other infected persons.

42. Management of Sex Partners • Treatment for sex partners of women with PID is imperative. • The management of women with PID should be considered inadequate unless their sex partners have been appropriately evaluated and treated. • Failure to manage her sex partner (s) effectively places a woman at risk for recurring infection and related complications. • Moreover, untreated sex partners often unknowingly transmit STD in a community because of asymptomatic infection.

43. Surveillance • At all levels, PID surveillance is affected by four main constraints: • PID is difficult to diagnose accurately. • PID is diagnosed in a wide variety of clinical settings. • Microbiology test results are needed to determine the etiology of PID.

44. Patient Education • The NP’s role as a health educator is central to effective management. • NPs should explain to women the nature of their disease and should encourage them to comply with therapy and prevention recommendations. • Specifically, NPs should: • Emphasize the need for taking all the medication, regardless of symptoms. • http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

45. Patient Education • Review contraindications and potential side effects. • Identify and discuss potential compliance problems. • Review the medical purpose of follow-up evaluation. • Emphasize the need to avoid sex until treatment is completed. • Emphasize the need to refer sex partners for evaluation and treatment. • http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

46. Patient Education • When medical-care messages are clear, explicit, relevant, and rigorously delivered by providers, patients are likely to comply. • Reinforcement of these messages can be achieved by providing written information. • Information on written materials for patient distribution can be obtained from CDC or local and state health departments • http://www.cdc.gov/mmwr/preview/mmwrhtml/00031002.htm

47. Controversies Surrounding PID • The exact incidence of PID is unknown • The disease cannot be diagnosed reliably from clinical signs and symptoms. • Laparoscopy exam of the pelvic organs continues to be the "gold standard" approach to diagnosis of PID. • But, because this is a surgical procedure which requires an incision in the abdomen, the high priority is to design and development of non-invasive techniques, with smaller costs and fewer risks. • OC may reduce the risk of PID that is not attributable to C. trachomatis.

48. Relevant Research Findings • Recently, a study conducted at the University of Washington School of Medicine confirmed that regular douching is associated with pelvic inflammatory disease. • An earlier study had shown a significant association between vaginal douching and ectopic pregnancy. • Pelvic inflammatory disease is also a major factor in ectopic pregnancy.

49. Research Findings • In a comparison of 100 women with confirmed pelvic inflammatory disease (PID) and 762 randomly selected controls, at Harborview Medical Center in Seattle • The investigators report that women who douche once or twice a month were 2.5 times more likely to have PID than those who douched less than once a month. • However, the risk of PID does not appear to increase with more frequent douching.

50. Relevant Research Studies on PID • It is thought that douching increases the risk of PID by wiping out beneficial vaginal bacteria making it possible for disease producing bacteria to get the upper hand. • Another theory is that douching flushes vaginal and cervical bacteria back into the uterine cavity where they cause trouble.